A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

Summary

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

Abstract

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation.

This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Introduction

Ultrasound is a tool that allows an immediate evaluation at the patient's bedside without having to transfer them to another room or floor in the hospital. It can be repeated, it is simple, economical, and precise, and it does not emit ionizing radiation. Ultrasound has been increasingly used by emergency physicians¹, anesthesiologists², and intensivists³ to obtain anatomical and functional images at the patient's bedside. It is a practical tool that is considered by some authors as the fifth pillar of physical examination, as an extension of the human senses⁴ (insp....

Protocol

This protocol was approved by the institution's human research ethics committee; written consent was obtained for acquiring and publishing anonymized images. Never substitute a traditional maneuver, such as auscultating, for an ultrasound image (they can be done simultaneously or alternately by different operators). The consolidated core steps for a critically Ill newborn are a rapid series of supportive actions that need to be remembered as the POCUS team assesses the patient. Always have a second member of the POCUS team securing the endotracheal tube (ETT). Adapt the scanning to the patient's needs without interfering with resuscitation maneuvers.

Results

The inspection of cardiac function by "eyeballing" can be applied to qualitatively assess the global cardiac systolic function. Any suspicion of impaired cardiac function should lead to an urgent HC with pediatric cardiology for the assessment of congenital heart disease (CHD). Treatment must be started according to the pathophysiology, and the treatment should be integrated and modified according to a comprehensive anatomical and functional echocardiography study²⁷. If ductal-dependent CDH is sus.......

Discussion

Compared to children and adults, most cases of acute deterioration/cardiac arrest are due to respiratory causes in newborns. The original SAFE protocol was modified in our unit, a tertiary referral care neonatal center, due to this unit expecting several ventilated patients with indwelling catheters. The protocol has been adapted to different scenarios and equipment for use in low- and medium-income countries. As an institution with a neonatal hemodynamics and POCUS program, and after giving LUS workshops in different st.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Conductivity gel	Ultra/Phonic, Pharmaceutical innovations, New Jersey, United States	36-1001-25
Handheld linear probe, 10.0 MHz	Konted, Beijing, China	C10L	handheld device
Hockey stick probe 8–18 MHz, L8-18I-SC Probe	GE Medical Systems, Milwaukee, WI, United States	H40452LZ	high-end ultrasound equipment
iPad Air 2	Apple Inc	MGWM2CL/A	electronic tablet
Phased array probe 6-12 MHz, 12S-D Phased Array Probe	GE Medical Systems, Milwaukee, WI, United States	H45021RT	high-end ultrasound equipment
Vivid E90 v203 Console Package	GE Medical Systems, Milwaukee, WI, United States	H8018EB	Vivid E90 w/OLED monitor v203 Console