Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment

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.

Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children

OBJECTIVES

To evaluate management changes and outcomes in critically ill children after formal echocardiography.

DESIGN

Retrospective cohort study between January 1, 2011, and December 31, 2020.

SETTING

Tertiary care children's hospital.

PATIENTS

Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function.

METHODS

Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Spo2/Fio2. An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors.

CONCLUSIONS

Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.

POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

Pediatric Shock Review

Shock occurs when there is energy failure due to inadequate oxygen/glucose delivery to meet metabolic demands. Shock is a leading cause of death and disability in children worldwide. Types of shock include hypovolemic, cardiogenic, distributive, and obstructive. This review provides an overview of the epidemiology, pathophysiology, and clinical signs and symptoms of each of these types of shock, followed by a discussion of advancements in diagnostic tests and tools and management/treatment principles for different categories of shock.

Cardiac Point-of-Care Ultrasound in Pediatric Neurocritical Care: A Case Series

BACKGROUND

Pediatric brain injury is accompanied by hemodynamic perturbations complicating the optimization of cerebral physiology. Point-of-care ultrasound (POCUS) uses dynamic real-time imaging to complement the physical examination and identify hemodynamic abnormalities in preload, contractility, and afterload conditions, but the contribution of cardiac POCUS in the context of pediatric brain injury is unclear.

METHODS

We reviewed cardiac POCUS images integrated in clinical care to examine those with neurological injury and hemodynamic abnormalities.

RESULTS

We discuss three children with acute brain injury and myocardial dysfunction identified using cardiac POCUS by bedside clinicians.

CONCLUSIONS

Cardiac POCUS may have an important role in caring for children with neurologic injury. These patients received personalized care informed by POCUS data in attempts to stabilize hemodynamics and optimize clinical outcomes.

Updates in pediatric ultrasound

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) has various diagnostic and therapeutic applications in the pediatric acute care setting that have an impact on clinical outcomes.

RECENT FINDINGS

POCUS can improve diagnostic efficiency and expedite management in pediatric patients who present to the emergency department with common complaints such as respiratory distress, abdominal pain, shock, and pain.

SUMMARY

Rapid advancements in POCUS have allowed it to become a powerful tool in pediatric care. As the clinical applications of ultrasound diversify, research is needed to evaluate impacts on healthcare outcomes, delivery, and costs.

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.

Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography

Cardiac point-of-care ultrasound has the potential to improve patient care, but its application to children requires consideration of anatomic and physiologic differences from adult populations, and corresponding technical aspects of performance. This document is the product of an American Society of Echocardiography task force composed of representatives from pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric anesthesiology, and others, assembled to provide expert guidance. This diverse group aimed to identify common considerations across disciplines to guide evolution of indications, and to identify common requirements and infrastructure necessary for optimal performance, training, and quality assurance in the practice of cardiac point-of-care ultrasound in children. The recommendations presented are intended to facilitate collaboration among subspecialties and with pediatric echocardiography laboratories by identifying key considerations regarding (1) indications, (2) imaging recommendations, (3) training and competency assessment, and (4) quality assurance.

Establishing the international research priorities for pediatric emergency medicine point-of-care ultrasound: A modified Delphi study

BACKGROUND

The Pediatric Emergency Medicine (PEM) Point-of-care Ultrasound (POCUS) Network (P2Network) was established in 2014 to provide a platform for international collaboration among experts, including multicenter research. The objective of this study was to use expert consensus to identify and prioritize PEM POCUS topics, to inform future collaborative multicenter research.

METHODS

Online surveys were administered in a two-stage, modified Delphi study. A steering committee of 16 PEM POCUS experts was identified within the P2Network, with representation from the United States, Canada, Italy, and Australia. We solicited the participation of international PEM POCUS experts through professional society mailing lists, research networks, social media, and "word of mouth." After each round, responses were refined by the steering committee before being reissued to participants to determine the ranking of all the research questions based on means and to identify the high-level consensus topics. The final stage was a modified Hanlon process of prioritization round (HPP), which emphasized relevance, impact, and feasibility.

RESULTS

Fifty-four eligible participants (16.6%) provided 191 items to Survey 1 (Round 1). These were refined and consolidated into 52 research questions by the steering committee. These were issued for rating in Survey 2 (Round 2), which had 45 participants. At the completion of Round 2, all questions were ranked with six research questions reaching high-level consensus. Thirty-one research questions with mean ratings above neutral were selected for the HPP round. Highly ranked topics included clinical applications of POCUS to evaluate and manage children with shock, cardiac arrest, thoracoabdominal trauma, suspected cardiac failure, atraumatic limp, and intussusception.

CONCLUSIONS

This consensus study has established a research agenda to inform future international multicenter PEM POCUS trials. This study has highlighted the ongoing need for high-quality evidence for PEM POCUS applications to guide clinical practice.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit

Purpose of Review

Recent Findings

Summary

Supplementary Information

Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

Ultrasonography has been widely used in medicine for decades but often by specific users such as cardiologists, obstetricians, and radiologists. In the last several years, the use of this imaging modality has moved to the bedside, with clinicians performing and interpreting focused point of care ultrasonography to aid in immediate assessment and management of their patients. The growth of point of care ultrasonography has been facilitated by advancement in ultrasound-related technology and emerging studies and protocols demonstrating its utility in clinical practice. However, considerable challenges remain before this modality can be adopted across the spectrum of disciplines, primarily as it relates to training, competency, and standardization of usage. This review outlines the history, current state, challenges and the future direction of point of care ultrasonography specifically in the field of pediatric critical care medicine.

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.

Case report: Temporal alterations in vascular function during the first 2 weeks of pediatric septic shock

INTRODUCTION

During sepsis and septic shock, the host's immune systems generate an overwhelming and often, detrimental, inflammatory response. Part of this response results in significant alterations in blood flow and vasomotor tone regulated in part by endothelial and vascular smooth muscle cells. Here, we report on a series of 3 pediatric patients for whom vascular response was assessed by laser doppler perfusion coupled to iontophoresis over the first 2 weeks after hospitalization for septic shock to demonstrate similarities and dissimilarities in the vascular response.

CASE PRESENTATIONS

A 12-year-old male with a history of Burkitt's Lymphoma, a 21-year-old male with congenital porencephaly and epilepsy, and a 7-year-old male with no significant past medical history all were admitted to a tertiary care children's hospital with a diagnosis of septic shock requiring vasoactive infusions to maintain mean arterial blood pressure. Non-invasive laser doppler perfusion coupled with iontophoresis of either acetylcholine (endothelial-dependent response) or sodium nitroprusside (endothelial-independent response) was performed on hospital days 1, 3, 7, and 14. Variability and heterogeneity were demonstrated by the temporal assessments of the vascular response to sodium nitroprusside, but all three patients showed significant similarity in the temporal responsiveness to acetylcholine.

CONCLUSION

Assessment of baseline and temporal responsiveness to endothelial-dependent vascular reactivity may provide a predictable timeline to the resolution of pediatric septic shock.

Pediatric Sepsis Biomarker Risk Model Biomarkers and Estimation of Myocardial Dysfunction in Pediatric Septic Shock

OBJECTIVES

Sepsis-associated myocardial dysfunction is common in pediatric septic shock and negatively impacts outcomes. Early estimation of sepsis-associated myocardial dysfunction risk has the potential to inform clinical care and improve clinical trial design. The Pediatric Sepsis Biomarker Risk Model II is validated as a biomarker-based enrichment algorithm to discriminate children with septic shock with high baseline mortality probability. The objectives were to determine if Pediatric Sepsis Biomarker Risk Model biomarkers are associated with risk for sepsis-associated myocardial dysfunction in pediatric septic shock and to develop a biomarker-based model to reliably estimate sepsis-associated myocardial dysfunction risk.

DESIGN

Secondary analysis of prospective cohort study.

SETTING

Single-center, quaternary-care PICU.

PATIENTS

Children less than 18 years old admitted to the PICU from 2003 to 2018 who had Pediatric Sepsis Biomarker Risk Model biomarkers measured for determination of Pediatric Sepsis Biomarker Risk Model II mortality probability and an echocardiogram performed within 48 hours of septic shock identification.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric Sepsis Biomarker Risk Model II mortality probability was calculated from serum biomarker concentrations and admission platelet count. Echocardiograms were reread by a single cardiologist blinded to Pediatric Sepsis Biomarker Risk Model II data, and sepsis-associated myocardial dysfunction was defined as left ventricular ejection fraction less than 45% for primary analyses. Multivariable logistic regression analyzed the association of Pediatric Sepsis Biomarker Risk Model II mortality probability with sepsis-associated myocardial dysfunction. Classification and regression tree methodology was employed to derive a Pediatric Sepsis Biomarker Risk Model biomarker-based model for sepsis-associated myocardial dysfunction. Thirty-two of 181 children with septic shock demonstrated sepsis-associated myocardial dysfunction. Pediatric Sepsis Biomarker Risk Model II mortality probability was independently associated with sepsis-associated myocardial dysfunction (odds ratio, 1.45; 95% CI, 1.17-1.81; p = 0.001). Modeling with Pediatric Sepsis Biomarker Risk Model biomarkers estimated sepsis-associated myocardial dysfunction risk with an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.85-0.95). Upon 10-fold cross-validation, the derived model had a summary area under the receiver operating characteristic curve of 0.74. Model characteristics were similar when sepsis-associated myocardial dysfunction was defined by both low left ventricular ejection fraction and abnormal global longitudinal strain.

CONCLUSIONS

A newly derived Pediatric Sepsis Biomarker Risk Model biomarker-based model reliably estimates risk of sepsis-associated myocardial dysfunction in pediatric septic shock, but independent prospective validation is needed.