The evolution of cardiac point of care ultrasound for the neonatologist

Applications of Point-of-Care-Ultrasound in Neonatology: A Systematic Review of the Literature

Point-of-care ultrasound (POCUS) integration into neonatology offers transformative potential for diagnostics and treatment, enhancing immediacy and precision of clinical decision-making in this vulnerable patient population. This systematic review aims to synthesize evidence on POCUS applications, benefits, challenges, and educational strategies in neonatology. Literature search was conducted using SPIDER scheme keywords and MeSH terms related to POCUS and neonatology. Studies focusing on POCUS applications, its impact on clinical outcomes, and educational interventions for skill acquisition were included and analyzed using standardized tools, followed by a narrative synthesis of the findings. The search yielded 68 relevant publications, encompassing original research, reviews, and guidelines. POCUS applications varied across cardiovascular, pulmonary, neurological, and abdominal assessments. Key benefits included a reduced need for invasive procedures and rapid bedside diagnosis. Challenges included steep learning curves for clinicians and the need for standardized training and guidelines. Educational strategies highlighted the effectiveness of simulation-based training in enhancing ultrasound proficiency among neonatal care providers. POCUS represents a significant advancement in neonatal medicine, offering benefits for patient care. Addressing identified challenges through comprehensive training programs and developing standardized guidelines is crucial for optimized use. Future research should focus on evaluating educational outcomes and long-term impacts of POCUS integration into neonatal care.

Hemodynamic assessment by neonatologist using echocardiography: Primary provider versus consultation model

Hemodynamic instability is very common in sick neonates and the currently used traditional hemodynamic monitoring tools lack sensitivity and specificity. Hemodynamic evaluation on echocardiography can provide direct information regarding the pathophysiology causing the hemodynamic instability and help the bedside clinician in making a personalized treatment approach based upon the deranged pathophysiology. Assessment of cardiac function and hemodynamics is essential in the management of neonates with cardiorespiratory failure, and hence neonatologist-performed echocardiography is becoming an essential tool in modern neonatal care. Depending on the level and size of the NICU, there is a daily need for echocardiography, and for a subset of sick infants, serial echocardiographic assessments are warranted. Comprehensive guidelines for neonatologists performing echocardiography and targeted neonatal echocardiography have been published providing a framework for training and quality assurance. There has been a significant interest among the providers to learn echocardiography skills. This manuscript explores the various needs of neonatal care providers around echocardiography, the current challenges neonatologists face in learning echocardiography, and how they, especially neonatal fellows, can learn these important skills during their training.

Use of point-of-care ultrasound (POCUS) to monitor neonatal and pediatric extracorporeal life support

Extracorporeal membrane oxygenation (ECMO) is an invasive life support technique that requires a blood pump, an artificial membrane lung, and vascular cannulae to drain de-oxygenated blood, remove carbon dioxide, oxygenate, and return it to the patient. ECMO is generally used to provide advanced and prolonged cardiopulmonary support in patients with refractory acute cardiac and/or respiratory failure. After its first use in 1975 to manage a severe form of meconium aspiration syndrome with resultant pulmonary hypertension, the following years were dominated by the use of ECMO to manage neonatal respiratory failure and limited to a few centers across the world. In the 1990s, evidence for neonatal respiratory ECMO support increased; however, the number of cases began to decline with the use of newer pharmacologic therapies (e.g., inhaled nitric oxide, exogenous surfactant, and high-frequency oscillatory ventilation). On the contrary, pediatric ECMO sustained steady growth. Combined advances in ECMO technology and bedside medical management have improved general outcomes, although ECMO-related complications remain challenging. Point-of-care ultrasound (POCUS) is an essential tool to monitor all phases of neonatal and pediatric ECMO: evaluation of ECMO candidacy, ultrasound-guided ECMO cannulation, daily evaluation of heart and lung function and brain perfusion, detection and management of major complications, and weaning from ECMO support.  Conclusion: Based on these considerations and on the lack of specific guidelines for the use of POCUS in the neonatal and pediatric ECMO setting, the aim of this paper is to provide a systematic overview for the application of POCUS during ECMO support in these populations. What is Known: • Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary support for patients with refractory acute cardiac and/or respiratory failure and requires appropriate monitoring. • Point-of-care ultrasound (POCUS) is an accessible and adaptable tool to assess neonatal and pediatric cardiac and/or respiratory failure at bedside. What is New: • In this review, we discussed the use of POCUS to monitor and manage at bedside neonatal and pediatric patients supported with ECMO. • We explored the potential use of POCUS during all phases of ECMO support: pre-ECMO assessment, ECMO candidacy evaluation, daily evaluation of heart, lung and brain function, detection and troubleshooting of major complications, and weaning from ECMO support.

Echocardiography in the neonatal unit: current status and future prospects

INTRODUCTION

Traditionally echocardiography was used by pediatric cardiologists to diagnose congenital heart defects in neonates. Formalized neonatal hemodynamic fellowships have been established where neonatologists acquire advanced echocardiographic skills to gain anatomical, physiological, and hemodynamic information in real time and utilize this information in making a timely and accurate physiology-based clinical decision.

AREA COVERED

Differences between a comprehensive formal structural echocardiography, neonatologist performed targeted echocardiography and limited assessment on point-of-care-ultrasonography for specific indications have been covered. This article is focused at providing a comprehensive review of the status of echocardiography in the neonatal units, recent advancements and its future prospects in the neonatal intensive care units.

EXPERT OPINION

Comprehensive guidelines providing the scope of practice, a framework for training, and robust clinical governance process for the neonatologist performed targeted echocardiography have been established. In the last decade, echocardiography has emerged as essential vital bedside diagnostic tool in providing high-quality care to the sick infants in the neonatal units, and it has proved to improve the outcomes in neonates. It is now being considered as a modern hemodynamic monitoring tool. Advances in technology, machine learning, and application of artificial intelligence in applications of echocardiography seem promising adjunct tools for rapid assessment in emergency situations.

Secular Trends in Patent Ductus Arteriosus Management in Infants Born Preterm in the National Institute of Child Health and Human Development Neonatal Research Network

We evaluated changes in patent ductus arteriosus (PDA) diagnosis and treatment from 2012 through 2021 in a network of US academic hospitals. PDA treatment decreased among infants born at 26-28 weeks but not among infants born at 22-25 weeks. Rates of indomethacin use and PDA ligation decreased while acetaminophen use and transcatheter PDA closure increased.

The advantage of point-of-care ultrasound in central venous catheterization and related pericardial effusion in infants in the NICU

Background

Central venous catheterization (CVC) is broadly used in neonatal intensive care units (NICUs) for efficient vascular access; however, its establishment and maintenance are associated with numerous risks and complications. Here, we focus on investigating the value of point-of-care ultrasound (POCUS) in the early diagnosis and treatment of pericardial effusion associated with CVC and compare the differences in ultrasound and radiography in CVC localization and monitoring in the NICU.

Methods

Twenty-five infants with CVC-associated pericardial effusion (PCE) who were hospitalized in the NICU of Peking University Third Hospital between January 2013 and March 2023 were retrospectively selected for the study. Data concerning their catheterization characteristics, CVC tip position, clinical and imaging manifestations of PCE, treatments, and prognoses were analyzed.

Results

The mean gestational age of our cohort was 29.3 ± 3.1 weeks, and the mean birth weight was 1,211 ± 237 g. The incidence of CVC-associated PCE was 0.65%, and 80% of PCE cases occurred within 4 days of CVC. After PCE, the most common symptoms were tachypnea (44%) and tachycardia (64%). Chest radiographs revealed cardiothoracic enlargement, and only 2 cases (9.10%) showed a "flask heart". Cardiac ultrasound showed that the catheter tip extended deep into the heart in 72% of infants with PCE. Cardiac insufficiency was observed in 12 cases (48%). Overall, 8 infants (32%) had pericardial tamponade, 7 (87.5%) of whom underwent pericardiocentesis. Overall, 2 (8%) infants died, and the remaining 23 (92%) were cured.

Conclusion

CVC-associated PCE mostly occurs in the early post-catheterization stages (within 4 days) in infants. Some cases may have critical clinical manifestations and progress rapidly, with some even developing pericardial tamponade. A CVC tip being deep into the heart cavity is an important cause of PCE. Compared with chest radiography, point-of-care ultrasound is more accurate for CVC tip positioning and can detect PCE more quickly. Furthermore, it is more advantageous for locating and monitoring CVC-associated PCE. Early identification and diagnosis can effectively reduce fatality rates and improve the prognosis of infants with CVC-associated PCE.

Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review

PURPOSE OF THIS REVIEW

The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology.

RECENT FINDINGS

Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED.

SUMMARY

While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.

Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians

Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.

Update on pre-ECMO evaluation and treatment for term infants in respiratory failure

The epidemiology, diagnostic and management approach to severe hypoxemic respiratory failure in the term and near-term neonate has evolved over time, as has the need for extracorporeal membrane oxygenation (ECMO) support in this patient population. Many patients who historically would have required ECMO support now respond to less invasive therapies, with patients requiring ECMO generally representing a higher risk and more heterogenous group of underlying diagnoses. This review will highlight these changes over time and the current available evidence for the diagnosis and management of these infants, as well as the current indications and relative contraindications to ECMO support when oxygen delivery cannot meet demand with less invasive management.

Neonatal POCUS: Embracing our modern day "stethoscope"

The dramatic technologic advancements seen in ultrasound have accelerated the growth of point-of-care ultrasound (POCUS) in medicine. Neonatology has lagged behind other pediatric and adult specialties in incorporating POCUS into clinical practice despite there being numerous applications in cardiac and non-cardiac arenas. Widely available training programs are aiding in improving this situation but significantly more structure and orchestration for neonatal POCUS dissemination will be needed to fully actualize the potential for POCUS to augment its widespread clinical application.