Bedside ultrasound in pediatric critical care: a review

Remote out-of-hours ultrasound live supervision in pediatrics - improvement of diagnostics and training

PURPOSE

Ultrasound (US) is the preferred imaging modality in pediatrics for diagnostic and therapeutic issues. The absence of radiation and the constant on-site accessibility make it the ideal tool for children. However, despite remarkable technical advances in resolution and applicability, many sophisticated medical questions still require profound expertise on the part of the examiner, thus often hampering fast decisions particularly outside regular working hours.

MATERIALS AND METHODS

This single-center study, at a university children's hospital evaluated the use of US during emergency service. A four-week documentation period was followed by a subsequent eight-week supervision period with live supervision availability on demand guided by a remote US expert. The demand for expert support, diagnosis, grading of urgency, duration and success of examination, and satisfaction of both examiners were analyzed.

RESULTS

108 patients (mean age 9.7 years) were included. In 38% of cases, US was supervised on demand with a definite diagnosis in 92.6% of cases (25/27). Image quality and technical performance were graded sufficient in 100% of cases. Supervised compared to non-supervised US examinations were prolonged (14.4 min vs. 7.1 min, p<0.001), were more prevalent within the first 24 h in the hospital (70% vs. 56.8%, p=0.06), and were classified more frequently as emergency (22.2% vs. 2.3%; p=0.015). All participants classified the availability of US supervision as decisively helpful.

CONCLUSION

Remote live supervised pediatric US was feasible and effective. It combined timely, high-quality diagnostics even in the case of challenging medical questions with simultaneous US training.

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.

Reliability of renal point-of-care ultrasound (POCUS) performed by pediatric postgraduates to diagnose hydronephrosis in infants

Purpose

Point-of-care ultrasound (POCUS) has gained prominence in a variety of medical specialties due to advances in ultrasound technology. POCUS has not been fully integrated into pediatric residency training programs despite its widespread use and proven benefits. At our institution, renal POCUS is performed by pediatric residents for the evaluation of hydronephrosis, which is the main pathology for which ultrasound is used in the clinical practice of pediatric nephrology. This study was conducted to evaluate the quality of renal POCUS performed by pediatric residents in infants.

Methods

Four pediatric residents, comprising two first-year and two second-year residents at Konyang University Hospital, participated in the study conducted from May 2021 to May 2022. All participants had completed our Point-of-Care Ultrasound (POCUS) training program. The study focused on infants admitted to the pediatric inpatient unit, identified by attending physicians as requiring renal ultrasound. All infants underwent their initial kidney ultrasound examination. Temporal alignment between renal Point-of-Care Ultrasound (POCUS) performed by pediatric residents and conventional ultrasound (USG) conducted by radiologists was asynchronous. Pediatric residents conducted POCUS sessions during scheduled radiologist appointments throughout the day, occurring either before or after the radiologist's examination. There was no mutual awareness of each other's results. Inter-observer agreement between radiologists and pediatric residents was compared for the presence or absence of hydronephrosis and its grade, which are primary considerations in pediatric renal ultrasound.

Results

Our study found that 53 infants (68.8%) were diagnosed with hydronephrosis using point-of-care ultrasound (POCUS), compared to 48 infants (62.3%) diagnosed with conventional ultrasound (USG). Among the POCUS examinations conducted by pediatric residents, hydronephrosis of SFU grades 1, 2, 3, and 4 were observed in 56.6%, 35.8%, 7.5%, and 0%, respectively. Inter-observer reliability between POCUS and conventional USG showed good agreement, with Cohen's kappa coefficients exceeding 0.8 for sensitivity and 0.6 for grading.

Conclusions

Renal POCUS performed well in diagnosing and grading hydronephrosis in infants when performed by pediatric residents who had completed a two-phase training program.

Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit

Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.

Ultrasound to Verify Gastric Tube Position in Infants and Children: A Systematic Review

BACKGROUND

Placement of gastric tubes is commonly performed in infants and children but malpositioning is common and is associated with significant complications.

OBJECTIVE

The aim of this systematic review is to identify the evidence on the use of ultrasound to verify correct gastric tube placement in infants and children and gaps in the research.

METHODS

This review was performed using CINAHL, PUBMED, EMBASE and Web of Science databases. Studies were included if they used an empirical study design, were published in English, included infants or children, and evaluated the use of ultrasound to verify correct gastric tube placement compared to radiograph. Sensitivity, specificity, positive and negative predictive values were evaluated.

RESULTS

Four articles were included in the review. Sensitivity estimates were 0.88 to 1.00 and a positive predictive value of 0.99 was reported in one study. Specificity was not reported in any of the included studies. Ultrasound may be an important method to correctly identify gastric tube placement in infants and children with less radiation exposure and cost.

IMPLICATIONS FOR PRACTICE

Ultrasound could be a used to verify gastric tube positioning in infants and children for both initial placement and continued verification leading to reduced radiation exposure and cost.

IMPLICATIONS FOR RESEARCH

Research should focus on evaluating ultrasound specificity and the clinical feasibility of using ultrasound as a standard practice, including cost and time required to complete the exam, as well as the ability of ultrasound to verify gastric tube placement in infants weighing less than 1500 grams.

The Inter-Rater Reliability of Pediatric Point-of-Care Lung Ultrasound Interpretation in Children With Acute Respiratory Failure

OBJECTIVES

Use of point-of-care lung ultrasound (POC-LUS) has increased significantly in pediatrics yet it remains under-studied in the pediatric intensive care unit (PICU). No studies explicitly evaluate the reliability of POC-LUS artifact interpretation among critically ill children with acute respiratory failure (ARF) in the PICU. We thus designed this study to determine the inter-rater reliability of POC-LUS interpretation in pediatric ARF among pediatric intensivists trained in POC-LUS and an expert intensivist.

METHODS

We compared the interpretation of lung sliding, pleural line characteristics, ultrasound artifacts, and POC-LUS diagnoses among pediatric intensivists and an expert intensivist in a cohort of children admitted to the PICU for ARF. Kappa statistics (k) adjusted for maximum attainable agreement (k/k_max ) were used to quantify chance-correct agreement between the pediatric intensivist and expert physician.

RESULTS

We enrolled 88 patients, evaluating 3 zones per hemithorax (anterior, lateral, and posterior) for lung sliding, pleural line characteristics, ultrasound artifacts, and diagnosis. There was moderate agreement between the PICU intensivist and expert-derived diagnoses with 56% observed agreement (k/k_max  = 0.46, 95% confidence interval [CI] 0.31-0.65). Agreement in identification of lung sliding (k = 0.19, 95% CI -0.17 to 0.56) and pleural line characteristics (k = 0.24, 95% CI 0.08-0.40) was slight and fair, respectively, while agreement in the interpretation of ultrasound artifacts ranged from moderate to substantial.

CONCLUSIONS

Evidence supporting the evaluation of neonatal and adult patients with POC-LUS should not be extrapolated to critically ill pediatric patients. This study adds to the evidence supporting use of POC-LUS in the PICU by demonstrating moderate agreement between PICU intensivist and expert-derived POC-LUS diagnoses.

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.

Bedside Ultrasound for Procedural Assistance in Pediatrics

Point-of-care ultrasound (POCUS) is a noninvasive imaging tool with both diagnostic and therapeutic applications. In this article, the author will review the role of POCUS for vascular access, endotracheal intubation, lumbar puncture, chest tube, and diagnosing coronavirus disease 2019 lung pathology. This will include a review of the evidence, technique, and strategies for optimizing performance of these procedures. [Pediatr Ann. 2021;50(10):e404-e410.].

Chest sonography versus chest radiograph in children admitted to paediatric intensive care - A prospective study

There is a paucity of studies on the correlation between chest radiograph and ultrasound (US) in children. Our objective was to study the correlation between bedside chest radiograph and ultrasound findings in 413 children with 1002 episodes of chest radiograph and US enrolled for a prospective, double-blinded observational study in a multidisciplinary paediatric intensive care unit. Weighted κ statistic for agreement was different for right and left lungs and varied from 50% for left pleural effusion to 98% for right pneumothorax. Pulmonary oedema, pneumothorax and pleural effusion were diagnosed by ultrasound alone in a significantly higher number of patients as compared to chest radiograph (P = 0.001). Chest ultrasound is therefore deemed more sensitive than chest radiograph in detection of pleural effusion, pulmonary oedema and pneumothorax.

Utility of gastric ultrasound in evaluating nil per os status in a child

Although rare, the aspiration of gastric contents can lead to significant morbidity or even mortality in pediatric patients receiving anesthetic care. For elective cases, routine preoperative practices include the use of standard nil per os times to decrease the risk of aspiration. However, patients may fail to adhere to provided NPO guidelines or other patient factors may impact the efficacy of standard NPO times. Gastric point-of-care ultrasound provides information on the volume and quality of gastric contents and may allow improved patient management strategies. We present a 4-year-old patient who presented for bilateral myringotomy with tympanostomy tube insertion, who was found to have evidence of a full stomach during preoperative gastric ultrasound examination. The use of preoperative gastric point-of-care ultrasound in evaluating stomach contents and confirming NPO times is reviewed and its application to perioperative practice discussed.

Taking the Pulse of POCUS: The State of Point-of-Care Ultrasound at a Pediatric Tertiary Care Hospital

We aim to quantify and categorize point-of-care ultrasound (POCUS) usage by pediatric practitioners and trainees at our tertiary care center, and assess the degree of interest from pediatric residents, fellows, and program leaders for integrating POCUS into their training. Data was collected via online survey, evaluating the current use of POCUS in clinical decision making, desire for further formal training, and opinions on the importance of POCUS to future clinical practice. In total, 14 program directors/assistant program directors (PD/APDs) representing 10 of 15 training programs, 30 of 95 fellows representing 9 of 15 fellowships, and 32 of 82 residents responded. From PD/APDs, only 2 of the programs reported active use POCUS for clinical decision making, but 13 of the fellows and 9 residents reported doing so. In regard to desire for a formal POCUS program, 30.8% of PD/APDs, 43.8% of fellows without current curricula, and 87.5% of residents were interested in participating in such a program. When considering specialty, some non-acute care-based PD/APDs and fellows at our institution felt that POCUS was important to future practice. Pediatric subspecialty PD/APDs and their fellows had divergent outlooks on the importance of POCUS in future practice. Finally, an overwhelming majority of residents at our institution expressed a desire to learn, and half believing it will be important to future practice. Based on the degree of interest, medicolegal considerations, and trajectory of patient care, pediatric residency and fellowship programs should strongly consider integrating POCUS education into their curricula.

The use of lung ultrasound compared to chest X-ray to diagnose pneumothorax following the Nuss procedure for pectus excavatum repair in children

BACKGROUND

Pectus Excavatum is the most common deformation of the skeletal chest wall, and the Nuss procedure is used to correct this deformation. Residual pneumothorax is a frequent postoperative complication after thoracoscopy. Primary aim of this prospective observational study was to compare the level of agreement among readers using lung ultrasound and chest X-ray.

METHODS

This was an inter-reader single-center prospective observational agreement study for lung ultrasound and chest X-ray. Three lung ultrasound evaluations were performed at the end of surgery in the operating room by two Consultant Anesthesiologist (A1 and A2) and by a medical student (A3). Chest X-ray was interpreted by a consultant Radiologist (R1) and a pool of 11 radiologists (collectively named R2). Cohen's kappa was used to evaluate the level of agreement between the two imaging techniques.

RESULTS

Sixty-eight pediatric patients were included in the study. The overall agreement among (A = Anesthesiologist) A1, A2, A3, (R = Radiologist) R1, and R2 in assessing pneumothorax was fair (k = 0.32; 95% CI 0.21-0.40). The stratified analysis showed moderate inter-reader agreement among lung ultrasound readers A1, A2, and A3 (k 0.58; 95% CI 0.44-0.71), as opposed to the fair agreement found among chest X-ray readers R1 and R2 (k = 0.39; 95% CI 0.18-0.60).

CONCLUSIONS

Our results support the use of lung ultrasound to diagnose pneumothorax after Nuss procedure. We found that the inter-reader accuracy was better with ultrasound compared to X-ray at our institution.

Central venous pressure, global end-diastolic index, and the inferior vena cava collapsibility/distensibility indices to estimate intravascular volume status in critically ill children: A pilot study

BACKGROUND

The assessment of the volume status in critically ill paediatric patients in intensive care units is vitally important for fluid therapy management. The most commonly used parameter for detecting volume status is still central venous pressure (CVP); however, in recent years, various kinds of methods and devices are being used for volume assessment in intensive care units.

OBJECTIVES

We aimed to evaluate the relationship between CVP, the global end-diastolic index (GEDI), and ultrasound measurements of the collapsibility and distensibility indices of the inferior vena cava (IVC) in paediatric patients undergoing Pulse index Contour Cardiac Output (PiCCO) monitoring.

METHODS

Fifteen patients receiving PiCCO monitoring were prospectively included in the study. Forty-nine PiCCO measurements were evaluated, and simultaneous CVP values were noted. After each measurement, IVC collapsibility (in spontaneously breathing patients) and distensibility (in mechanically ventilated patients) indices were measured with bedside ultrasound.

RESULTS

The mean age was 93.2 ± 61.3 months. Significant and negative correlations of the GEDI were found with the IVC collapsibility index (in spontaneously breathing patients) and the IVC distensibility index (in mechanically ventilated patients) (r = -0.502, p < 0.001; r = -0.522, p = 0.001, respectively). A significant and weakly positive correlation was found between the GEDI and CVP (r = 0.346, p = 0.015), and a significant and negative correlation was found between the IVC collapsibility index and CVP (r = -0.482, p = 0.03). The correlation between the IVC distensibility index and CVP was significant and negative (r = -0.412, p = 0.04).

CONCLUSION

The use of PiCCO as an advanced haemodynamic monitoring method and the use of bedside ultrasound as a noninvasive method are useful to evaluate the volume status in critically ill paediatric patients in intensive care. These methods will gradually come to the fore in paediatric intensive care.

Current Clinical Practice in Point-of-Care Ultrasound Use in the PICUs Across Europe

OBJECTIVES

1) To investigate the current practice in point-of-care ultrasound use in PICUs across Europe; 2) to understand the barriers for point-of-care ultrasound implementation in the clinical practice; 3) to identify existing point-of-care ultrasound training programs; and 4) to assess training needs.

DESIGN

Cross-sectional electronic survey.

SUBJECTS

Medical directors of European PICUs.

MEASUREMENTS AND MAIN RESULTS

The response rate was 42.3%; 142 of the 336 invited PICU medical directors from 26 European countries completed the survey. The clinicians in almost all the PICUs across Europe were reported to use point-of-care ultrasound in some form. A significant variation in the clinical practice according to the patient characteristics and presence of a fellowship training program was observed. PICUs with cardiosurgical patients reported using point-of-care ultrasound significantly more often than others. Ultrasound-guided vascular access was the most common point-of-care ultrasound indication, except in PICUs providing joint care for neonates and children. Units with a fellowship training program reported an increased use of point-of-care ultrasound for hemodynamic evaluation, during resuscitation and a positive impact on collaboration with imaging specialties. Although no barrier was deemed substantial to impede point-of-care ultrasound implementation, a number of potential hindrances to its implementation were reported-such as lack of formal training curriculum, collaborative learning opportunities, and quality assurance processes. Bedside informal teaching in point-of-care ultrasound was reported the most common method to acquire point-of-care ultrasound skills.

CONCLUSIONS

Point-of-care ultrasound is being used extensively across heterogeneously organized PICU settings in Europe. However, there remains a significant variation in the clinical practice across the units. Clear needs for improved point-of-care ultrasound training programs and clinical governance structure were identified. Evidence-based point-of-care ultrasound guidelines, structured training programs dedicated to neonatal and pediatric intensive care settings, and educational research in point-of-care ultrasound use may help in strengthening clinical governance, making clinical practice uniform and enhancing quality assurance.

Lung ultrasound for detecting pneumothorax in injured children: preliminary experience at a community-based Level II pediatric trauma center

BACKGROUND

Ultrasound (US) has been used in the adult trauma population with reported moderate to high sensitivities, but data are scarce in the pediatric trauma population.

OBJECTIVE

The purpose of this study was to specifically examine the sensitivity and specificity of one lung US methodology (single-point anterior exam) in the pediatric trauma population when compared to chest radiography or CT.

MATERIALS AND METHODS

We conducted a retrospective review of pediatric trauma patients who received lung US as an extension of the focused assessment with sonography for trauma (FAST) exam. We compared lung US findings with chest radiography and CT scans.

RESULTS

Two hundred twenty-six pediatric trauma patients underwent lung US exam with confirmatory exams; 11 pneumothoraces (4.8%) were observed. Of those 11, 6 were evaluated as false negatives on the lung US. Analyses resulted in 45.5% sensitivity, 98.6% specificity and 96.0% accuracy. Pneumothoraces undetected by lung US were small and apical and were likely not observed because of their size and location. None of the false negatives required intervention. All true positives were associated with lung contusions.

CONCLUSION

Pneumothorax is less common in the pediatric than the adult trauma population, and when encountered in children pneumothorax is often occult and might be associated with lung contusions. Existing evidence supports the usefulness of chest US in detecting pneumothorax in adults and suggests that it can be translated to injured children. However, our findings suggest that the sensitivity of lung US as a single-point anterior exam extension of the FAST exam might not be as reliable in the pediatric trauma population as in adults. Other methodologies using lung US might improve sensitivity.

Ultrasonographic postoperative evaluation of diaphragm function of patients with congenital heart defects

Background

This study aims to investigate the role of ultrasonography in the postoperative evaluation of diaphragm function in patients with congenital heart defect.

Methods

This prospective study included a total of 360 patients (176 males, 184 females; mean age 2 years; range, 1 month to 8 years) who underwent congenital heart surgery and 44 patients (22 males, 22 females; mean age 1 years; range, 1 month to 4 years) who underwent diaphragm ultrasonography between September 2018 and March 2019. Ultrasonography was performed for the patients who had difficulty in weaning from mechanical ventilation or who were thought to have diaphragm dysfunction due to pathological findings on postoperative chest X-rays. The findings were interpreted as normal, paresis, or paralysis.

Results

Diaphragm dysfunction was demonstrated in 23 patients (6.3%), paralysis in 11 patients (3%), and paresis in 12 patients (3.3%). A median sternotomy was performed in 21 patients (91%), and seven of them (30%) were redo cases. Five patients (21%) had single ventricle physiology. Six patients (1.6%) needed an intervention due to diaphragm dysfunction. The interventional procedures were diaphragm plication in three patients (0.8%) and tracheotomy in three patients (0.8%). Three of these patients had a single ventricle and three had biventricular physiology. The median time after surgery for these procedures was 36 days. One patient (0.2%) died in the intensive care unit. The mean length of stay in the intensive care unit and hospital was 36±12 and 48±21 days, respectively.

Conclusion

Diaphragm dysfunction should be kept in mind in patients undergoing congenital heart surgery and in those who need prolonged intubation during the postoperative period. Ultrasonography is a non-invasive diagnostic tool which can be used to identify diaphragm dysfunction and the best course of management of this clinical condition.

Rapid Assessment of the Neonate With Sonography (RANS) Scan

The use of point-of-care sonography in clinical settings such as emergency medicine and intensive care units has increased, but adoption in neonatology has been slow. Unlike the focused assessment with sonography for trauma scan used in adults, a quick bedside scan to rapidly evaluate an acutely deteriorating neonate does not exist. The objective of our article is to introduce a focused bedside ultrasound scan that is easy to learn, rapidly performed, and relatively inexpensive.© 2018 by the American Institute of Ultrasound in Medicine.

The usefulness of respiratory ultrasound assessment for modifying the physiotherapeutic algorithm in children after congenital heart defect surgeries

Background

The aim of the study was to assess the effectiveness and the possible use of diagnostic transthoracic ultrasound of the respiratory tract to qualify patients for therapy and to monitor the effectiveness of physiotherapy in children after cardiac surgeries.

Materials and methods

A total of 103 patients aged between 1 and 12 months who underwent a series of congenital heart surgeries using cardiopulmonary bypass were qualified for the prospective analysis. Point-of-care respiratory ultrasound imaging was performed according to a tailored protocol during the patient’s stay in the intensive care unit. In order to evaluate the method, the obtained findings were subject to comparative analysis against the available radiographic findings with a division into sectors.

Results

The comparative analysis of ultrasonographic and radiographic findings with a division into sectors showed the highest concordance rate (89.6%) for S1L (the apex of the left lung) and the lowest concordance rate (57.0%) for S2L (pericardial region). The highest discordance rate, i.e. when a lesion was detected in radiography (X-ray = 1), but was not confirmed by ultrasound (US = 0), was reported for sectors S1P (right lung apex) – 26.1%, and S2L – 40.0%, whereas the lowest discordance rate was reported for S1L – 7.0%. The highest discordance rate, i.e. when a lesion was shown in ultrasound (US = 1), but was not confirmed by radiography (X-ray = 0) was reported for S3P (the base of the right lung) and S3L (base of the right lung) – 28.3% and 26.1%, respectively.

Conclusions

The author’s protocol for ultrasonographic assessment of the respiratory tract is an optimal tool for determining therapeutic goals, as well as for the assessment of the efficacy of pulmonary physiotherapy. The diagnostic value of ultrasonographic assessment of the respiratory tract and standard radiography in the study group depends on the location of the investigated lung segment.

Ultrasonography for endotracheal tube position in infants and children

Ultrasonography (US) has been shown to be effective for verifying endotracheal tube (ETT) position in adults but has been less studied in infants and children. We review the literature regarding US for ETT positioning in the pediatric population. A literature search was conducted using the Ovid and MEDLINE databases with search terms regarding US relating to ETT intubation and positioning in infants and children. Most studies in neonates and infants used the midsagittal suprasternal view. Studies reported >80% visualization of the ETT tip by US, and US interpretation of the ETT position correlated with the XR position in 73-100% of cases. Studies of older children used the suprasternal views, substernal views, and mid-axillary intercostal views. US appears comparable to XR and capnography in determining ETT position in this population.

CONCLUSION

US for ETT verification appears to be well tolerated in infants and children and may augment determination of proper ETT position in combination with other ETT verification modalities. Further studies are needed regarding technique and training. What is Known: • Point-of-care ultrasonography is realizing increased availability and use in several pediatric specialties. • Ultrasonography has been shown to be effective for verifying ETT position in adults but have been less studied in infants and children. What is New: • Ultrasonography for endotracheal tube verification appears to be well tolerated in infants and children. • Ultrasonography may augment determination of proper endotracheal tube position in combination with other verification modalities such as radiography and capnography in the pediatric population.

Bedside Ultrasound for the Diagnosis of Abnormal Diaphragmatic Motion in Children After Heart Surgery

OBJECTIVE

To assess the utility of bedside ultrasound combining B- and M-mode in the diagnosis of abnormal diaphragmatic motion in children after heart surgery.

DESIGN

Prospective post hoc blinded comparison of ultrasound performed by two different intensivists and fluoroscopy results with electromyography.

SETTING

Tertiary university hospital.

SUBJECTS

Children with suspected abnormal diaphragmatic motion after heart surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Abnormal diaphragmatic motion was suspected in 26 children. Electromyography confirmed the diagnosis in 20 of 24 children (83.3%). The overall occurrence rate of abnormal diaphragmatic motion during the study period was 7.5%. Median patient age was 5 months (range, 16 d to 14 yr). Sensitivity and specificity of chest ultrasound performed at the bedside by the two intensivists (91% and 92% and 92% and 95%, respectively) were higher than those obtained by fluoroscopy (87% and 83%). Interobserver agreement (k) between both intensivists was 0.957 (95% CI, 0.87-100).

CONCLUSIONS

Chest ultrasound performed by intensivists is a valid tool for the diagnosis of diaphragmatic paralysis, presenting greater sensitivity and specificity than fluoroscopy. Chest ultrasound should be routinely used after pediatric heart surgery given its reliability, reproducibility, availability, and safety.

The state of point-of-care ultrasonography use and training in neonatal-perinatal medicine and pediatric critical care medicine fellowship programs

OBJECTIVE

The current state of point-of-care ultrasonography (POCUS) use and education in neonatal-perinatal medicine (NPM) and pediatric critical care medicine (PCCM) is unknown. Our aim was to quantify POCUS use, training and perceptions regarding education and barriers among the United States NPM and PCCM fellowship programs.

STUDY DESIGN

A 14-question survey was emailed to the fellowship directors of all the United States NPM and PCCM fellowship programs.

RESULTS

The response rate was 55% (52/95) and 59% (39/66) for NPM and PCCM programs, respectively. Over 90% of respondents in both groups believe that fellows and attendings should receive POCUS training. PCCM programs, compared with NPM, had greater access to POCUS machines (97% vs 63%, P<0.001), and more often used POCUS for diagnoses and management (76% vs 29%, P<0.001) and procedural guidance (95% vs 37%, P<0.001). The most common indications were cardiac/hemodynamics, pulmonary pathology and vascular access in both specialties. PCCM reported more training to fellows (90% vs 29%, P<0.001). Both group perceived lack of time to learn, lack of equipment/funds, liability concerns, lack of personnel to train physicians and cardiology/radiology resistance as significant barriers to POCUS implementation.

CONCLUSIONS

Both NPM and PCCM fellowship programs believe in the benefits of POCUS and that their physicians should receive the necessary training. Compared with PCCM, NPM fellowships programs have less access to POCUS machines and less frequently use POCUS and train their fellows and attendings. There remain significant barriers to utilization of POCUS, especially in NPM.

Analysis of lawsuits related to point-of-care ultrasonography in neonatology and pediatric subspecialties

OBJECTIVE

Point-of-care ultrasonography (POCUS) is becoming increasingly available for neonatologists and pediatric subspecialists (PSS); however, concerns over potential litigation from possible missed diagnoses or incorrect management have been documented. This study aims to define the extent and quality of lawsuits filed against neonatologists and PSS related to POCUS.

STUDY DESIGN

We conducted a retrospective study of all United States reported state and federal cases in the Westlaw database from January 1990 through October 2015. Cases were reviewed and included if either a neonatologist or PSS were accused of misconduct or the interpretation or failure to perform an ultrasound/echocardiogram was discussed. Descriptive statistics were used to evaluate the data.

RESULTS

Our search criteria returned 468 results; 2 cases were determined to be relevant to the study objective. The two cases alleged a failure to perform a diagnostic test and implicated POCUS as an option. There were no cases of neonatologists and PSS being sued for POCUS performance or interpretation.

CONCLUSION

This study of a major legal database suggests that POCUS use and interpretation is not a significant cause of lawsuits against neonatologists and PSS.

Does Bedside Sonography Effectively Identify Nasogastric Tube Placements in Pediatric Critical Care Patients?

BACKGROUND

A nasogastric tube (NGT) insertion is a common procedure in intensive care units, with some serious complications that result from the malposition of the NGT tip. This pilot study was designed to investigate the efficiency of ultrasound in verifying correct NGT placement and to compare these results with radiographic findings.

MATERIALS AND METHODS

This was a single-center, double-blind prospective study of patients who had received an NGT in the pediatric critical care unit. Twenty-one patients aged 1 month to 18 years were included in this study. All NGTs were inserted by the same critical care physician. After insertion, the physician first confirmed NGT placement by the auscultation of the epigastrium following the insufflation of air. Confirmation was supplemented with an abdominal radiograph. A radiologist who was unaware of the radiographic findings performed bedside sonography on all patients and verified the location of the NGTs. The findings from these 2 physicians were then compared.

RESULTS

NGTs were inserted without any complications, and none of the NGTs were positioned in the respiratory tract in any of the patients. All NGT tips were visualized by radiography and sonography with a sensitivity of 100%.

CONCLUSION

Bedside sonography performed by a radiologist is an effective and sensitive diagnostic procedure for confirming the correct NGT position in patients in the pediatric critical care unit.

Useful but not used: pediatric critical care physician views on bedside ultrasound

OBJECTIVE

The purpose of this study was to assess the learning needs of pediatric critical care (PCC) physicians in bedside ultrasound (BUS) use.

METHODS

This was a survey-based study conducted at an academic center with a PCC fellowship program. We surveyed PCC fellows and faculty to elicit their views on BUS and asked them about the frequency of use, their perception of the clinical utility, and their level of confidence in performing different BUS applications.

RESULTS

There was no statistical difference in the self-reported use of BUS applications in the faculty and fellows, except for cardiac arrest, which 66.7% of the faculty used but none of the fellows did (P < 0.05). There were no statistically significant differences between perceived usefulness and confidence in the performance of BUS applications between the fellows and faculty. The largest gaps between perceived usefulness and confidence in performing BUS applications were for left ventricle ejection fraction (Δ = 2.72), inferior vena cava collapse (Δ = 2.67), pulmonary edema (Δ = 2.22), and pneumothorax (Δ = 2.11).

CONCLUSIONS

Pediatric critical care providers report limited confidence in several applications that they perceive as useful and are therefore likely motivated to learn BUS applications. Concentrating curricula on those applications with the greatest differences between usefulness and confidence and building on the confidence of those applications the PCC providers are already using will serve to expand availability and increase use of this high-impact technology.

Implementation of a pediatric critical care focused bedside ultrasound training program in a large academic PICU

OBJECTIVES

To determine the feasibility and describe the process of implementing a pediatric critical care bedside ultrasound program in a large academic PICU and to evaluate the impact of bedside ultrasound on clinical management.

DESIGN

Retrospective case series, description of program implementation.

SETTING

Single-center quaternary noncardiac PICU in a children's hospital.

PATIENTS

Consecutive patients from January 22, 2012, to July 22, 2012, with bedside ultrasounds performed and interpreted by pediatric critical care practitioners.

INTERVENTIONS

A pediatric critical care bedside ultrasound program consisting of a 2-day immersive course followed by clinical performance with internal quality assurance review was implemented. Studies performed in the PICU following training were documented and reviewed against reference standards including subspecialist-performed ultrasound or clinical response.

MEASUREMENTS AND MAIN RESULTS

Seventeen critical care faculties and eight fellows recorded 201 bedside ultrasound studies over 6 months in defined core applications: 57 procedural (28%), 76 hemodynamic (38%), 35 thoracic (17%), and 33 abdominal (16%). A quality assurance review identified 23 studies (16% of all nonprocedural studies) as critical (affected clinical management or gave valuable information). Forty-eight percent of those studies (11/23) were within the hemodynamic core. The proportion of critical studies were not significantly different across the applications (hemodynamic, 11/76 [15%] vs thoracic and abdominal, 12/68 [18%]; p = 0.65). Examples of critical studies include evidence of tamponade secondary to pleural effusions, identification of pulmonary hypertension, hemodynamic assessment before tracheal intubation, recognition of hypovolemia and systemic vascular resistance abnormalities, determination of pneumothorax, location of chest tube and urinary catheter, and differentiation of pleural fluid from pulmonary consolidation.

CONCLUSIONS

Implementation of a critical care bedside ultrasound program for critical care providers in a large academic PICU is feasible. Bedside ultrasound evaluation and interpretation by intensivists affected the management of critically ill children.

Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study*

OBJECTIVES

To evaluate the cardiovascular aberrations using multimodal monitoring in fluid refractory pediatric septic shock and describe the clinical characteristics of septic myocardial dysfunction.

DESIGN

Prospective observational study of patients with unresolved septic shock after infusion of 40 mL/kg fluid in the first hour.

SETTING

Two tertiary care referral Indian PICUs.

PATIENTS

Patients aged 1 month to 16 years who had fluid refractory septic shock.

INTERVENTIONS

Changes in therapy were based on findings of clinical assessment, bedside echocardiography, and invasive blood pressure monitoring within 6 hours of recognition of septic shock.

MEASUREMENTS AND MAIN RESULTS

Over a 4-year period, 48 patients remained in septic shock despite at least 40 mL/kg fluid infusion. On clinical examination, 21 patients had cold shock and 27 had warm shock. Forty-one patients (85.5%) had vasodilatory shock on invasive blood pressure; these included 14 patients who initially presented with cold shock. The commonest echocardiography findings were impaired left ± right ventricular function in 19 patients (39.6%) and hypovolemia in 16 patients (33%). Three patients who had normal myocardial function on day 1 developed secondary septic myocardial dysfunction on day 3. Echocardio graphy, along with invasive arterial pressure monitoring, allowed fluid, inotropy, and pressors to be titrated more precisely in 87.5% of patients. Shock resolved in 46 of 48 patients (96%) and 44 patients (91.6%) survived to discharge.

CONCLUSION

Bedside echocardiography provided crucial information leading to the recognition of septic myocardial dysfunction and uncorrected hypovolemia that was not apparent on clinical assessment. With invasive blood pressure monitoring, echocardiography affords a simple noninvasive tool to determine the cause of low cardiac output and the physiological basis for adjustment of therapy in patients who remain in shock despite 40 mL/kg fluid.