Echocardiographic Evaluation of Hemodynamics in Neonates and Children
Yogen Singh, Yogen Singh
Abstract
Hemodynamic instability and inadequate cardiac performance are common in critically ill children. The clinical assessment of hemodynamic status is reliant upon physical examination supported by the clinical signs such as heart rate, blood pressure, capillary refill time, and measurement of the urine output and serum lactate. Unfortunately, all of these parameters are surrogate markers of cardiovascular well-being and they provide limited direct information regarding the adequacy of blood flow and tissue perfusion. A bedside point-of-care echocardiography can provide real-time hemodynamic information by assessing cardiac function, loading conditions (preload and afterload) and cardiac output. The echocardiography has the ability to provide longitudinal functional assessment in real time, which makes it an ideal tool for monitoring hemodynamic assessment in neonates and children. It is indispensable in the management of patients with shock, pulmonary hypertension, and patent ductus arteriosus. The echocardiography is the gold standard diagnostic tool to assess hemodynamic stability in patients with pericardial effusion, cardiac tamponade, and cardiac abnormalities such as congenital heart defects or valvar disorders. The information from echocardiography can be used to provide targeted treatment in intensive care settings such as need of fluid resuscitation versus inotropic support, choosing appropriate inotrope or vasopressor, and in providing specific interventions such as selective pulmonary vasodilators in pulmonary hypertension. The physiological information gathered from echocardiography may help in making timely, accurate, and appropriate diagnosis and providing specific treatment in sick patients. There is no surprise that use of bedside point-of-care echocardiography is rapidly gaining interest among neonatologists and intensivists, and it is now being used in clinical decision making for patients with hemodynamic instability. Like any other investigation, it has certain limitations and the most important limitation is its intermittent nature. Sometimes acquiring high quality images for precise functional assessment in a ventilated child can be challenging. Therefore, it should be used in conjunction with the existing tools (physical examination and clinical parameters) for hemodynamic assessment while making clinical decisions.
Keywords: echocardiography in NICU; functional echocardiography; hemodynamic assessment in intensive care; hemodynamic evaluation; neonates and children.
Figures
References
- Kluckow M, Seri I, Evans N. Functional echocardiography: an emerging clinical tool for the neonatologist. J Pediatr (2007) 150:125–30.10.1016/j.jpeds.2006.10.056
- Evans N, Kluckow M. Early determinants of right and left ventricular output in ventilated preterm infants. Arch Dis Child Fetal Neonatal Ed (1996) 74:F88–94.10.1136/fn.74.2.F88
- Sehgal A, McNamara PJ. Does point-of-care functional echocardiography enhance cardiovascular care in the NICU? J Perinatol (2008) 28:729–35.10.1038/jp.2008.100
- El-Khuffash AF, Jain A, Weisz D, Mertens L, McNamara PJ. Assessment and treatment of post patent ductus arteriosus ligation syndrome. J Pediatr (2014) 165:46–52.10.1016/j.jpeds.2014.03.048
- Stanko LK, Jacobsohn E, Tam JW, de Wet CJ, Avidan M. Transthoracic echocardiography: impact on diagnosis and management in tertiary care intensive care units. Anaesth Intensive Care (2005) 33:492–6.
- Vignon P, Mentec H, Terré S, Gastinne H, Gueret P, Lemaire F. Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU. Chest (1994) 106:1829–34.10.1378/chest.106.6.1829
- Singh Y, Gupta S, Groves AM, Gandhi A, Thomson J, Qureshi S, et al. Expert consensus statement ‘neonatologist-performed echocardiography (NoPE)’-training and accreditation in UK. Eur J Pediatr (2016) 175:281–7.10.1007/s00431-015-2633-2
- Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, et al. Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. Writing Group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). J Am Soc Echocardiogr (2011) 24:1057–78.10.1016/j.echo.2011.07.014
- De Boode WP, Singh Y, Gupta S, Austin T, Bohlin K, Dempsey E, et al. Recommendations for neonatologist performed echocardiography in Europe: consensus statement endorsed by European Society for Paediatric Research (ESPR) and European Society for Neonatology (ESN). Pediatr Res (2016) 80:465–71.10.1038/pr.2016.126
- Ranjit S, Aram G, Kissoon N, Ali MK, Natraj R, Shresti S, et al. Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study. Pediatr Crit Care Med (2014) 15:e17–26.10.1097/PCC.0b013e3182a5589c
- Manasia AR, Nagaraj HM, Kodalietal RB. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth (2005) 19:155–9.10.1053/j.jvca.2005.01.023
- Vincent JL, Backer D. Circulatory shock. N Engl J Med (2013) 369:1726–34.10.1056/NEJMra1208943
- DeCara JM, Lang RM, Koch R, Bala R, Penzotti J, Spencer KT. The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr (2003) 4:141–7.10.1053/euje.4.2.141
- Vignon P, Mücke F, Bellecetal F. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med (2011) 39:636–42.10.1097/CCM.0b013e318206c1e4
- Longjohn M, Wan J, Joshi V, Pershad J. Point-of-care echocardiography by pediatric emergency physicians. Pediatr Emerg Care (2011) 27:693–6.10.1097/PEC.0b013e318226c7c7
- Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, et al. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics (2004) 114:e667–71.10.1542/peds.2004-0881
- Spurney CF, Sable CA, Berger JT, Martin GR. Use of a hand-carried ultrasound device by critical care physicians for the diagnosis of pericardial effusions, decreased cardiac function, and left ventricular enlargement in pediatric patients. J Am Soc Echocardiogr (2005) 18:313–9.10.1016/j.echo.2004.10.016
- Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, et al. Focused training for goal-oriented hand-held echocardiography performed by non-cardiologist residents in the intensive care unit. Intensive Care Med (2007) 33:1795–9.10.1007/s00134-007-0742-8
- Poelaert JI, Schupfer G. Hemodynamic monitoring utilizing transesophageal echocardiography. The relationships among pressure, flow, and function. Chest (2005) 127:379–90.10.1378/chest.127.1.379
- Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr (2005) 18:1440–63.10.1016/j.echo.2005.10.005
- Slama M, Masson H, Teboul JL, Arnout ML, Susic D, Frohlich E. Respiratory variations of aortic VTI: a new index of hypovolemia and fluid responsiveness. Am J Physiol Heart Circ Physiol (2002) 283:1729–33.10.1152/ajpheart.00308.2002
- Feissel M, Michard F, Mangin I, Ruyer O, Faller JP, Teboul JL. Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest (2001) 119:867–73.10.1378/chest.119.3.867
- Bates S, Odd D, Luyt K, Mannix P, Wach R, Evans D, et al. Superior vena cava flow and intraventricular haemorrhage in extremely preterm infants. J Matern Fetal Neonatal Med (2016) 29:1581–7.10.3109/14767058.2015.1054805
- Kluckow M, Evans N. Superior vena cava flow in newborn infants: a novel marker of systemic blood flow. Arch Dis Child Fetal Neonatal Ed (2000) 82:F182–7.10.1136/fn.82.3.F182
- Lee A, Liestøl K, Nestaas E, Brunvand L, Lindemann R, Fugelseth D. Superior vena cava flow: feasibility and reliability of the off-line analyses. Arch Dis Child Fetal Neonatal Ed (2010) 95:F121–5.10.1136/adc.2009.176883
- Groves AM, Kuschel CA, Knight DB, Skinner JR. Echocardiographic assessment of blood flow volume in the superior vena cava and descending aorta in the newborn infant. Arch Dis Child Fetal Neonatal Ed (2008) 93:F24–8.10.1136/adc.2006.109512
- Ficial B, Finnemore AE, Cox DJ, Broadhouse KM, Price AN, Durighel G, et al. Validation study of the accuracy of echocardiographic measurements of systemic blood flow volume in newborn infants. J Am Soc Echocardiogr (2013) 26:1365–71.10.1016/j.echo.2013.08.019
- Ficial B, Bonafiglia E, Padovani EM, Prioli MA, Finnemore AE, Cox DJ, et al. A modified echocardiographic approach improves reliability of superior vena caval flow quantification. Arch Dis Child Fetal Neonatal Ed (2017) 102:F7–11.10.1136/archdischild-2015-309523
- Pereira de Souza Neto E, Grousson S, Duflo F, Ducreux C, Joly H, Convert J, et al. Predicting fluid responsiveness in mechanically ventilated children under general anaesthesia using dynamic parameters and transthoracic echocardiography. Br J Anaesth (2011) 106:856–64.10.1093/bja/aer090
- Renner J, Broch O, Duetschke P, Scheewe J, Höcker J, Moseby M, et al. Prediction of fluid responsiveness in infants and neonates undergoing congenital heart surgery. Br J Anaesth (2012) 108:108–15.10.1093/bja/aer371
- Choi DY, Kwak HJ, Park HY, Kim YB, Choi CH, Lee JY. Respiratory variation in aortic blood flow velocity as a predictor of fluid responsiveness in children after repair of ventricular septal defect. Pediatr Cardiol (2010) 31:1166–70.10.1007/s00246-010-9776-8
- Feissel M, Michard F, Faller J-P, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med (2004) 30:1834–7.10.1007/s00134-004-2233-5
- Barbier C, Loubières Y, Schmit C, Hayon J, Ricôme JL, Jardin F, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med (2004) 30:1740–6.10.1007/s00134-004-2259-8
- Amiel J-B, Grumann A, Lheritier G, Clavel M, Francois B, Pichon N, et al. Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients. Crit Care (2012) 16:29.10.1186/cc11198
- Razi R, Estrada JR, Doll J, Spencer KT. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr (2011) 24:1319–24.10.1016/j.echo.2011.07.013
- Gaspar HA, Morhy SS, Lianzaetal AC, de Carvalho WB, Andrade JL, do Prado RR, et al. Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians. BMC Med Educ (2014) 14:25.10.1186/1472-6920-14-25
- Klugman D, Berger JT. Echocardiography as a hemodynamic monitor in critically ill children. Pediatr Crit Care Med (2011) 12:S50–4.10.1097/PCC.0b013e3182211c17
- Lopez L, Colan SD, Frommelt PC, Ensing GJ, Kendall K, Younoszai AK, et al. Recommendations for quantification methods during the performance of a pediatric echo-cardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. J Am Soc Echocardiogr (2010) 23:465–95.10.1016/j.echo.2010.03.019
- Colan SD, Trowitzsch E, Wernovsky G, Sholler GF, Sanders SP, Castaneda AR. Myocardial performance after arterial switch operation for transposition of the great arteries with intact ventricular septum. Circulation (1988) 78:132–41.10.1161/01.CIR.78.1.132
- Elkins RC, Knott-Craig CJ, Ahn JH, Murray CK, Overholt ED, Ward KE, et al. Ventricular function after the arterial switch operation for transposition of the great arteries. Ann Thorac Surg (1994) 57:826–31.10.1016/0003-4975(94)90183-X
- Harada K, Toyono M, Yamamoto F. Assessment of right ventricular function during exercise with quantitative Doppler tissue imaging in children late after repair of tetralogy of Fallot. J Am Soc Echocardiogr (2004) 17:863–9.10.1016/j.echo.2004.04.037
- Jain A, Mohamed A, El-Khuffash A, Connelly KA, Dallaire F, Jankov RP, et al. A comprehensive echocardiographic protocol for assessing neonatal right ventricular dimensions and function in the transitional period: normative data and z scores. J Am Soc Echocardiogr (2014) 27:1293–304.10.1016/j.echo.2014.08.018
- Cecconi M, de Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med (2014) 40:1795–815.10.1007/s00134-014-3525-z
- Sutherland GR, Di Salvo G, Claus P, D’hooge J, Bijnens B. Strain and strain rate imaging: a new clinical approach to quantifying regional myocardial function. J Am Soc Echocardiogr (2004) 17:788–802.10.1016/j.echo.2004.03.027
- Breatnach CR, Levy PT, James AT, Franklin O, El-Khuffash A. Novel echocardiography methods in the functional assessment of the newborn heart. Neonatology (2016) 110:248–60.10.1159/000445779
- Gorcsan J, 3rd, Strum DP, Mandarino WA, Gulati VK, Pinsky MR. Quantitative assessment of alterations in regional left ventricular contractility with color-coded tissue Doppler echocardiography: comparison with sonomicrometry and pressure-volume relations. Circulation (1997) 95:2423–33.10.1161/01.CIR.95.10.2423
- Herbots L, Maes F, D’hooge J, Claus P, Dymarkowski S, Mertens P, et al. Quantifying myocardial deformation throughout the cardiac cycle: a comparison of ultra-sound strain rate, grey-scale M-mode and magnetic resonance imaging. Ultrasound Med Biol (2004) 30:591–8.10.1016/j.ultrasmedbio.2004.02.003
- Vassalos A, Lilley S, Young D, Peng E, MacArthur K, Pollock J, et al. Tissue Doppler imaging following paediatric cardiac surgery: early patterns of change and relationship to outcome. Interact Cardiovasc Thorac Surg (2009) 9:173–7.10.1510/icvts.2008.201723
- Cheung MM, Smallhorn JF, Vogel M, Van Arsdell G, Redington AN. Disruption of the ventricular myocardial force-frequency relationship after cardiac surgery in children: noninvasive assessment by means of tissue Doppler imaging. J Thorac Cardiovasc Surg (2006) 131:625–31.10.1016/j.jtcvs.2005.09.056
- Fyfe DA, Ketchum D, Lewis R, Sabatier J, Kanter K, Mahle W, et al. Tissue Doppler imaging detects severely abnormal myocardial velocities that identify children with pre-terminal cardiac graft failure after heart transplantation. J Heart Lung Transplant (2006) 25:510–7.10.1016/j.healun.2005.11.453
- Vieillard-Baron A. Assessment of right ventricular function. Curr Opin Crit Care (2009) 15:254–60.10.1097/MCC.0b013e32832b70c9
- Aggarwal S, Stockmann P, Klein MD, Natarajan G. Echocardiographic measures of ventricular function and pulmonary artery size: prognostic markers of congenital diaphragmatic hernia? J Perinatol (2011) 31:561–6.10.1038/jp.2011.3
- Moenkemeyer F, Patel N. Right ventricular diastolic function measured by tissue Doppler imaging predicts early outcome in congenital diaphragmatic hernia. Pediatr Crit Care Med (2014) 15:49–55.10.1097/PCC.0b013e31829b1e7a
- Malowitz JR, Forsha DE, Smith PB, Cotten CM, Barker PC, Tatum GH. Right ventricular echocardiographic indices predict poor outcomes in infants with persistent pulmonary hypertension of the newborn. Eur Heart J Cardiovasc Imaging (2015) 16:1224–31.10.1093/ehjci/jev071
- Osman D, Monnet X, Castelain V, Anguel N, Warszawski J, Teboul JL, et al. Incidence and prognostic value of right ventricular failure in acute respiratory distress syndrome. Intensive Care Med (2009) 35:69–76.10.1007/s00134-008-1307-1
- Jone PN, Ivy PD. Echocardiography in pediatric pulmonary hypertension. Front Pediatr (2014) 2:1–15.10.3389/fped.2014.00124
- Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr (2010) 23:685–713.10.1016/j.echo.2010.05.010
- Burgess MI, Bright-Thomas RJ, Ray SG. Echocardiographic evaluation of right ventricular function. Eur J Echocardiogr (2002) 3:252–62.10.1053/euje.2002.0172
- Lammers AE, Haworth SG, Riley G, Maslin K, Diller GP, Marek J. Value of tissue Doppler echocardiography in children with pulmonary hypertension. J Am Soc Echocardiogr (2012) 25:504–10.10.1016/j.echo.2012.01.017
- Koestenberger M, Nagel B, Ravekes W, Urlesberger B, Raith W, Avian A, et al. Systolic right ventricular function in preterm and term neonates: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 258 patients and calculation of Z-score values. Neonatology (2011) 100:85–92.10.1159/000322006
- Levy PT, Patel MD, Groh G, Choudhry S, Murphy J, Holland MR, et al. Pulmonary artery acceleration time provides a reliable estimate of invasive pulmonary hemodynamics in children. J Am Soc Echocardiogr (2016) 29:1056–65.10.1016/j.echo.2016.08.013
- Koestenberger M, Grangl G, Avian A, Gamillscheg A, Grillitsch M, Cvirn G, et al. Normal reference values and z scores of the pulmonary artery acceleration time in children and its importance for the assessment of pulmonary hypertension. Circ Cardiovasc Imaging (2017) 10(1):e005336.10.1161/CIRCIMAGING.116.005336
- Alverson DC, Eldridge M, Dillon T, Yabek SM, Berman W, Jr. Noninvasive pulsed Doppler determination of cardiac output in neonates and children. J Pediatr (1982) 101:46–50.10.1016/S0022-3476(82)80178-9
- Alverson DC. Neonatal cardiac output measurement using pulsed Doppler ultrasound. Clin Perinatol (1985) 12:101–27.
- Groves AM, Chiesa G, Durighel G, Goldring ST, Fitzpatrick JA, Uribe S, et al. Functional cardiac MRI in preterm and term newborns. Arch Dis Child Fetal Neonatal Ed (2011) 96:F86–91.10.1136/adc.2010.189142
- Tsai-Goodman B, Martin RP, Marlow N, Skinner JR. The repeatability of echocardiographic determination of right ventricular output in the newborn. Cardiol Young (2001) 11:188–94.10.1017/S1047951101000099
- Chew MS, Poelaert J. Accuracy and repeatability of pediatric cardiac output measurement using Doppler: 20-year review of the literature. Intensive Care Med (2003) 29:1889–94.10.1007/s00134-003-1967-9
- Osborn DA, Evans N, Kluckow M, Bowen JR, Rieger I. Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants. Pediatrics (2007) 120:372–80.10.1542/peds.2006-3398
- Miletin J, Dempsey EM. Low superior vena cava flow on day 1 and adverse outcome in the very low birthweight infant. Arch Dis Child Fetal Neonatal Ed (2008) 93:F368–71.10.1136/adc.2007.129304
Source: PubMed