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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.
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Pediatric point-of-care ultrasonography (POCUS) has grown in utilization and is now an integral part of pediatric acute care. Applications within the pediatric critical care, neonatology and pediatric emergency were once limited to evaluation of undifferentiated shock states, abdominal free fluid assessments in trauma resuscitation and procedural guidance. The body of pediatric POCUS literature is ever expanding and recently published international consensus guidelines are available to guide implementation into clinical practice. The authors present a review of emerging applications and controversies within thoracic, hemodynamic, neurologic, and ocular POCUS in pediatric acute care medicine.
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BACKGROUND: Ultrasound-based diaphragmatic assessments are becoming more common in pediatric acute care, but baseline pediatric diaphragm thickness and contractility values remain unknown. METHODS: We conducted a prospective, observational study of healthy children aged <18 years undergoing elective surgery. Diaphragm thickness at end-expiration (Tdi-exp), thickening fraction (DTF) and excursion were measured by ultrasound during spontaneous breathing and during mechanical ventilation. Diaphragm strain and peak strain rate were ascertained post hoc. Measurements were compared across a priori specified age groups (<1 year, 1 to <3, 3 to <6, 6 to <12, and 12 to <18 years) and with versus without mechanical ventilation. RESULTS: Fifty subjects were evaluated (n = 10 per age group). Baseline mean Tdi-exp was 0.19 ± 0.04 cm, DTF 0.19 ± 0.09, excursion 1.69 ± 0.97 cm, strain -10.3 ± 4.9, peak strain rate -0.48 ± 0.21 s-1 . No significant difference in Tdi-exp or DTF was observed across age groups (p > .05). Diaphragm excursion increased with age (p < .0001). Diaphragm strain was significantly greater in the 12-17-year age group (-14.3 ± 6.4), p = .048, but there were no age-related differences in peak strain rate (p = .08). During mechanical ventilation, there were significant decreases in DTF 0.12 ± 0.04 (p < .0001), excursion 1.08 ± 0.31 cm (p < .0001), strain -4.60 ± 1.93 (p < .0001), and peak strain rate -0.20 ± 0.10 s-1 (p < .0001) while there was no change in Tdi-exp 0.18 ± 0.03 cm (p = .25) when compared to baseline values. CONCLUSION: Pediatric Tdi-exp, DTF, and diaphragm peak strain rate were similar across age groups. Diaphragm excursion and strain varied across age groups. All measures of diaphragm contractility were diminished during mechanical ventilation.
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Diafragma , Respiración Artificial , Humanos , Niño , Adolescente , Diafragma/diagnóstico por imagen , Estudios Prospectivos , Tórax , Respiración , UltrasonografíaRESUMEN
OBJECTIVES: To assess focused cardiac ultrasound impact on clinician hemodynamic characterization of patients with suspected septic shock as well as expert-generated focused cardiac ultrasound algorithm performance. DESIGN: Retrospective, observational study. SETTING: Single-center, noncardiac PICU. PATIENTS: Less than 18 years old receiving focused cardiac ultrasound study within 72 hours of sepsis pathway initiation from January 2014 to December 2016. INTERVENTIONS: Hemodynamics of patients with suspected septic shock were characterized as fluid responsive, myocardial dysfunction, obstructive physiology, and/or reduced systemic vascular resistance by a bedside clinician before and immediately following focused cardiac ultrasound performance. The clinician's post-focused cardiac ultrasound hemodynamic assessments were compared with an expert-derived focused cardiac ultrasound algorithmic hemodynamic interpretation. Subsequent clinical management was assessed for alignment with focused cardiac ultrasound characterization and association with patient outcomes. MEASUREMENTS AND MAIN RESULTS: Seventy-one patients with suspected septic shock (median, 4.7 yr; interquartile range, 1.6-8.1) received clinician performed focused cardiac ultrasound study within 72 hours of sepsis pathway initiation (median, 2.1 hr; interquartile range, -1.5 to 11.8 hr). Two patients did not have pre-focused cardiac ultrasound and 23 patients did not have post-focused cardiac ultrasound hemodynamic characterization by clinicians resulting in exclusion from related analyses. Post-focused cardiac ultrasound clinician hemodynamic characterization differed from pre-focused cardiac ultrasound characterization in 67% of patients (31/46). There was substantial concordance between clinician's post-focused cardiac ultrasound and algorithm hemodynamic characterization (33/48; κ = 0.66; CI, 0.51-0.80). Fluid responsive (κ = 0.62; CI, 0.40-0.84), obstructive physiology (к = 0.87; CI, 0.64-1.00), and myocardial dysfunction (1.00; CI, 1.00-1.00) demonstrated substantial to perfect concordance. Management within 4 hours of focused cardiac ultrasound aligned with algorithm characterization in 53 of 71 patients (75%). Patients with aligned management were less likely to have a complicated course (14/52, 27%) compared with misaligned management (8/19, 42%; p = 0.25). CONCLUSIONS: Incorporation of focused cardiac ultrasound in the evaluation of patients with suspected septic shock frequently changed a clinician's characterization of hemodynamics. An expert-developed algorithm had substantial concordance with a clinician's post-focused cardiac ultrasound hemodynamic characterization. Management aligned with algorithm characterization may improve outcomes in children with suspected septic shock.
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Sepsis , Choque Séptico , Adolescente , Niño , Hemodinámica , Humanos , Estudios Retrospectivos , Choque Séptico/diagnóstico por imagen , Choque Séptico/terapia , UltrasonografíaRESUMEN
Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCMPerspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.
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Médicos , Sistemas de Atención de Punto , Niño , Cuidados Críticos , Atención a la Salud , Humanos , UltrasonografíaRESUMEN
OBJECTIVES: Diaphragm atrophy is evident during invasive ventilation for pediatric acute respiratory failure, but with unknown significance. We hypothesized that diaphragm atrophy in pediatric acute respiratory failure is associated with prolonged noninvasive positive pressure ventilation following extubation. DESIGN: Prospective observational study. SETTING: Single-center academic PICU. PATIENTS: Invasively ventilated children with acute respiratory failure. INTERVENTIONS: Diaphragm ultrasound was performed within 36 hours after intubation and repeated within 48 hours preceding extubation. Rapid shallow breathing index at 15 and 30 minutes of a spontaneous breathing trial and negative inspiratory force were collected in a subset of patients concurrently with the ultrasound measurements. MEASUREMENTS AND MAIN RESULTS: Diaphragm thickness at end-expiration was measured to assess for diaphragm atrophy during mechanical ventilation. Percentage change in diaphragm thickness at end-expiration was defined as baseline diaphragm thickness at end-expiration minus final, preextubation diaphragm thickness at end-expiration divided by baseline diaphragm thickness at end-expiration. The primary outcome measure was duration of noninvasive positive pressure ventilation following extubation with prolonged use defined as noninvasive positive pressure ventilation use for greater than 24 hours postextubation. Among 56 children, 47 (median age, 15.5 mo; interquartile range, 6-53 mo) had diaphragm thickness at end-expiration measured within 48 hours prior to extubation. Fourteen (30%) had prolonged noninvasive positive pressure ventilation use with median duration 110 hours (interquartile range, 52-130 hr). The median percentage change of diaphragm thickness at end-expiration from baseline among those with and without prolonged noninvasive positive pressure ventilation use was -20% (interquartile range, -32% to -10%) versus -7% (interquartile range, -21% to 0%) (p = 0.04). CONCLUSIONS: Diaphragm atrophy is associated with prolonged postextubation noninvasive positive pressure ventilation in children with acute respiratory failure. Serial bedside diaphragm ultrasound may identify children at risk for prolonged noninvasive positive pressure ventilation use after extubation.
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Ventilación no Invasiva , Insuficiencia Respiratoria , Adolescente , Extubación Traqueal , Atrofia/patología , Niño , Diafragma/diagnóstico por imagen , Diafragma/patología , Humanos , Respiración Artificial , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/patología , Insuficiencia Respiratoria/terapia , Desconexión del VentiladorRESUMEN
Point-of-care ultrasound is currently widely used across the landscape of pediatric care. Ultrasound machines are now smaller, are easier to use, and have much improved image quality. They have become common in emergency departments, ICUs, inpatient wards, and outpatient clinics. Recent growth of supportive evidence makes a strong case for using point-of-care ultrasound for pediatric interventions such as vascular access (in particular, central-line placement), lumbar puncture, fluid drainage (paracentesis, thoracentesis, pericardiocentesis), suprapubic aspiration, and soft tissue incision and drainage. Our review of this evidence reveals that point-of-care ultrasound has become a powerful tool for improving procedural success and patient safety. Pediatric patients and clinicians performing procedures stand to benefit greatly from point-of-care ultrasound, because seeing is believing.
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Cateterismo Venoso Central/métodos , Cateterismo Periférico/métodos , Sistemas de Atención de Punto , Ultrasonografía Intervencional/métodos , Niño , Humanos , Pruebas en el Punto de AtenciónRESUMEN
High-frequency oscillatory ventilation (HFOV) is a mode of mechanical ventilation used in severe pediatric respiratory failure. Thoracic ultrasound (US) is a powerful tool for diagnosing acute pathophysiologic conditions during spontaneous respiration and conventional noninvasive and invasive mechanical ventilation. High-frequency oscillatory ventilation differs from conventional modes of ventilation in that it does not primarily use bulk flow delivery for gas exchange but, rather, a number of alternative mechanisms as the result of pressure variations oscillating around a constant distending pressure. Thoracic US has not been well described in patients receiving HFOV, and it is unclear whether the US findings for assessing thoracic pathophysiologic conditions during conventional ventilation are applicable to patients receiving HFOV. We discuss the similarities and differences of thoracic US findings in patients who are spontaneously breathing or receiving conventional ventilation compared to those in patients receiving HFOV.
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Ventilación de Alta Frecuencia/métodos , Pulmón/diagnóstico por imagen , Pulmón/fisiopatología , Insuficiencia Respiratoria/terapia , Enfermedades Torácicas/diagnóstico por imagen , Ultrasonografía/métodos , Adolescente , Humanos , Masculino , Enfermedades Torácicas/fisiopatologíaRESUMEN
OBJECTIVES: Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children with acute respiratory failure. DESIGN: Prospective, observational study. SETTING: Single-center tertiary noncardiac PICU in a children's hospital. PATIENTS: Invasively ventilated children with acute respiratory failure. MEASUREMENTS AND MAIN RESULTS: Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5-52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83-201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8-2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2-2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was -13.8% (interquartile range, -27.4% to 0%), with a -3.4% daily atrophy rate (interquartile range, -5.6 to 0%). Thickening fraction = ([thickness at end-inspiration - thickness at end-expiration]/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2-14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (-16.4%, [interquartile range, -28.4% to -7.0%] vs -7.3%; [interquartile range, -10.9% to -0%]; p = 0.036). CONCLUSIONS: Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy.