Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

Summary

Presented here is a protocol to perform comprehensive neonatal echocardiography by trained neonatologists in the neonatal intensive care unit. The trained individuals provide longitudinal assessments of heart function, systemic and pulmonary hemodynamics in a consultative role. The manuscript also describes the requirements to become a fully trained neonatal hemodynamics specialist.

Abstract

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

Introduction

Targeted neonatal echocardiography (TnECHO) refers to the bedside use of echocardiography to longitudinally assess myocardial function, systemic and pulmonary blood flow, and intracardiac and extracardiac shunts¹. When TnECHO is integrated with clinical findings, it can provide vital information in diagnosis, the guidance of therapeutic interventions, and the dynamic monitoring of response to treatments². TnECHO is frequently performed by trained neonatologists in response to a specific clinical question with the goal of acquiring hemodynamics information that can complement and provide physiologic insights into the....

Protocol

This protocol was approved by the institution's human research ethics committee, and written consent was obtained from the patient before the procedure.

1. Preparation

1. For image acquisition, use ultrasound systems that include two-dimensional (2D), M-mode, and full Doppler capabilities, as well as simultaneous electrocardiographic tracing display ability.
2. Ensure that multi-frequency probes, 5-6 MHz (for infants >2 kg) and 8-12 MHz (for infants <2 kg), are available for use in the appropriate size of infants. Commonly used echocardiographic terms are described in Table 1 wit....

Results

The following representative results outline the evaluation of a hemodynamically significant patent ductus arteriosus (hsPDA) as an example of the use of TnECHO in clinical settings. As mentioned earlier, a comprehensive assessment with multiple measurements is performed to adjudicate hemodynamic significance. The Iowa PDA score (Table 3) is one of the scoring systems adopted into clinical use as it assists in quantifying the consequences of volume loading and systemic hypoperfusion associated with PDA s.......

Discussion

TnECHO-guided care has been adopted in many neonatal intensive care units as an adjunct to the clinical assessment of hemodynamic instability in infants by neonatologists⁴. Accredited training programs have been developed in accordance with the 2011 ASE³ with a focus on a competence-based approach to training. The unique vulnerability of the immature cardiovascular system and the complexity of cardiovascular adaptation during the postnatal transition are key determinants of.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
DICOM VIEWER EP	GEHealthcare	H45581CC	DICOM Viewer on MediaThis option provides the ability to export DICOM images including a DICOM viewer to storage media (USB, DVD), for easy access to patient images on offline computers.
2D Strain	GEHealthcare	H45561WF	Automated 2D EF Measurement tool based upon 2D-Speckle tracking algorithm.
EchoPAC* Software Only v203	GEHealthcare	H8018PF
EchoPAC* Advanced Bundle Package	GEHealthcare	H8018PG	Advanced QScan provides dedicated parametric imaging applications for quantitative display of regional wall deformation.
Multi-Link 3-lead ECG Care cable neonatal DIN, AHA (3.6 m/12 feet)	GEHealthcare	H45571RD	Multi-Link 3-lead ECG Care cable neonatal DIN, AHA (3.6 m/12 feet) Used together with neonatal leads H45571RJ
Myocardial Work		H45591AG	Myocardial Work adjusts the AFI (strain) results using the systolic and diastolic blood pressure measured immediately prior to the echo exam. Using the Myocardial Work feature helps achieve a less load dependent strain/ pressure curve and work efficiency index
12S-D Phased Array Probe	GEHealthcare	H45021RT
6S-D Phased Array Probe	GEHealthcare	H45021RR
Sterile ultrasound gel	Parker labs	PM-010-0002D	sterile water solubel single packet ultrasound transmission gel
Ultrasound gel warmer	Parker Labs	SKU 83-20	ultrasound gel warmer for single gel package.
Wireless USB adapter		H45591HS	Wireless external G type USB adapter with extension cable and hardware for mounting on the rear panel.
Vivid* E90 v203 Console Package	GEHealthcare	H8018EB	Vivid E90 w/OLED monitor v203 Console