Targeted neonatal echocardiography (TNE) consult service in a large tertiary perinatal center in Canada

Evolution and Impact of a Diagnostic Point-of-Care Ultrasound Program in a PICU

OBJECTIVES

To evaluate the impact of point-of-care ultrasound (POCUS) use on clinicians within a PICU and to assess infrastructural elements of our POCUS program development.

DESIGN

Retrospective observational study.

SETTING

Large academic, noncardiac PICU in the United States.

SUBJECTS

Patients in a PICU who had diagnostic POCUS performed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between January 1, 2017, and December 31, 2022, 7201 diagnostic POCUS studies were ordered; 1930 (26.8%) had a quality assurance (QA) record generated in an independent POCUS QA database. The cardiac domain was most frequently imaged (81.0% of ordered studies, 81.2% of reviewed studies). POCUS images changed clinician understanding of pathophysiology in 563 of 1930 cases (29.2%); when this occurred, management was changed in 318 of 563 cases (56.5%). Cardiac POCUS studies altered clinician suspected pathophysiology in 30.1% of cases (472/1568), compared with 21.5% (91/362) in noncardiac studies (p = 0.06). Among cases where POCUS changed clinician understanding, management changed more often following cardiac than noncardiac POCUS (p = 0.02). Clinicians identified a need for cardiology consultation or complete echocardiograms in 294 of 1568 cardiac POCUS studies (18.8%). Orders for POCUS imaging increased by 94.9%, and revenue increased by 159.4%, from initial to final study year. QA database use by both clinicians and reviewers decreased annually as QA processes evolved in the setting of technologic growth and unit expansion.

CONCLUSIONS

Diagnostic POCUS imaging in the PICU frequently yields information that alters diagnosis and changes management. As PICU POCUS use increased, QA processes evolved resulting in decreased use of our initial QA database. Modifications to QA processes are likely necessary as clinical contexts change over time.

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.

Hemodynamic management of congenital diaphragmatic hernia: the role of targeted neonatal echocardiography

Congenital diaphragmatic hernia (CDH) is a major congenital anomaly, resulting from the herniation of abdominal contents into the thoracic cavity, thereby impeding the proper development of the lungs and pulmonary vasculature. CDH severity correlates with a spectrum of pulmonary hypoplasia, pulmonary hypertension (PHT), and cardiac dysfunction, constituting the pathophysiological triad of this complex condition. The accurate diagnosis and effective management of PHT and cardiac dysfunction is pivotal to optimizing patient outcomes. Targeted neonatal echocardiography is instrumental in delivering real-time data crucial for the bespoke, pathophysiology-targeted hemodynamic management of CDH-associated PHT.

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..

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.

Targeted Neonatal Echocardiography: Basics of Knobology 101

Targeted neonatal echocardiography (TNE) is essential when approaching hemodynamic instability in neonates. Competency in this field requires standardized training, including robust hands-on experience. Proficiency in understanding the key elements of ultrasound knobology is indispensable for optimal acquisition of imaging. This is a narrative review summarizing the key elements of knobology in TNE. Literature review was mainly done through PubMed. There was no funding allocated for the production of this manuscript. KEY POINTS: · Robust and structured training is essential. · Understanding knobology is required to achieve competency in TNE. · Optimizing knobology is critical for an accurate hemodynamic interpretation report.

Targeted Neonatal Echocardiography in the Management of Neonatal Pulmonary Hypertension

Pulmonary hypertension (PH) in neonates, originating from a range of disease states with heterogeneous underlying pathophysiology, is associated with significant morbidity and mortality. Although the final common pathway is a state of high right ventricular afterload leading to compromised cardiac output, multiple hemodynamic phenotypes exist in acute and chronic PH, for which cardiorespiratory treatment strategies differ. Comprehensive appraisal of pulmonary pressure, pulmonary vascular resistance, cardiac function, pulmonary and systemic blood flow, and extrapulmonary shunts facilitates delivery of individualized cardiovascular therapies in affected newborns.

The impact of a care bundle with an emphasis on hemodynamic assessment on the short-term outcomes in neonates with congenital diaphragmatic hernia

OBJECTIVE

To evaluate the short-term outcomes of implementing a care bundle emphasizing frequent hemodynamic assessments by echocardiography in neonates with congenital diaphragmatic hernia (CDH).

STUDY DESIGN

This was a retrospective cohort study of infants with CDH admitted to a quaternary perinatal unit from January 2013 to March 2021. The primary composite outcome was defined as mortality or use of extracorporeal membrane oxygenation or need for respiratory support at discharge.

RESULTS

We identified 37 and 20 CDH infants in Epoch I and II, respectively. More patch repairs (50% vs. 21.9%, p = 0.035) and echocardiograms (6[4-8] vs. 1[0-5], p = 0.003) were performed in Epoch II. While there were no differences in the primary outcome, there was a reduction in mortality in Epoch II (0% vs. 27%, p = 0.01).

CONCLUSION

With the implementation of a CDH care bundle with an emphasis on hemodynamic assessment, we demonstrated a significant reduction in mortality.

Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography

Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.

Echocardiographic Evaluations in Sick Neonates in Neonatal Intensive Care Unit: A Clinical Study

Introduction Echocardiography is pivotal in neonatal care by providing valuable insights into cardiac function, anatomy, and hemodynamics. The ability of echocardiography to guide clinical decision-making is evident in its capacity to influence and change management strategies. Therefore, the goal of the current study was to know the prevalence of heart disease and the association between echocardiographic indications and neonatal outcomes and interventions. Materials and method This prospective cross-sectional study was conducted in the Neonatology Department, Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha. Ill neonates admitted to the neonatal intensive care unit (NICU) were selected in a randomized manner, and echocardiography was performed. The decision was made on the indications for echocardiography, the echocardiographic findings, and any modifications to the clinical care. Mean differences were compared using an unpaired Student's t-test. A significant level is defined as a p-value of less than 0.05. Results Of all the ill neonates, heart disease was present in 60 (52.6%) neonates. The most frequent indication for echocardiography was respiratory distress in 39 (34.21%). In neonates with heart disease, 27(45%) had acyanotic heart disease, nine (15%) had cyanotic heart disease, and 24(40%) had miscellaneous heart disease. The mean appearance, pulse, grimace, activity, and respiration (APGAR) score at five minutes in neonates without heart disease was 9.05, and for those with heart disease, it was 8.95, with no statistically significant difference. Out of 114 neonates, the mean NICU stay of neonates without heart disease was 6.59 days, and those with heart disease was 9.95 days with a p-value of 0.0001, hence showing statistically significant differences. Out of all the 114 neonates, 57.89% underwent no intervention, 36.85% underwent medical intervention, and 5.26% underwent surgical interventions. Out of 114 neonates, 101 neonates were discharged, and 13 neonates were dead. Out of the 54 neonates with no cardiac abnormality, 50 (92.59%) were discharged, and four (7.41%) neonates were dead. Out of the 60 neonates with cardiac abnormality, 51 (85%) were discharged, and nine (15%) were dead, with a p-value of 0.203, showing no statistical significance between cardiac abnormality and neonatal outcome. Conclusion Our study emphasizes the pivotal role of echocardiography in the NICU for evaluating ill neonates. The findings underline the significance of early detection and precise diagnostic insights provided by echocardiography, contributing to tailored management strategies. The study highlights the transformative impact of echocardiography on clinical decision-making, facilitating timely interventions and improving overall neonatal care. Echocardiography is essential to improving outcomes for these susceptible newborns in the NICU as we continue to expand our knowledge of neonatal heart health.

Growth of targeted neonatal echocardiography in Chinese neonatal intensive care units: gaps in practice and training

To evaluate clinical practice, neonatologists' attitudes, and the extent of training and accreditation regarding targeted neonatal echocardiography (TnEcho) among Chinese neonatologists. A web-based questionnaire was emailed to 331 neonatologists across China who completed training in subspecialty neonatology. The survey covered various aspects of TnEcho, including the characteristics of clinical practice, attitudes towards its usefulness, and perceived barriers to implementation and training methods. Survey response rate was 68.0% (225/331). Seventy-nine (35.1%) respondents stated that TnEcho was utilized in their NICUs. Most respondents reported the use of echocardiography to evaluate hemodynamic significance of the patent ductus arteriosus (PDA, 94.9%). The eyeballing technique was most used to evaluate left (82.3%) and right (77.2%) ventricular function. Most respondents (87.3-96.2%) positively valued the role of TnEcho in providing timely and longitudinal hemodynamic information to guide cardiovascular care. Access to TnEcho was more likely in centers with on-site pediatric cardiology service (p = .003), larger bed capacity (p = .004), or level IV status (p = .003). Lack of experienced practitioners with echocardiography expertise (88.9%) and accredited training programs (85.8%) was perceived to be the major barrier to implementation. Of concern, most practitioners with TnEcho skills received training in an informal manner through workshops (60.8%) or self-directed learning (54.4%). Conclusions: The use of TnEcho for longitudinal evaluation of infants with hemodynamic instability is growing within Chinese NICUs. There is an urgent need to develop standardized training programs and accreditation for TnEcho which are adapted to the Chinese context.

Evaluation of the Hypotensive Preterm Infant: Evidence-Based Practice at the Bedside?

Choosing the appropriate management approach for the preterm infant with low blood pressure during the transition period generally involved intervening when the blood pressure drifted below a certain threshold. It is now clear that this approach is too simplistic and does not address the underlying physiology. In this chapter, we explore the many monitoring tools available for evaluation of the hypotensive preterm and assess the evidence base supporting or refuting their use. The key challenge relates to incorporating these outputs with the clinical status of the patient and choosing the appropriate management strategy.

Echocardiography performed by the neonatologist: the impact on the clinical management

BACKGROUND

The aim of this study was to assess whether neonatologist-performed echocardiography (NPE) changed the previously planned hemodynamic approach in critically ill newborn infants.

METHODS

This prospective cross-sectional study included the first NPE of 199 neonates. Before the exam, the clinical team was asked about the planned hemodynamic approach and the answer was classified as an intention to change or not to change the therapy. After being informed about the NPE results, the clinical management was grouped as performed as previously planned (maintained) or modified.

RESULTS

NPE modified the planned pre-exam approach in 80 cases (40.2%; 95% CI: 33.3-47.4%), and variables associated with an increased chance of this modification were exams to assess pulmonary hemodynamics (prevalent ratio (PR): 1.75; 95% CI: 1.02-3.00) and to assess systemic flow (PR: 1.68; 95% CI: 1.06-2.68) in relation to those requested for patent ductus arteriosus, pre-exam intention of changing the prescribed management (PR: 2.16; 95% CI: 1.50-3.11), use of catecholamines (PR: 1.68; 95% CI: 1.24-2.28) and birthweight (per kg) (PR: 0.81; 95% CI: 0.68-0.98).

CONCLUSION

The NPE was an important tool to direct hemodynamic management in a different approach from the previous intention of the clinical team, mainly for critically ill neonates.

IMPACT

This study shows that neonatologist-performed echocardiography guides the therapeutic planning in the NICU, mainly in the more unstable newborns, with lower birthweight and receiving catecholamines. Exams requested with the intention of modifying the current approach were more likely to change the management in a different way than planned pre-exam.

Hospital variation in neonatal echocardiography among very preterm infants at US children's hospitals

OBJECTIVE

Estimate hospital variation in echocardiography (echo) among very preterm infants.

STUDY DESIGN

Retrospective cohort study of very preterm (<32 weeks) infants discharged between 2012 and 2019 from US children's hospitals. Echo exposure was identified using daily billing, and hospital variation was estimated after adjustment for illness severity. Variation in very early echo use (<3 days of life) was compared to exposure to treatment of a patent ductus arteriosus (PDA), and other practice patterns.

RESULTS

27,498 subjects across 39 children's hospitals were included. Very early echo use had the greatest hospital variation (3-34%). Increasing very early echo use was not associated with PDA treatment (p = 0.93), but was associated with nitric oxide (p < 0.01) and vasoactive medications (p < 0.01).

CONCLUSIONS

Hospital variation in echo use among preterm infants was greatest in the first few days of life and was associated with increasing nitric oxide and vasoactive medication use. The impact of this variation on clinical outcomes is uncertain and warrants further investigation.

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.

Targeted neonatal echocardiography service in neonatal intensive care in Manitoba, Canada

OBJECTIVE

To evaluate the impact of a targeted neonatal echocardiography (TNE) service on patient management in the neonatal intensive care units (NICU) in Winnipeg, Canada.

STUDY DESIGN

Retrospective cohort study of neonates who had TNEs from 2014 to 2019. The primary outcome was the change in clinical management based on TNE recommendation. Multivariate logistic regression analysis was used to identify predictors of the primary outcome.

RESULTS

A total of 747 echos were performed on 307 neonates. Patent ductus arteriosus assessment was the most common indication for TNE followed by evaluation of pulmonary hypertension and systemic hemodynamics. TNE led to a change in clinical management following 492 (66%) echos. Mechanical ventilation [Odds ratio (OR) 2.4, 95% CI: 1.7-3.4, P < 0.001) and receiving inhaled nitric oxide (1.9, 95% CI: 1.3-3.0, P = 0.003) were the predictors for the change in clinical management following TNE.

CONCLUSION

TNE has enhanced patient care by altering the management of patients in the NICU.

Hemodynamic considerations in preterm infants born at less than 25 weeks gestation

As survival rates continue to improve for infants born at less than 25 weeks gestation, delineating normal cardiovascular physiology from pathophysiology becomes much more challenging. With a paucity of 'normative' data for such infants, an over-reliance on studies at older gestations can result in a 'best guess' approach. Here we offer a pragmatic approach to these diagnostic challenges from a cardiovascular viewpoint. An appreciation of the unique physiology, from the immature myocardium and altered vascular tone to an innately large patent ductus arteriosus is essential, as is a thorough history for case specific contributing factors. We explore the additional difficulties in achieving a balance between minimal handling at the bedside and delineating important objective markers of perfusion. Finally, we discuss treatment approaches including inotrope therapy and patent ductus treatment, acknowledging the limited data available to guide these decisions.

Establishing a risk assessment framework for point-of-care ultrasound

Point-of-care ultrasound (POCUS) refers to the use of portable ultrasound (US) applications at the bedside, performed directly by the treating physician, for either diagnostic or procedure guidance purposes. It is being rapidly adopted by traditionally non-imaging medical specialties across the globe. Recent international evidence-based guidelines on POCUS for critically ill neonates and children were issued by the POCUS Working Group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). Currently there are no standardized national or international guidelines for its implementation into clinical practice or even the training curriculum to monitor quality assurance. Further, there are no definitions or methods of POCUS competency measurement across its varied clinical applications.

CONCLUSION

The Hippocratic Oath suggests medical providers do no harm to their patients. In our continued quest to uphold this value, providers seeking solutions to clinical problems must often weigh the benefit of an intervention with the risk of harm to the patient. Technologies to guide diagnosis and medical management present unique considerations when assessing possible risk to the patient. Frequently risk extends beyond the patient and impacts providers and the institutions in which they practice. POCUS is an emerging technology increasingly incorporated in the care of children across varied clinical specialties. Concerns have been raised by clinical colleagues and regulatory agencies regarding appropriate POCUS use and oversight. We present a framework for assessing the risk of POCUS use in pediatrics and suggest methods of mitigating risk to optimize safety and outcomes for patients, providers, and institutions.

WHAT IS KNOWN

• The use POCUS by traditionally non-imaging pediatric specialty physicians for both diagnostic and procedural guidance is rapidly increasing. • Although there are international guidelines for its indications, currently there is no standardized guidance on its implementation in clinical practice.

WHAT IS NEW

• Although standards for pediatric specialty-specific POCUS curriculum and training to competency have not been defined, POCUS is likely to be most successfully incorporated in clinical care when programmatic infrastructural elements are present. • Risk assessment is a forward-thinking process and requires an imprecise calculus that integrates considerations of the technology, the provider, and the context in which medical care is delivered. Medicolegal considerations vary across countries and frequently change, requiring providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS.

The evolution of cardiac point of care ultrasound for the neonatologist

Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.

The impact of neonatologist performed echocardiography in an Italian neonatal unit

BACKGROUND

The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed.

MATERIAL AND METHODS

We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed.

RESULTS

A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory.

CONCLUSIONS

The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists.Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Structured Neonatal Point-of-Care Ultrasound Training Program

OBJECTIVE

Point-of-care ultrasound (POC US) has been increasingly used by intensive care physicians. Growing use of POC US necessitates defining distinct clinical indications for its application, as well as structured POC US training programs. Homogeneous approach to POC US education combined with rigorous quality assurance should further enable POC US to become standard-of-care clinical tool. This study aimed to present the first, innovative, and structured POC US program in neonatal-perinatal medicine field. In addition, we reviewed the availability of the POC US training programs across different medical specialties.

STUDY DESIGN

Available English-language publications on POC US training programs in general and neonatal-perinatal medicine were reviewed in this study.

DISCUSSION

Mounting body of evidence suggests improved procedural completion rates, as well as clinical decision making with the use of POC US. However, limited research supported the existence of structured, comprehensive POC US programs. It was recognized that medical institutions need to develop syllabuses, teach, and credential increasing number of health care professionals in the use of POC US. We defined intuitive educational strategy that encompasses POC US clinical indications, educational curriculum, scanning protocols, competence evaluation, and finally credentialing process. In addition, we offered description of the imaging quality assurance, as well as POC US coding, and reimbursement.

CONCLUSION

Future efforts need to be dedicated to the ongoing development of neonatal POC US as a clinical instrument. It should allow for eventual paradigm change and improved effectiveness in management of critically ill neonates.

Pulmonary hypertension in late onset neonatal sepsis using functional echocardiography: a prospective study

PURPOSE

Pulmonary hypertension (PH) in the newborn period is associated with significant morbidity and mortality. Sepsis has been identified as an independent risk factor for PH in newborns. Data on the proportion and severity of PH in association with neonatal sepsis are scarce. This study was aimed to measure the pulmonary artery systolic pressure (PASP) in neonates with late onset sepsis (LOS) and to estimate the proportion of PH in neonatal sepsis using functional echocardiography (FnECHO).

METHODS

This prospective observational study was conducted at a tertiary neonatal intensive care unit (NICU). All neonates admitted in the NICU with suspected LOS underwent FnECHO within 6 hours of onset of clinical signs and PASP was recorded. Pulmonary hypertension was defined as PASP of > 35 mmHg. PASP of neonates with positive culture results (proven LOS) was compared with that of gestational age-matched stable controls without sepsis.

RESULTS

Thirty three neonates with proven LOS were analysed (study group). Sixteen neonates (49%) in the study group had PH. Mean PASP of the study group was significantly higher than that of the control group (35.3 ± 10.13 mmHg and 12.58 ± 3.92 mmHg, respectively; P < 0.0001). None of the neonates in the control group had PH.

CONCLUSION

Pulmonary artery pressure was higher in neonates with late onset neonatal sepsis as compared to that of stable babies without sepsis. Pulmonary hypertension was seen in nearly half of term as well as preterm neonates with late onset sepsis.

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.

The Future of Cardiac Ultrasound in the Neonatal Intensive Care Unit

Cardiac ultrasound is increasingly used to guide hemodynamic decision making in the neonatal intensive care unit (NICU). This article focuses on likely future progress in training, accreditation, digital connectivity, miniaturization, and modality development. Many documents have been published internationally to guide cardiac ultrasound training, accreditation, and implementation in the NICU, but challenges remain in providing assessments of hemodynamic status without risking missed structural diagnoses. Advances in simulation training and digital connectivity provide an opportunity to standardize approaches across institutions and continents. Development of machine learning and ultrasound modalities in turn provide huge scope for improving robustness and completeness of assessment.

The Use of Cardiotonic Drugs in Neonates

There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.

Targeted Neonatal Echocardiography-Guided Therapy in Vein of Galen Aneurysmal Malformation: A Report of Two Cases with a Review of Physiology and Approach to Management

Vein of Galen malformation results in predictable changes in physiology which exist on a continuum. Severe pulmonary hypertension may present as hypoxemia; however, excessive reduction in pulmonary vascular resistance may precipitate progressive pulmonary overcirculation and impaired systemic blood flow. Right ventricular performance and the patency and direction of the ductus arteriosus may play a crucial role in postductal organ perfusion. Physiological stabilization may be complex and variable over time. The utilization of targeted neonatal echocardiography to guide treatment decisions may improve the ability to provide therapy tailored to the specific disease pathophysiology and monitor serially as conditions change. An enhanced approach to physiological stabilization may reduce the risk of unexpected decompensation and allow for thoughtful, controlled endovascular embolization in appropriate candidates.

Merits and perils of targeted neonatal echocardiography-based hemodynamic research: a position statement

In the neonatal setting, point-of-care ultrasound is increasingly being used to help clinicians with the evaluation of heart function. Practices in neonatology, particularly with regard to acute and chronic hemodynamic managements, were traditionally more driven on dogma and predefined thresholds and not always supported by demonstrable physiology. For the first time, targeted neonatal echocardiography (TNE) provided neonatal intensivists with a bedside tool that made real-time assessment of neonatal hemodynamics status feasible in even the tiniest of babies. This opened the door towards more targeted physiological driven practices, allowing us to test historical approaches to clinical problems in a more precise way. Despite the standardization of TNE training and the creation of a formalized curriculum, little attention has been paid to the establishment of an empirical framework to adjudicate scientific investigation. In this position statement, we reflect on the evolution of TNE in Canadian neonatal intensive care units, appraise its strengths and limitations, and suggest guiding principles for clinicians and researchers to consider as they take this field forward.