Echocardiography and the neonatologist

Targeted Neonatal Echocardiography Performed by Nurse Practitioners in the NICU: Attitudes and Perceptions of the Healthcare Team

BACKGROUND

Targeted neonatal echocardiography (TNE) and hemodynamic consultation have typically been performed by physicians. The Stollery Children's Hospital neonatal intensive care unit (NICU) expanded their TNE training program to include neonatal nurse practitioners (NNPs), the first in North America.

PURPOSE

This study examines the thoughts and perceptions of clinicians about the incorporation of NNPs providing TNE and hemodynamic consultation and investigates key facilitators and challenges for consideration when planning future training, expansion of service in Edmonton, or beyond.

METHODS

In this descriptive study using qualitative methodology, purposive sampling was used to invite NICU clinicians to participate. Using a semistructured topic guide, a focus group and 2 individual interviews were conducted.

RESULTS

Participants were supportive of NNPs. Advantages included increased access to service, acquisition and retention of skills, provision of patient-centered care, and leveraged interpersonal relationships in the decision-making process. Key aspects of program expansion included climate and culture of the NICU, presence of adequate patient volume, and resources to support training.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Support across disciplines and the collaborative working nature of the NICU are key factors in the success of the program's development and implementation. Benefits of having NNPs on the TNE team were clearly expressed. Benefits to the health system included rapid access to hemodynamic information allowing for care based on specific pathophysiology and additional local capacity to perform TNE and reducing demand on other trained providers. Additional research could consider parental views of NNPs performing TNE and hemodynamic consultation as well as the accuracy of diagnosis between the NNPs and physician group.

Educational Impact of Targeted Neonatal Echocardiography and Hemodynamics Programs on Neonatal-Perinatal Medicine Fellows

OBJECTIVE

Targeted neonatal echocardiography (TNE) is a real-time cardiac imaging modality used by a hemodynamics program to aid in diagnosis, treatment, and monitoring of neonatal cardiovascular illness. This study aimed to describe trainees' perspectives on existing hemodynamics education and perceived impacts of TNE and hemodynamics services on their education.

STUDY DESIGN

This was a mixed quantitative and qualitative study that surveyed neonatal-perinatal medicine (NPM) fellow trainees in Canada and the United States, at programs both with and without a hemodynamics service.

RESULTS

Ninety-two fellows responded to the survey, of whom 24 (26%) were enrolled in a program with an active hemodynamics service, 64 (70%) were training at a program without a hemodynamics service, and 4 (4%) were unsure. Trainees at centers with a hemodynamics service were more satisfied with their cardiovascular physiology education (91 vs. 69%, p = 0.040). Twenty-five percent of all trainees felt they do not have sufficient hemodynamics training to prepare them for independent practice. Areas of knowledge gaps were identified. Bedside teaching combined with didactic teaching was identified as useful means of teaching.

CONCLUSION

Most trainees believed that TNE and a hemodynamics service are valuable educational assets. Thoughtful curriculum design for real-time and consolidation learning, with specific emphasis on content gaps, should be considered.

KEY POINTS

· NPM Fellows perceive TNE & Neonatal Hemodynamics service as a valuable educational opportunity.. · Incorporation of TNE/Hemodynamics teaching into NPM curriculum can enrich trainee experience.. · Combining bedside and classroom teaching is key to successful cardiovascular training..

Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study

OBJECTIVE

Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service.

STUDY DESIGN

This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013-2016) versus Epoch-2 (TNE 2018-2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related) RESULTS:  A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2.

CONCLUSION

With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era.

KEY POINTS

· TNE allows comprehensive hemodynamic assessment of PDA.. · Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.. · Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need..

Point-of-Care Ultrasound Educational Development in Australasia: A Scoping Review

Point-of-care ultrasound (PoCUS) technology is evolving rapidly and is being adopted by many health professionals in their clinical practice. Ultrasound is a complex skill requiring dedicated training. Appropriate integration of ultrasound education into medical, surgical, nursing and allied health professions is a current challenge worldwide. There are patient safety implications for use of ultrasound without adequate training and frameworks. The purpose of the review was to overview the status of PoCUS education in Australasia; investigate what is being taught and learned about ultrasound across the health professions; and identify potential gaps. The review was limited to postgraduate and qualified health professionals with established or emerging clinical use for PoCUS. A scoping review methodology was used to include literature in peer-reviewed articles, policies, guidelines, position statements, curricula and online material relating to ultrasound education. One hundred thirty-six documents were included. The literature revealed heterogeneity in ultrasound teaching and learning across the health professions. Several health professions lacked any defined scopes of practice, policies or curricula. Significant investment in resourcing ultrasound education is required to address the current needs in Australia and New Zealand.

Targeted Neonatal Echocardiography in Patients With Hemodynamic Instability

Targeted neonatal echocardiography (TNE) has been increasingly used at the bedside in neonatal care to provide an enhanced understanding of physiology, affecting management in hemodynamically unstable patients. Traditional methods of bedside assessment, including blood pressure, heart rate monitoring, and capillary refill are unable to provide a complete picture of tissue perfusion and oxygenation. TNE allows for precision medicine, providing a tool for identifying pathophysiology and to continually reassess rapid changes in hemodynamics. A relationship with cardiology is integral both in training as well as quality assurance. It is imperative that congenital heart disease is ruled out when utilizing TNE for hemodynamic management, as pathophysiology varies substantially in the assessment and management of patients with congenital heart disease. Utilizing TNE for longitudinal hemodynamic assessment requires extensive training. As the field continues to grow, guidelines and protocols for training and indications are essential for ensuring optimal use and providing a platform for quality assurance.

Clinical and echocardiographic characteristics associated with evolution of patent ductus arteriosus in preterm neonates: A prospective cohort study

BACKGROUND

In preterm infants, persistence of ductus arteriosus is an important medical condition. Functional echocardiography for patent ductus arteriosus (PDA) may guide clinical decision-making regarding treatment requirement strategies. Objectives of the study were to assess the trends of clinical and functional echocardiographic parameters with evolution of ductus arteriosus in babies≤1250 gm of birth weight and to evaluate whether there is any association of these parameters with persistence of ductus.

METHODS

In this prospective observational study, recruited babies were assessed serially for clinical events and functional echocardiography. Babies were classified into three groups: without PDA, with PDA but PDA spontaneously closed (within 7 days) and persistent PDA.

RESULT

We included 143 infants (Birth weight 1017±179 g, gestational age 30.8±2.7 weeks). Out of 60 babies with PDA, PDA failed to close spontaneously in first week in 32 (53.4 %) infants. PDA Doppler flow pattern on day 3 was found to be one of the most significant markers for future ductus. The highest frequency of growing pattern (37.5%) and pulsatile pattern (59.4%) was seen in persistence ductus group. PDA diameter and LA/Ao ratio were found strongly correlated with all other variables except E/A ratio.

CONCLUSION

We noticed persistence of ductus in preterm infants had significant clinical and echocardiographic association. PDA doppler flow pattern on day 3 was found to be a significant marker for future behaviour of ductus. Significant correlation was found among individual functional echocardiographic parameters in babies with PDA. This would guide judicious treatment of PDA in preterm neonates.

Neonatologist Performed Echocardiography for Evaluating the Newborn Infant

The interest in the use of cardiac ultrasound for hemodynamic evaluation in neonates has increased in the last decades. Several overlapping terms exists, and a non-comprehensive list includes point-of-care ultrasound, clinician-performed ultrasound, focused cardiac ultrasound, targeted neonatal echocardiography, and neonatologist performed echocardiography. This review will use the term neonatologist performed echocardiography. Neonatologist performed echocardiography is primarily echocardiography to obtain snapshots of hemodynamics and heart function, usually as repeated exams during intensive care. It provides the neonatologist with in-depth information on the hemodynamics not available by blood pressure, pulse oximetry, capillary refill time, and various blood tests. The review provides a brief overview of some relevant methods for assessment of hemodynamics and heart function. It does not discuss training, implementation, accreditation, and certification nor in-depth technical aspects and detailed use of neonatologist performed echocardiography. If the information obtainable by neonatologist performed echocardiography had been accessible easily (e.g., via a sensor put on the neonate similarly to a pulse oximeter), neonatologist performed echocardiography would have been more widely used. Acquiring skills for neonatologist performed echocardiography take time and resources. Future developments probably include a stronger focus on education, training, and certification. It is likely that echocardiographic methods will evolve further, probably involving establishing new indexes and methods and implementing artificial intelligence in the analyses procedure to improve accuracy and workflow. It is important to acknowledge that neonatologist performed echocardiography is not a therapeutic intervention; it is a diagnostic tool providing additional information.

Real-time ultrasound for tip location of umbilical venous catheter in neonates: a pre/post intervention study

BACKGROUND

Recent guidelines advocate the use of real-time ultrasound to locate umbilical venous catheter tip. So far, training programs are not well established.

METHODS

A pre/post interventional study was carried out in our tertiary neonatal intensive care unit centre to evaluate the efficacy of a training protocol in the use of real-time ultrasound. Primary outcome was the percentage in the use of real-time ultrasound.

RESULTS

Fifty-four patients were enrolled. The use of real-time ultrasound for tip location significantly increased after the training program (15.3% vs 89.2%, p <  0.0001). After the training the tip of the catheters was more frequently placed at the junction of the inferior vena cava and right atrium (75% vs 30.7%, p = 0.0023). Twenty-two catheters were also evaluated with serial scans during the intervention phase to assess migration rate which was 50%.

CONCLUSION

a multimodal, targeted training on the use of real-time ultrasound for umbilical venous catheter placement is feasible. Real-time ultrasound is easily teachable, increases the number of umbilical venous catheters placed in a correct position, reduces the number of line manipulations and the need of chest-x-rays.

Cardiovascular management following hypoxic-ischemic encephalopathy in North America: need for physiologic consideration

BACKGROUND

Hypotension and hypoxemic respiratory failure are common among neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Right ventricular (RV) dysfunction is associated with adverse neurodevelopment. Individualized management utilizing targeted neonatal echocardiography (TnECHO) may enhance care.

METHODS

We evaluated the influence of TnECHO programs on cardiovascular practices in HIE/TH patients utilizing a 77-item REDCap survey. Nominated representatives of TnECHO (n = 19) or non-TnECHO (n = 96) sites were approached.

RESULTS

Seventy-one (62%) sites responded. Baseline neonatal intensive care unit characteristics and HIE volume were comparable between groups. Most centers monitor invasive blood pressure; however, we identified 17 unique definitions of hypotension. TnECHO centers were likelier to trend systolic/diastolic blood pressure and request earlier echocardiography. TnECHO responders were less likely to use fluid boluses; TnECHO responders more commonly chose an inotrope first-line, while non-TnECHO centers used a vasopressor. For HRF, TnECHO centers chose vasopressors with a favorable pulmonary vascular profile. Non-TnECHO centers used more dopamine and more extracorporeal membrane oxygen for patients with HRF.

CONCLUSIONS

Cardiovascular practices in neonates with HIE differ between centers with and without TnECHO. Consensus regarding the definition of hypotension is lacking and dopamine use is common. The merits of these practices among these patients, who frequently have comorbid pulmonary hypertension and RV dysfunction, need prospective evaluation.

IMPACT

Cardiovascular care following HIE while undergoing therapeutic hypothermia varies between centers with access to trained hemodynamics specialists and those without. Because cardiovascular dysfunction is associated with brain injury, precision medicine-based care may be an avenue to improving outcomes. Therapeutic hypothermia has introduced new physiological considerations and enhanced survival. It is essential that hemodynamic strategies evolve to keep pace; however, little literature exists. Lack of consensus regarding fundamental definitions (e.g., hypotension) highlights the importance of collaboration among the scientific community to advance the field. The value of enhanced cardiovascular care guided by hemodynamic specialists requires prospective evaluation.

Neonatologist performed echocardiography (NPE) in Italian neonatal intensive care units: a national survey

Background

Neonatologist performed echocardiography (NPE) has increasingly been used to assess the hemodynamic status in neonates. Aim of this survey was to investigate the utilization of NPE in Italian neonatal intensive care units (NICUs).

Methods

We conducted an on-line survey from June to September 2017. A questionnaire was developed by the Italian neonatal cardiology study group and was sent to each Italian NICU.

Results

The response rate was 77%. In 94% of Italian NICUs functional echocardiography was used by neonatologists, cardiologists or both (57, 15 and 28% respectively). All the respondents used NPE in neonates with patent ductus arteriosus and persistent pulmonary hypertension, 93% in neonates with hypotension or shock, 85% in neonates with perinatal asphyxia, 78% in suspicion of cardiac tamponade, and 73% for line positioning.

In 30% of center, there was no NPE protocol. Structural echocardiography in stable and critically ill neonates was performed exclusively by neonatologists in 46 and 36% of center respectively.

Conclusions

NPE is widely used in Italian NICUs by neonatologists. Structural echocardiography is frequently performed by neonatologists. Institutional protocols for NPE are lacking. There is an urgent need of a formal training process and accreditation to standardize the use of NPE.

Prediction of ductus closure and development of adverse clinical outcome by functional echocardiography in very low birth weight newborn

OBJECTIVE

To evaluate the role of functional echocardiography for prediction of patent ductus arteriosus (PDA) closure and development of adverse outcome in very low birth weight newborn.

METHODS AND STUDY DESIGN

Functional echocardiography was done in 143 neonates with birth weight less than 1250 g on day 3. Nine echocardiographic parameters were analyzed for babies with PDA for prediction of spontaneous closure and development of one or more adverse outcomes (bronchopulmonary dysplasia, necrotizing enterocolitis≥stage 2 and intraventricular hemorrhage > grade 2) during hospital stay.

RESULT

The mean (±SD) birthweight and gestational age of the cohort were 1017 (±17) g and 30.8 (±2.7) weeks. PDA was found in 60 (41.9%) babies on day 3 among the recruited babies. Binary logistic regression model showed strong prediction ability of early (day 3) functional echocardiography markers in predicting future spontaneous closure of PDA and development of one or more adverse clinical outcome. In multivariate analysis, abnormal flow pattern (growing or pulsatile) was found to have increased risk for persistence of PDA (adjusted OR 22.9, CI 1.97-269) in comparison to PDA with closing/bidirectional pattern.

CONCLUSION

Early functional echocardiography, especially the flow pattern, is useful for prediction of PDA closure. Adverse clinical outcome prediction is possible with functional echocardiography markers when combined with gestational age and PDA closure status.

Intra- and Inter-rater Agreement of Superior Vena Cava Flow and Right Ventricular Outflow Measurements in Late Preterm and Term Neonates

OBJECTIVES

To explore the intra- and inter-rater agreement of superior vena cava (SVC) flow and right ventricular (RV) outflow in healthy and unwell late preterm neonates (33-37 weeks' gestational age), term neonates (≥37 weeks' gestational age), and neonates receiving total-body cooling.

METHODS

The intra- and inter-rater agreement (n = 25 and 41 neonates, respectively) rates for SVC flow and RV outflow were determined by echocardiography in healthy and unwell late preterm and term neonates with the use of Bland-Altman plots, the repeatability coefficient, the repeatability index, and intraclass correlation coefficients.

RESULTS

The intra-rater repeatability index values were 41% for SVC flow and 31% for RV outflow, with intraclass correlation coefficients indicating good agreement for both measures. The inter-rater repeatability index values for SVC flow and RV outflow were 63% and 51%, respectively, with intraclass correlation coefficients indicating moderate agreement for both measures.

CONCLUSIONS

If SVC flow or RV outflow is used in the hemodynamic treatment of neonates, sequential measurements should ideally be performed by the same clinician to reduce potential variability.

Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring

Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.

Golden hour of neonatal life: Need of the hour

"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.

Extensive use of vasodilator agents and functional echocardiography to monitor extremely-low-birth-weight infants in Japan

National surveys were conducted in Japan to assess the current practices for circulatory management of extremely-low-birth-weight infants (ELBWIs) in acute phases. Approximately 80 and 100 institutions were surveyed in 2006 and 2011, respectively. Echocardiography was identified as an important diagnostic tool at 95% of the surveyed institutions. Furthermore, 74% of the institutions survey in 2011 used vasodilator agents. In 2011, the mean velocity of circumferential fiber shortening (mVcfc) and left ventricular end-systolic wall stress (ESWS) were used by 60% of the surveyed institutions to evaluate the relationship between afterload of the left ventricle and left ventricular contractility. Overall, the data collected from these national surveys clarified the current practices for circulatory management of ELBWIs in Japan, particularly the use of echocardiography and cardiovascular agents, including catecholamines and vasodilators.

Accurate diagnosis of CHD by Paediatricians with Expertise in Cardiology

Introduction Paediatricians with Expertise in Cardiology assess children with a full history, examination, and often perform an echocardiogram. A minority are then referred to an outreach clinic run jointly with a visiting paediatric cardiologist. The accuracy of the echocardiography diagnosis made by the Paediatrician with Expertise in Cardiology is unknown. Materials and methods We conducted a retrospective review of clinic letters for children seen in the outreach clinic for the first time between March, 2004 and March, 2011. Children with CHD diagnosed antenatally or elsewhere were excluded. We recorded the echocardiography diagnosis made by the paediatric cardiologist and previously by the Paediatrician with Expertise in Cardiology.

RESULTS

The Paediatrician with Expertise in Cardiology referred 317/3145 (10%) children seen in the local cardiac clinics to the outreach clinic over this period, and among them 296 were eligible for inclusion. Their median age was 1.5 years (range 1 month-15.1 years). For 244 (82%) children, there was complete diagnostic agreement between the Paediatrician with Expertise in Cardiology and the paediatric cardiologist. For 29 (10%) children, the main diagnosis was identical with additional findings made by the paediatric cardiologist. The abnormality had resolved in 17 (6%) cases by the time of clinic attendance. In six (2%) patients, the paediatric cardiologist made a different diagnosis. In total, 138 (47%) patients underwent a surgical or catheter intervention. Discussion Paediatricians with Expertise in Cardiology can make accurate diagnoses of CHD in children referred to their clinics. This can allow effective triage of children attending the outreach clinic, making best use of limited specialist resources.

A review of superior vena cava flow measurement in the neonate by functional echocardiography

Neonatologists have begun using superior vena cava flow as assessed by functional echocardiography to facilitate real-time decision-making on cardiovascular care. This review aims to describe the basis of the technique, summarise the evidence for its use and compare the technique to existing clinical, biochemical and radiological techniques for assessing neonatal circulatory status.

CONCLUSION

Although echocardiographic measurements of superior vena cava flow, like other measures of perfusion, are not perfect, their noninvasive nature and ability to facilitate real-time decision-making means that at present, they remain the best available methodology of monitoring central perfusion in the neonatal population.

Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It?

Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.

Near-Infrared Spectroscopy: The New Must Have Tool in the Intensive Care Unit?

Standard hemodynamic monitoring such as blood pressure and pulse oximetry may only provide a crude estimation of organ perfusion in the critical care setting. Near-infrared spectroscopy (NIRS) is based on the same principle as a pulse oximeter and allows continuous noninvasive monitoring of hemoglobin oxygenation and deoxygenation and thus tissue saturation "StO2" This review aims to provide an overview of NIRS technology principles and discuss its current clinical use in the critical care setting. The study selection was performed using the PubMed database to find studies that investigated the use of NIRS in both the critical care setting and in the intensive care unit. Currently, NIRS in the critical care setting is predominantly being used for infants and neonates. A number of studies in the past decade have shown promising results for the use of NIRS in surgical/trauma intensive care units during shock management as a prognostic tool and in guiding resuscitation. It is evident that over the past 2 decades, NIRS has gone from being a laboratory fascination to an actively employed clinical tool. Even though the benefit of routine use of this technology to achieve better outcomes is still questionable, the fact that NIRS is a low-cost, noninvasive monitoring modality improves the attractiveness of the technology. However, more research may be warranted before recommending its routine use in the critical care setting.

Functional Neonatal Echocardiography: Indian Experience

INTRODUCTION

Functional echocardiography, as opposed to echocardiography as performed by the cardiologist, is the bedside utilization of cardiac ultrasound to take after functional and haemodynamic changes longitudinally. Information reflecting cardiovascular capacity and systemic and pulmonary blood flow in sick preterm and term neonates can be observed utilizing this strategy. Information is lacking on its use in neonatal units in India.

AIM

To characterize the impact of Functional neonatal echocardiography (FnECHO) programme on decision making in a tertiary care centre in India by evaluating its frequency of use, patient characteristics, and indications.

MATERIALS AND METHODS

Prospective observational study of neonates in a tertiary Neonatal Intensive Care Unit (NICU) in Pune (India) from February 2014 to January 2015. All the neonates undergoing FnECHO during this 12 month period based on clinical findings were included in the study. Data extracted from the review of the clinical notes included gestational age, birth-weight, mode of delivery, Apgar scores, details of respiratory and cardiovascular support, timing of FnECHO and any other clinical diagnosis. The findings of echocardiography were recorded and correlated with the clinical and other laboratory or X-ray findings. If these findings indicated a change in management, it was instituted.

RESULTS

A total of 348 echocardiographic studies were performed in 187 neonates (mean 1.86; SD 2.02). The most frequent indication was Patent Ductus Arteriosus (PDA) assessment (n= 174, 50%), followed by haemodynamic instability (n=43, 12.36%). The results of FnECHO modified treatment in 148 cases (42.50%) in the form of addition and/or change in the treatment or avoidance of unnecessary intervention.

CONCLUSION

FnECHO is frequently used in the NICU setting and may be a useful tool to guide treatment. PDA assessment and haemodynamic instability are the most frequent indications. To validate its usefulness, well co-ordinated large prospective studies are needed.

A telemedicine network for remote paediatric cardiology services in north-east Brazil

Problem

Providing health care for children with congenital heart diseases remains a major challenge in low- and middle-income countries.

Approach

In October 2011, the Government of Paraíba, Brazil, established a paediatric cardiology network in partnership with the nongovernmental organization Círculo do Coração. A cardiology team supervised all network activities, using the Internet to keep in contact with remote health facilities. The network developed protocols for screening heart defects. Echocardiograms were performed by physicians under direct online supervision of a cardiologist; alternatively, a video recording of the examination was subsequently reviewed by a cardiologist. Cardiovascular surgeons came to a paediatric hospital in the state capital once a week to perform heart surgeries.

Local setting

Until 2011, the State of Paraíba had no structured programme to care for children with heart disease. This often resulted in missed or late diagnosis, with adverse health consequences for the children.

Relevant changes

From 2012 to 2014, 73 751 babies were screened for heart defects and 857 abnormalities were identified. Detection of congenital heart diseases increased from 4.09 to 11.62 per 1000 live births (P < 0.001). Over 6000 consultations and echocardiograms were supervised via the Internet. Time to diagnosis, transfers and hospital stays were greatly reduced. A total of 330 operations were carried out with 6.7% (22/330) mortality.

Lessons learnt

Access to an echocardiography machine with remote supervision by a cardiologist improves the detection of congenital heart disease by neonatologists; virtual outpatient clinics facilitate clinical management; the use of Internet technology with simple screening techniques allows resources to be allocated more efficiently.

Neonatal echocardiography

Echocardiography is a technique within neonatal care increasingly used in acute management of patients because of its potential to guide care and hemodynamic management. However, its use continues to provoke controversy, as it was originally within the purview of pediatric cardiologists trained to identify structural as well as functional heart disease. This article examines some of the echocardiographic techniques available to the neonatologist, their applications, and the concerns surrounding their use on neonatal units.

Right ventricular function in preterm and term neonates: reference values for right ventricle areas and fractional area of change

BACKGROUND

Right ventricular (RV) fractional area of change (FAC) is a quantitative two-dimensional echocardiographic measurement of RV function. RV FAC expresses the percentage change in the RV chamber area between end-diastole (RV end-diastolic area [RVEDA]) to end-systole (RV end-systolic area [RVESA]). The objectives of this study were to determine the maturational (age- and weight-related) changes in RV FAC and RV areas and to establish reference values in healthy preterm and term neonates.

METHODS

A prospective longitudinal study was conducted in 115 preterm infants (23-28 weeks' gestational age at birth, 500-1,500 g). RV FAC was measured at 24 hours of age, 72 hours of age, and 32 and 36 weeks' postmenstrual age (PMA). The maturational patterns of RVEDA, RVESA, and RV FAC were compared with those in 60 healthy full-term infants in a cross-sectional study (≥37 weeks, 3.5 ± 1 kg), who underwent echocardiography at birth (n = 25) and 1 month of age (n = 35). RVEDA and RVESA were traced in the RV-focused apical four-chamber view, and FAC was calculated using the formula 100 × [(RVEDA - RVESA)/RVEDA)]. Premature infants who developed chronic lung disease or had clinically and hemodynamically significant patent ductus arteriosus were excluded (n = 55) from the reference values. Intra- and interobserver reproducibility analysis was performed.

RESULTS

RV FAC ranged from 26% at birth to 35% by 36 weeks' PMA in preterm infants (n = 60) and increased almost 2 times faster in the first month of age compared with healthy term infants (n = 60). Similarly, RVEDA and RVESA increased throughout maturation in both term and preterm infants. RV FAC and RV areas were correlated with weight (r = 0.81, P < .001) but were independent of gestational age at birth (r = 0.3, P = .45). RVEDA and RVESA were correlated with PMA in weeks (r = 0.81, P < .001). RV FAC trended lower in preterm infants with bronchopulmonary dysplasia (P = .04) but was not correlated with size of patent ductus arteriosus (P = .56). There was no difference in RV FAC based on gender or need for mechanical ventilation.

CONCLUSIONS

This study establishes reference values of RV areas (RVEDA and RVESA) and RV FAC in healthy term and preterm infants and tracks their maturational changes during postnatal development. These measures increase from birth to 36 weeks' PMA, and this is reflective of the postnatal cardiac growth as a contributor to the maturation of cardiac function These measures are also linearly associated with increasing weight throughout maturation. This study suggests that two-dimensional RV FAC can be used as a complementary modality to assess global RV systolic function in neonates and facilitates its incorporation into clinical pediatric and neonatal guidelines.

Cardiac sonography by the neonatologist: clinical usefulness and educational perspective

OBJECTIVES

Clinicians are increasingly using cardiac sonography in clinical practice. The objectives of this study were to assess the current state of clinician-performed cardiac sonography practice in the Australia-New Zealand region, with particular reference to the scope of clinical practice and type of training offered.

METHODS

A prospective cross-sectional survey was conducted, and an electronic Web-based questionnaire was e-mailed to neonatologists and advanced trainees in the region. Information was collected on respondents (demographics, clinician-performed cardiac sonography experience, and opinions), equipment use, and training frameworks. Main outcome measures ascertained were clinical use and educational perspectives.

RESULTS

The overall survey response rate was 64% (113 of 176). Eighty-five percent of respondents reported that clinician-performed cardiac sonography was performed in their units, most commonly to use the physiologic information obtained in conjunction with clinical information to refine decision making. The most common clinical indication was evaluation of a hemodynamically relevant ductus arteriosus. A dedicated echocardiographic machine was available to 80% of respondents. Most respondents reported "self-directed" learning as the most common method of training. More than 85% of respondents reported having access to either on-site or off-site pediatric cardiology services.

CONCLUSIONS

Widespread availability and use of clinician-performed cardiac sonography in units across the Australia-New Zealand region was noted. The need for a structured training program was identified.

New developments in paediatric cardiac functional ultrasound imaging

Ultrasound imaging can be used to estimate the morphology as well as the motion and deformation of tissues. If the interrogated tissue is actively deforming, this deformation is directly related to its function and quantification of this deformation is normally referred as 'strain imaging'. Tissue can also be deformed by applying an internal or external force and the resulting, induced deformation is a function of the mechanical tissue characteristics. In combination with the load applied, these strain maps can be used to estimate or reconstruct the mechanical properties of tissue. This technique was named 'elastography' by Ophir et al. in 1991. Elastography can be used for atherosclerotic plaque characterisation, while the contractility of the heart or skeletal muscles can be assessed with strain imaging. Rather than using the conventional video format (DICOM) image information, radio frequency (RF)-based ultrasound methods enable estimation of the deformation at higher resolution and with higher precision than commercial methods using Doppler (tissue Doppler imaging) or video image data (2D speckle tracking methods). However, the improvement in accuracy is mainly achieved when measuring strain along the ultrasound beam direction, so it has to be considered a 1D technique. Recently, this method has been extended to multiple directions and precision further improved by using spatial compounding of data acquired at multiple beam steered angles. Using similar techniques, the blood velocity and flow can be determined. RF-based techniques are also beneficial for automated segmentation of the ventricular cavities. In this paper, new developments in different techniques of quantifying cardiac function by strain imaging, automated segmentation, and methods of performing blood flow imaging are reviewed and their application in paediatric cardiology is discussed.

Prematurity and congenital heart disease

Significant advances in technology and therapy have led to dramatic improvements in the survival of preterm babies over the last 2 decades. Similarly, improvements in surgical and cardiac intensive care techniques have increased the feasibility of supporting even very small babies to the point of surgical repair, leading some to adopt an approach of early and complete surgical repair in preterm infants, with the aim of minimizing potential preoperative morbidity associated with extended medical management or surgical palliation. (1,2) However, multiple diagnostic and therapeutic challenges complicate the care of premature infants. Major errors in echocardiography are more common in neonates weighing less than 2.5 kg, (3) and the ideal timing and type of surgical intervention in premature infants remains unknown. These problems are compounded by the need for critical care practices that optimize management of immature cardiopulmonary, gastrointestinal, and neurological systems. This review will summarize some of the recent advances in neonatal and perinatal medicine, which have the potential to contribute to improved management of preterm infants with critical cardiac disease.

Benefits of predischarge echocardiography service for postnatal heart murmurs

AIM

To review the findings and outcomes of predischarge echocardiography service for postnatal heart murmurs provided by neonatologists.

METHODS

We retrospectively reviewed all predischarge echocardiograms performed on babies from the postnatal wards (PNW) over the last 3 years. We evaluated the indications, median age, findings and outcome.

RESULTS

A total of 408 echocardiograms were performed on 350 babies on the PNW. The most common indication was presence of a murmur (58%). In babies with a heart murmur, 26% had a normal echocardiogram, 2% had major structural heart defects, 38% had minor structural heart defects and 34% had transient circulatory changes. 32% were discharged with no follow-up, 28% were followed up in the local cardiac clinic and 40% were referred to the cardiologist.

CONCLUSION

Predischarge echocardiography service for postnatal heart murmurs provided by neonatologists has the benefit of providing an early diagnosis, counselling of the parents and arranging appropriate follow-up. It helps to triage the referrals to the cardiologist. We felt that we were able to alleviate parental anxieties by providing a definitive diagnosis and written information prior to discharge from hospital. We strongly believe that this service should only be provided by those appropriately trained and skilled in echocardiography.

Functional echocardiographic assessment of myocardial performance in anemic premature infants: a pilot study

This prospective observational study conducted in a neonatal intensive care unit aimed to evaluate echocardiographic changes provoked by anemia and transfusion of packed red blood cells (pRBCs) in premature infants. In this study, 32 anemic premature infants had serial echocardiographic assessment of left ventricular (LV) systolic performance, LV preload, and afterload immediately before, within 48 h, and up to 120 h after the transfusion of pRBCs. Pretransfusional evaluations also were compared with similar assessments of 71 nonanemic inpatient premature infants analogous for sex, gestational age at birth, and postnatal age. Left ventricular systolic performance was estimated from fractional shortening, LV output, and LV myocardial performance index (LVMPI). The LV preload was estimated from the LV end-diastolic dimension and the ratio of left atrium-to-aortic root dimension (LA/Ao ratio). The LV afterload was estimated from end-systolic wall stress. The LVMPI was found to decrease with increasing corrected gestational age in both the nonanemic (R = 0.173; p = 0.03) and anemic (R = 0.460; p = 0.007) infants. The LVMPI was the only index that changed after transfusion of pRBCs, decreasing in the younger anemic infants (p = 0.011) and increasing in the older anemic infants (p = 0.012). Finally, a significant inverse relationship between pre- and posttransfusional LVMPI values (R = 0.730; p < 0.001) was noted. The LVMPI may allow for identification of preterm infants more likely to be helped by transfusion of pRBCs.

The ductus arteriosus: a refined approach!

Although ongoing patency of the ductus arteriosus is common in small extremely preterm infants, consensus is lacking regarding its clinical significance and treatment strategies. Literature regarding likelihood of spontaneous closure, impact on neonatal morbidity and long-term outcomes, and adverse effects of intervention has led to uncertainty as to the best course of action. Enhancing the determination of hemodynamic significance and refining patient selection for therapeutic intervention will streamline the decision-making process. Targeted neonatal echocardiography performed by the clinician has gained popularity worldwide, and preliminary data show that it has the potential to optimize patient outcomes. We review the arguments for and against medical and surgical therapy, explore how targeted neonatal echocardiography used in conjunction with biomarkers may refine the treatment approach, and consider future directions in the field.

Has the time come to use near-infrared spectroscopy as a routine clinical tool in preterm infants undergoing intensive care?

Several instruments implementing spatially resolved near-infrared spectroscopy (NIRS) to monitor tissue oxygenation are now approved for clinical use. The neonatal brain is readily assessible by NIRS and neurodevelopmental impairment is common in children who were in need of intensive care during the neonatal period. It is likely that an important part of the burden of this handicap is due to brain injury induced by hypoxia-ischaemia during intensive care. In particular, this is true for infants born extremely preterm. Thus, monitoring of cerebral oxygenation has considerable potential benefit in this group. The benefit, however, should be weighed against the disturbance to the infant, against the limitations imposed on clinical care and against costs. The ultimate way of demonstrating the 'added value' is by a randomized controlled trial. Cerebral oximetry must reduce the risk of a clinically relevant endpoint, such as death or neurodevelopmental handicap. We estimate that such a trial should recruit about 4000 infants to have the power to detect a reduction in brain injury by one-fifth. This illustrates the formidable task of providing first-grade evidence for the clinical value of diagnostic methods. Is it a window of opportunity for the establishment of a rational basis before another technology is added to an already overly complex newborn intensive care?

Early functional echocardiogram and inhaled nitric oxide: usefulness in managing neonates born following extreme preterm premature rupture of membranes (PPROM)

AIM

Poor neonatal outcome of preterm premature rupture of membranes (PPROM) < 24 weeks' gestational age (GA) is probably a result of abnormalities in both airway and vascular developments, ventilation perfusion mismatch, and possibly persistent pulmonary hypertension of the newborn (PPHN). Perinatal mortality of 50-90% has been reported in the past, with recent literature reporting significant improvement in neonatal survival. We report our 8-year experience in this group of infants using early diagnostic functional echocardiography (fECHO), high-frequency ventilation (HFV) and inhaled nitric oxide (iNO).

METHODS

The obstetric and neonatal databases were searched to identify babies with PPROM (< 20 weeks' gestation) or rupture earlier than 25 weeks for more than 14 days.

RESULTS

Twenty-six infants were identified, of whom 20 were admitted to the neonatal intensive care unit (NICU; mean GA 27.8 weeks, mean birth weight (BW) 1207 g). Early echocardiographic data were available in 12/15 infants requiring mechanical ventilation of whom 10 had evidence of PPHN. All infants who received iNO therapy survived to discharge and only two infants died. Survival to discharge was 69% for the whole cohort of infants and 90% for infants admitted to the NICU. In contrast, for the cohort from pre-iNO and -HFV era, the overall survival to discharge was 62% and 66% for the infants admitted to the NICU.

CONCLUSION

Premature infants with PPROM and presumed severe hypoxemic respiratory failure because of hypoplastic lungs often have significant PPHN and may show improvement in oxygenation after treatment with HFV and iNO. Early fECHO results in earlier identification and treatment of infants with PPHN in this high-risk group.

Ultrasound-guided umbilical catheter insertion in neonates

OBJECTIVE

Umbilical catheter placement is a routine neonatal emergency procedure that has large variability in technical methods. Commonly used methods are unable to accurately estimate insertion lengths, and X-rays cannot always identify malpositioned catheters. In clinical practice, the placement of umbilical lines takes time away from nursing during a critical transition period. Ultrasound is a safe and commonly used tool in the nursery for clinical management of sick neonates and has been shown to readily identify central catheter tip position. In this study, we sought to determine a more time-efficient and accurate means of umbilical catheter placement using bedside ultrasound.

STUDY DESIGN

This is a prospective, randomized, pilot trial of infants of any age or weight admitted to the neonatal intensive care unit who required umbilical catheter placement. Infants were excluded if they had congenital heart disease, abdominal wall defects or had a single umbilical artery. Catheters were placed using either the conventional method, with blinded evaluation of the catheters using ultrasound, or with ultrasound guidance, with input pertaining to catheter tip location. The number of X-rays required to confirm proper positioning, completion time points throughout the procedure and manipulations of the lines were recorded for both groups.

RESULT

Ultrasound use decreased the time of line placement with an average saving of 64 min, as well as decreased the number of manipulations required and X-rays taken to place the catheters. The average X-ray time from request to viewing per X-ray was 40 min for all subjects.

CONCLUSION

Ultrasound-guided umbilical catheter placement is a faster method to place catheters requiring fewer manipulations and X-rays when compared with conventional catheter placement.

Functional echocardiography in assessment of the cardiovascular system in asphyxiated neonates

Perinatal asphyxia commonly results in multi-organ damage, and cardiovascular dysfunction is a frequent association. Myocardial damage, right ventricular dysfunction, abnormal circulatory transition, and impaired autoregulation may all contribute to postnatal neurological damage. Adequate monitoring and appropriate targeted treatment therefore are essential after an asphyxial insult. Standard methods of cardiovascular monitoring in the neonate have limitations. Point of care ultrasound scanning or functional echocardiography offers extra information to assist the clinician in identifying when there is significant cardiovascular impairment, classifying the underlying abnormal physiology and potentially targeting appropriate therapy, thereby optimizing the post-insult cerebral blood flow and oxygen delivery.

Pathophysiology and treatment of septic shock in neonates

Neonatal septic shock is a devastating condition associated with high morbidity and mortality. Definitions for the sepsis continuum and treatment algorithms specific for premature neonates are needed to improve studies of septic shock and assess benefit from clinical interventions. Unique features of the immature immune system and pathophysiologic responses to sepsis, particularly those of extremely preterm infants, necessitate that clinical trials consider them as a separate group. Keen clinical suspicion and knowledge of risk factors will help to identify those neonates at greatest risk for development of septic shock. Genomic and proteomic approaches, particularly those that use very small sample volumes, will increase our understanding of the pathophysiology and direct the development of novel agents for prevention and treatment of severe sepsis and shock in the neonate. Although at present antimicrobial therapy and supportive care remain the foundation of treatment, in the future immunomodulatory agents are likely to improve outcomes for this vulnerable population.

Functional echocardiography; from physiology to treatment

Functional echocardiography (fECHO) is the bedside use of ultrasound to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intra and extracardiac shunts. This review will focus on fECHO as a tool for the clinician to assess the hemodynamic condition of sick neonates and describe situations where fECHO can help determine a pathophysiological choice for cardiovascular support. The very low birth weight infant with hypotension during the first 24h of life, assessment and monitoring of the ductus arteriosus, assessment and response to treatment of infants with pulmonary hypertension, the infant with perinatal asphyxia and the infant with sepsis and cardiovascular compromise are reviewed. Close cooperation with pediatric cardiology, proper logistics and training programs are mandatory to achieve a 24h a day fECHO service run by bedside clinicians.

Does echocardiography facilitate determination of hemodynamic significance attributable to the ductus arteriosus?

INTRODUCTION

The assignment of hemodynamic significance to a patent ductus remains a challenge for neonatal intensivists. The impact is medical uncertainty and ongoing debate as to when treatment should be provided if ever.

DISCUSSION

Patent ductus arteriosus is associated with significant neonatal morbidities including necrotizing enterocolitis and brain injury; causality has not been proven. In addition, there are limited data suggesting a beneficial effect of therapeutic intervention. The inability to accurately differentiate the pathological ductus arteriosus from the innocent ductus arteriosus may contribute, in part, to the lack of scientific evidence of benefit or causality. Our group has previously proposed the need for a staging system to characterize the clinical and echocardiography impact of the ductus arteriosus. This approach requires comprehensive echocardiography evaluation to assess ductal size and the degree of pulmonary overcirculation/systemic hypoperfusion related to the transductal shunt.

CONCLUSION

In this review, we will highlight the evidence for echocardiography markers of hemodynamic significance and speculate as to how they may facilitate improved decision making in the neonatal intensive care unit.