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.

Incidence and outcome of anaphylaxis in cardiac surgical patients.

Introduction: Anaphylaxis is a rare but serious and potentially fatal complication of anesthesia. Little is known about the incidence and outcome of anaphylaxis in cardiac surgical patients, which we aimed to investigate. Methods: This was a 21-year retrospective study of cardiac surgical patients at Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK. Results: A total of 19 cases of anaphylaxis were reported among 17,589 patients (0.108%) undergoing cardiac surgery. The majority (15/19) occurred before cardiopulmonary bypass (CPB), mostly during or within 30 min after the induction of anesthesia (10/19). Two occurred within 15 min of going onto CPB. Of these 17 cases, 11 were abandoned, and 6 proceeded. The severity of reactions in the patients who proceeded ranged from grade II to grade IV of the Ring and Messmer classification. Two cases occurred after the completion of surgery. All patients survived to 90 days. However, this did not appear to be related to CPB or protamine as most of the reactions occurred before CPB. Instead, the most common causative agents were gelofusine, antibiotics, muscle relaxants, and chlorhexidine. In 6 cases, surgery proceeded despite the anaphylaxis, in 11 cases the surgery was postponed, and in 2 cases the procedure had already been completed. Conclusion: As all patients survived, our results provide preliminary support for proceeding with surgery although we cannot speculate on the likely outcomes of patients who were postponed, had their surgery proceeded. Based on our data, the incidence of anaphylaxis in cardiac surgical patients may be 10-20 times higher than in the general surgical population.

Joint British Societies' guideline on management of cardiac arrest in the cardiac catheter laboratory.

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

Getting the best from the Heart Team: guidance for cardiac multidisciplinary meetings.

The purpose of this document is to update the existing joint British Societies recommendations on multidisciplinary meetings (MDMs) published in 2015 to reflect changes in practice. We aim to provide guidance on the structure and function of MDMs which should be taking place in every cardiac surgical centre. Out of scope are MDMs that do not require the routine presence of a cardiac surgeon such as electrophysiology MDMs and those which are not provided in every centre, such as complex aortic surgery.

Symmetric coalescence of two hydraulic fractures.

The formation of a fracture network is a key process for many geophysical and industrial practices from energy resource recovery to induced seismic management. We focus on the initial stage of a fracture network formation using experiments on the symmetric coalescence of two equal coplanar, fluid-driven, penny-shaped fractures in a brittle elastic medium. Initially, the fractures propagate independently of each other. The fractures then begin to interact and coalesce, forming a bridge between them. Within an intermediate period after the initial contact, most of the fracture growth is localized along this bridge, perpendicular to the line connecting the injection sources. Using light attenuation and particle image velocimetry to measure both the fracture aperture and velocity field, we characterize the growth of this bridge. We model this behavior using a geometric volume conservation argument dependent on the symmetry of the interaction, with a 2D approximation for the bridge. We also verify experimentally the scaling for the bridge growth and the shape of the thickness profile along the bridge. The influence of elasticity and toughness of the solid, injection rate of the fluid, and initial location of the fractures are captured by our scaling.

Extracorporeal membrane oxygenation in adult congenital heart disease: a case series and literature review.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) can be used as rescue intervention for cardiac and/or respiratory failure. High-risk adult patients with adult congenital heart disease (ACHD) may require pre- and post-operative ECMO support. DESIGN, SETTING AND PARTICIPANTS: Retrospective data collection within a five-year time period from 2011 to 2016, at a single-centre study at a tertiary university hospital and regional unit for ACHD. Patients with ACHD in cardiogenic shock or failure to be separated from cardio-pulmonary bypass (CPB) were included. INTERVENTION: Venoarterial (VA) ECMO. RESULTS: Three patients had Ebstein anomaly and one patient had a double-outlet right ventricle transposition type and severe atrioventricular valve insufficiency. Three male patients and one female patient were aged ranging from 19 to 52 years. All received VA ECMO, two each with central or peripheral cannulation. The mean duration of ECMO support was 7 days (range, 3-13 days) and bleeding complications were the main complications observed, with a range of 12 to 104 blood products used. One patient required renal replacement therapy for acute kidney injury and also had leg ischaemia. MAIN OUTCOME MEASURES: Two of four patients (50%) were successfully weaned off ECMO and survived to hospital discharge in this high-risk group of patients in severe heart failure. The patients are currently at 3 and 4 years follow-up, with improved mobility and exercise tolerance compared with pre-operatively. CONCLUSION: ECMO is a promising temporary rescue intervention for patients with ACHD and cardiogenic shock. The extracorporeal cardiac support is a useful bridge to recovery.

A safety checklist for transoesophageal echocardiography from the British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists.

The World Health Organisation (WHO) launched the Surgical Safety Checklist in 2008. The introduction of this checklist resulted in a significant reduction in the incidence of complications and death in patients undergoing surgery. Consequently, the WHO Surgical Safety checklist is recommended for use by the National Patient Safety Agency for all patients undergoing surgery. However, many invasive or interventional procedures occur outside the theatre setting and there are increasing requirements for a safety checklist to be used prior to such procedures. Transoesophageal echocardiography (TOE) is an invasive procedure and although generally considered to be safe, it carries the risk of serious and potentially life-threatening complications. Strict adherence to a safety checklist may reduce the rate of significant complications during TOE. However, the standard WHO Surgical Safety Checklist is not designed for procedures outside the theatre environment and therefore this document is designed to be a procedure-specific safety checklist for TOE. It has been endorsed for use by the British Society of Echocardiography and the Association of Cardiothoracic Anaesthetists.