Recurrent acute pancreatitis: a harbinger for irreversible chronic pancreatitis.

Recurrent acute pancreatitis is beginning to be recognized as an intermediary stage in the continuous spectrum between acute and chronic pancreatitis. It is crucial to identify this disease stage and intervene with diagnostic and therapeutic modalities to prevent the painful and irreversible condition of chronic pancreatitis. We review the recent advances in diagnosing and managing this important 'call for action' condition.

Transoesophageal echocardiography in cardiac arrest: From the emergency department to the intensive care unit.

Cardiac arrest is a hyper-acute condition with a high mortality that requires rapid diagnostics and treatment. As such, point-of-care ultrasound (POCUS) has become a valuable tool in the assessment of these patients. While transthoracic echocardiography (TTE) is the more conventional modality used to find reversible causes of cardiac arrest, transoesophageal echocardiography (TOE) has been increasingly utilised due to its superior image quality, continuous imaging, and ability to be operated away from the patient's chest. TOE also has a number of applications in the aftermath of cardiac arrest, such as during the initiation of extracorporeal cardiopulmonary resuscitation (ECPR) and the subsequent monitoring of extracorporeal membranous oxygenation (ECMO). As TOE has evolved, multiple variations have been developed with different utilities. In this article, we will review the evidence supporting the use of TOE in cardiac arrest and where the different forms of TOE can be applied to evaluate the cardiac arrest patient in a timely and accurate manner.

Focused transoesophageal TOE (fTOE): A new accreditation pathway.

The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.