Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice

Current situation of pediatric intensive care specialty and pediatric intensive care units in Turkey: Results of a national survey

Objective

In this study, we have planned to present the results of a national survey performed to evaluate the last situation of pediatric intensive care specialty and pediatric intensive care units in Turkey.

Material and Methods

We have sent an electronic survey which includes 47 questions about the characteristics of pediatric intensive care units, staff, and equipment to members of the Turkish Society of Pediatric Emergency and Intensive Care via email.

Results

A total of 58 participant units responded to our survey. 93.2% of the centers have tertiary level pediatric intensive care units. There were 841 tertiary level pediatric intensive care beds. There were 35 pediatric intensive care faculty members, 44 pediatric intensive care specialists, and 53 pediatric intensive care fellows. In the participant units, the total number of invasive mechanical ventilators in the units was 806, the number of specific non-invasive mechanical ventilators was 126. It was learned that 79.3% of the centers could apply continuous renal replacement therapy, 84.4% of therapeutic plasma exchange, 46.5% of extracorporeal membrane oxygenation.

Conclusion

We see that the way we have traveled in the 20 years since the establishment of the first units is very important and proud. The number of educated new generation pediatric intensive care specialists and the well-equipped pediatric intensive care units established by these specialists in every region of our country together with the fellowship education applied in many centers make a great contribution to the treatment of the critically ill pediatric patient population in our country.

A Call to Action for the Pediatric Critical Care Community

Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCMPerspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.

Point-of-care ultrasound for the evaluation of venous cannula position in neonatal extracorporeal membrane oxygenation

OBJECTIVE

To assess the ability of point-of-care ultrasound (POCUS) to identify venous cannula position in neonates on extracorporeal membrane oxygenation (ECMO) and compare with conventional imaging.

STUDY DESIGN

Retrospective review of 37 infants on ECMO with 51 POCUS studies between January 2017 and October 2019. Studies were reviewed for identification of venous cannula location and compared with plain radiography and echocardiography. Kappa statistic and predictive values were calculated.

RESULTS

Venous cannula tip position was identified in 90% of POCUS studies. Fifty percent of the cannula tips were malpositioned. Plain radiography, the most commonly used method for evaluating tip position, showed poor agreement (57%) with POCUS (kappa 0.13). There was substantial agreement (89%) between echocardiography and POCUS (kappa 0.78).

CONCLUSION

This study provides preliminary evidence that POCUS is more accurate than plain radiography for the evaluation of ECMO venous cannula position. Adoption of this practice may prevent potentially catastrophic ECMO complications.

Training pediatric residents in point-of-care ultrasound: An assessment of the needs and barriers to acquire the skill

Introduction

The use of point-of-care ultrasound (POCU) is increasing globally. However, owing to the epidemiology of diseases and local management strategies, POCU may not be universally applicable. Before developing a POCU training program, because of limited resources for medical education, it was pivotal to conduct a needs assessment and identify the training barriers.

Methods

This study used a validated paper questionnaire. The survey instrument was distributed to 120 pediatric residents (male 60, female 60) training at our institution to assess their self-reported level of skill in POCU, and their perceptions with regard to the applicability of POCU, measured with a 5-point Likert scale. The skills deficit was measured by subtracting the self-reported level of skills in lung, cardiac, and abdominal POCU from the perceived applicability of POCU.

Results

Fifty-nine residents participated, resulting in a response rate of 50 and 48% (n = 29) for the male group, and 50% (n = 30) for the female group. The level of knowledge and proficiency was low. Scanning for free abdominal fluid was deemed the most applicable (mean 4.2 ± SD 1.1); however, the use of POCU to detect consolidation was considered least applicable (mean 2.7 ± SD 1.3). The skills deficit was highest for an abdominal POCU (mean 2.4 ± SD 1.6) and lowest for lung ultrasound (mean 1.4 ± SD 1.6). Although the majority (n = 48) agreed that this skill was essential, 3 (5%) had no interest, and 39% (n = 23) indicated a lack of time to acquire the skill.

Conclusions

Though pediatric residents in Saudi Arabia agree that POCU is an essential skill, large skill deficits exist, supporting the necessity to provide POCU training. However, there are several barriers to overcome to achieve this.

Point-of-Care Ultrasound Assists in Rapid Diagnosis of T-cell Lymphoblastic Lymphoma in a Young Boy

T-cell lymphoblastic lymphoma (T-cell LBL) is an uncommon diagnosis for acute dyspnea in pediatric emergencies. This case details a 13-year-old boy presenting to the ED with dyspnea, who was diagnosed with T-cell LBL. It was a unique presentation in which there was no obvious mediastinal mass on the examination or primary imaging. As a safe and cost-effective modality for a patient that was too unstable to transfer to the radiology department for computed tomography, point-of-care ultrasound (POCUS) was useful in the patient's rapid assessment for suspected pericardial and pleural effusion. This case highlights the advantage of early utilization of POCUS for pediatric patients with dyspnea.

Regulating Critical Care Ultrasound, It Is All in the Interpretation

Point-of-care ultrasound (POCUS) use is rapidly expanding as a practice in adult and pediatric critical care environments. In January 2020, the Joint Commission endorsed a statement from the Emergency Care Research Institute citing point-of-care ultrasound as a potential hazard to patients for reasons related to training and skill verification, oversight of use, and recordkeeping and accountability mechanisms for clinical use; however, no evidence was presented to support these concerns. Existing data on point-of-care ultrasound practices in pediatric critical care settings verify that point-of-care ultrasound use continues to increase, and contrary to the concerns raised, resources are becoming increasingly available for point-of-care ultrasound use. Many institutions have recognized a successful approach to addressing these concerns that can be achieved through multispecialty collaborations.

Point of care ultrasound in the paediatric acute care setting: Getting to the 'heart' of respiratory distress

Point-of-care ultrasound (POCUS) is a growing interesting tool in the emergency setting. Its usefulness in diagnostic and therapeutic pathway of patients with respiratory distress in addition to clinical evaluation is well established in adult emergency medicine while paediatric specific data, although growing, remain limited. We report a case series of paediatric patients presenting with respiratory distress successfully diagnosed with cardiac dysfunction following POCUS evaluations. Lung POCUS, in combination with cardiac POCUS, is a very useful supplementary diagnostic tool to assess the breathless child and to rapidly identify life-threatening primary etiologies or secondary physiologies. Thus, fast echocardiography is a desirable aid for paediatric emergency physicians and should be supported in all paediatric emergency settings following an adequate training that is mandatory regarding image acquisition and data interpretation.

Point-of-care ultrasound by the pediatrician in the diagnosis and follow-up of community-acquired pneumonia

OBJECTIVES

To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines.

SOURCE OF DATA

A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected.

SYNTHESIS OF DATA

CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance.

CONCLUSIONS

Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

Trends of computed tomography use among children in Finland

Objectives

CT is an essential diagnostic tool in health care. However, CT delivers relatively high levels of radiation which has been associated with an increased risk of childhood cancer. To address this, we evaluated patterns and time trends of CT use among children in Finland during the period in which changes in pediatric CT imaging practices were reported in several countries.

Methods

Data on CTs performed on children younger than 15 years were obtained from Finland’s largest eight hospitals. CT data included the period 1996–2010 with an estimated coverage of more than 80 % of pediatric CT imaging in Finland. Joinpoint regression was used for trends analysis. CT radiation doses were estimated based on a Finnish dosimetry survey.

Results

A total of 48,807 pediatric CTs were performed in 1996–2010. More boys (55.5 %) were scanned than girls (42.8 %). CT numbers increased up to 2002, then decreased significantly (-6.9 % per year, 95 % CI: -10.4 to -3.2) towards 2005 and to a lesser extent thereafter, particularly among younger children. All CT types decreased in recent years, except for chest, spine, and extremities. The frequency of head CTs related to the diagnoses of intracranial injury, migraine and headache decreased towards the end of the study period. The estimated annual average effective dose from the three most common CT examinations was 0.004 mSv per child in the population.

Conclusions

The frequency of pediatric CTs in Finland started to decrease after 2002. Apart from chest and orthopedic CTs, the utilization of pediatric CT imaging declined in recent years, most likely explained by improved awareness of medical radiation risks and reliance on alternative modalities such as MRI and ultrasound.

Lung ultrasound in the neonatal intensive care unit: Review of the literature and future perspectives

Lung ultrasound (LU) has been increasingly used as a point-of-care method in recent years. LU has numerous advantages compared to traditional imaging tools such as chest X-ray (radiography) (CXR): it is faster and portable, does not use ionizing radiation, is performed by the same physician who cares for the patient, and can be repeated to follow the progress of the disease and the response to treatment. There is a large body of evidence that LU has an excellent diagnostic effectiveness compared to CXR, not only in adults and children, but also in neonates. This review article describes how to perform LU, how to interpret findings, and how to use LU to diagnose and differentiate common neonatal pulmonary diseases. Strengths but also limits of the technique are highlighted. Finally, we describe the recent revolutionary role of LU. The development of scoring methods in neonates with respiratory distress syndrome allowed to quantify the severity of the disease and to assist the physician in the clinical management and follow-up.

Aeromedical retrieval for suspected appendicitis in rural and remote paediatric patients

Introduction

The aim of this paper was to describe the characteristics of paediatric patients who underwent an aeromedical retrieval within Australia (gender and Indigenous status) for suspected appendicitis between 1 July 2014 and 30 June 2018 (4 years). By understanding these trends, we hope to further justify the need for point-of-care ultrasound training for clinicians working in rural and remote Australia.

Method

Participants included Royal Flying Doctor Service (RFDS) patients aged 0-18 years (inclusive) who underwent an aeromedical retrieval for suspected appendicitis within Australia. Data were collected and coded on each patient's inflight working diagnosis, using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding method. A combination of descriptive statistics and chi-square analyses was used in data analysis, with significance considered at <0.05.

Results

There were 384 children with a working diagnosis of suspected appendicitis, including 191 (49.7%) males and 193 (50.3%) females, with 133 (34.6%) patients identifying as Aboriginal and/or Torres Strait Islander (hereafter referred to as Indigenous) Australians. The aeromedical retrievals were from rural and remote locations to inner-regional or metropolitan hospitals, with an average distance flown of 339.0 (SD = 206.4) kilometres. The RFDS most frequently retrieved for acute appendicitis (n = 159; 41.4%), acute abdominal pain (n = 127; 33.1%), and unspecified appendicitis (n = 84; 21.9%). There were non-significant (P = 0.9) diagnostic differences between genders. Non-Indigenous patients were overrepresented, compared with Indigenous patients, in relation to a transfer with a diagnosis of acute appendicitis (P = <0.01), whereas Indigenous patients were overrepresented, compared with non-Indigenous patients, in relation to transfers with diagnoses of acute abdomen pain and unspecified appendicitis (P = <0.01).

Conclusion

A significant number of paediatric patients are aeromedically retrieved from rural and remote locations with a diagnosis of appendicitis or acute abdominal pain. Future research should consider whether training in abdominal point-of-care ultrasound reduces retrievals.