Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement.

BACKGROUND: The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventricular decompensation and death. METHODS: A systematic literature review was performed of studies in patients with PH undergoing non-cardiac and non-obstetric surgery. The management of patients with PH requiring sedation for endoscopy was also reviewed. Using a framework of relevant clinical questions, we review the available evidence guiding operative risk, risk assessment, preoperative optimisation, and perioperative management, and identifying areas for future research. RESULTS: Reported 30 day mortality after non-cardiac and non-obstetric surgery ranges between 2% and 18% in patients with PH undergoing elective procedures, and increases to 15-50% for emergency surgery, with complications and death usually relating to acute right ventricular failure. Risk factors for mortality include procedure-specific and patient-related factors, especially markers of PH severity (e.g. pulmonary haemodynamics, poor exercise performance, and right ventricular dysfunction). Most studies highlight the importance of individualised preoperative risk assessment and optimisation and advanced perioperative planning. CONCLUSIONS: With an increasing number of patients requiring surgery in specialist and non-specialist PH centres, a systematic, evidence-based, multidisciplinary approach is required to minimise complications. Adequate risk stratification and a tailored-individualised perioperative plan is paramount.

Case-based discussion from the neonatal intensive care unit: a case of an intentional oesophageal intubation.

Tracheal agenesis (TA) is a rare congenital defect consisting of complete or partial absence of the trachea below the larynx. Antenatal diagnosis is challenging, and most cases are detected in the postnatal period. Airway management of such cases, particularly in the absence of antenatal diagnosis, can be challenging. Various methods of management have been described but with limited success, and overall prognosis remains very poor. We present an unexpected case of TA, highlighting management issues and diagnostic methods.

Fatal cardiovascular instability secondary to hypercalcaemia and intracellular calcium deposition complicating T-cell leukaemia-lymphoma.

Adult T-cell leukaemia-lymphoma is a rare haematological malignancy, which can cause severe hypercalcaemia and metastatic calcification resulting in life-threatening arrhythmias.

Nicotinic modulation of human auditory sensory memory: Evidence from mismatch negativity potentials.

Impairment in mismatch negativity (MMN) generation is a robust biological marker of schizophrenia. Understanding the physiological and pharmacological processes involved in its generation may therefore advance our understanding of this complex disorder. The present study tested if acute administration of nicotine modulates human auditory sensory memory as measured with MMN. ERP responses to tone duration deviants were recorded using a stimulation protocol with continuously changing (roving) standard stimuli in order to measure the effect of stimulus repetitions on encoding of new stimuli (MMN memory trace effect). Twenty healthy adult volunteers were randomly assigned to receive either a nicotine gum or placebo after a baseline ERP recording. Nicotine administration augmented MMN amplitude in the treatment group compared to the baseline recording, while no MMN change was found in the placebo group. The drug effect was due to a selective enhancement of a frontal positive potential to standard stimuli (from 80-200 ms post-stimulus), while the negativity to deviants remained unaffected. Furthermore, under nicotine stimulation this repetition positivity showed a more marked increase with stimulus repetition compared to baseline and placebo. These results have potential implications for schizophrenia by suggesting that nicotinic agonists could ameliorate patients' MMN deficits by improving stimulus encoding and sensory memory trace formation.