No Critical Ultrasound, No Life: The Value of Point-of Care Critical Ultrasound in the Rescue of Critically Ill Infants.

Point-of-care critical ultrasound (POC-CUS) screening plays an increasingly important role in the treatment of critically ill infants. Without POC-CUS, the lives of many infants would not be saved in time and correctly. A premature infant with systemic multiple organ system dysfunction caused by fungal sepsis was treated and nursed under the guidance of POC-CUS monitoring, and the infant was ultimately cured. This premature infant had systemic multiple organ system dysfunction and disseminated intravascular coagulation (DIC) caused by fungal sepsis. In the hypercoagulable state of early-stage DIC, cardiac thrombosis could be found using ultrasound screening. For this case, right renal artery thrombosis was found via renal artery Doppler ultrasound examination. Due to the severity of this disease, ultrasound-guided peripherally inserted central catheter (PICC) insertion and ultrasound checks of the PICC tip's position were performed, which ensured the success of this one-time catheterization and shortened the catheterization time. Lung ultrasound is used for the diagnosis and differential diagnosis of pulmonary diseases, and to guide the application of mechanical ventilation. Because the abdominal circumference of the patient's markedly enlarged abdominal circumference, bloody stool, and absence of bowel sounds, abdominal ultrasonography was performed, which revealed a markedly enlarged liver, significant peritoneal effusion, and necrotizing enterocolitis. Guided by POC-CUS monitoring, we had the opportunity to implement timely and effective treatment that ultimately saved this critically ill patient's life. The successful treatment of this newborn infant fully reflects the importance of carrying out POC-CUS screening.

Ultrasound to guided epicutaneo-caval catheter insertion in newborn infants.

Objective: Recently, ultrasound (US) has been increasingly used for epicutaneo-caval catheter (ECC) tip positioning; however, the selection of blood vessels for ECC still depends on the operator's subjective judgment. This study aimed to explore the value of US in decision-making regarding the great saphenous vein (GSV), tip navigation, and tip location of ECC. Methods: Catheterization through the GSV of the lower extremity was selected. The running condition of the GSV was assessed by using US, and the angle between the GSV and the femoral vein was observed and measured. We selected the GSV with a smaller angle to the femoral vein for ECC catheterization. Results: ECC catheterization under ultrasound guidance increased the success rate at the time of catheterization from 82.5% to 100% (increased by 17.5%) and shortened the catheterization time from 56.1 ± 5.30 min to 31.5 ± 2.58 min on average (shortened by 44%). The incidence rate of catheter-related complications decreased by 58.2% catheter days from 6.80/1,000 to 2.84/1,000. Conclusion: ECC insertion under the guidance of US has numerous advantages, including significantly improving the success rate of one-time catheterization, shortening the time of catheterization, and reducing catheter-related complications.

The Outcome- or Cost-Effectiveness Analysis of LUS-Based Care or CXR-Based Care of Neonatal Lung Diseases: The Clinical Practice Evidence from a Level â ¢ NICU in China.

OBJECTIVE: To compare the effect of managing neonatal lung disease with lung ultrasound (LUS) or chest X-ray (CXR) monitoring on health outcomes and cost-effectiveness. METHODS: The data obtained from the NICU of the Beijing Chaoyang District Maternal and Child Healthcare Hospital were used as the study group, as LUS has completely replaced CXR in managing newborn lung disease in the hospital for the past 5 years. The primary outcomes of this study were the misdiagnosis rate of respiratory distress syndrome (RDS), the using status of mechanical ventilation, the incidence rate of bronchopulmonary dysplasia (BPD) and the survival rate in hospitalized infants. The secondary outcomes included the use pulmonary surfactant (PS), and the mortality rate of severe diseases (such as pneumothorax, pulmonary hemorrhage and RDS, etc.). RESULTS: Managing neonatal lung disease with LUS monitoring may enable the following effects: The frequency of ventilator use reducing by 40.2%; the duration of mechanical ventilation reducing by 67.5%; and the frequency of ventilator weaning failure being totally avoided. A misdiagnosis rate of 30% for RDS was also avoided. The dosage of PS was significantly reduced by 50% to 75%. No BPD occurred in the LUS-based care group for 5 years. The fatality rates of RDS, pneumothorax and pulmonary hemorrhage decreased by 100%. The poor prognosis rate of VLBW infants decreased by 85%, and the total mortality rate of hospitalized infants decreased by 90%. Therefore, the cost of LUS-based care was inevitably saved. CONCLUSIONS: Diagnosing and managing neonatal lung diseases with LUS monitoring have significant benefits, and this technology should be widely promoted and applied around the world.

Lung ultrasound completely replaced chest X-ray for diagnosing neonatal lung diseases: a 3-year clinical practice report from a neonatal intensive care unit in China.

BACKGROUND AND OBJECTIVE: Lung ultrasound (LUS) has been widely used in the diagnosis and differential diagnosis of neonatal lung diseases (NLDs), but whether it can replace the routine use of chest X-ray (CXR) in neonatal intensive care units (NICUs) remains controversial. This paper summarizes the clinical practice of our neonatal intensive care unit (NICU) during the past three years to explore the feasibility and necessity of using LUS instead of CXR to diagnose NLDs in the NICU setting. METHODS: The clinical data and LUS examination results from 1,381 newborn infants with respiratory difficulty who were hospitalized in our NICU from March 2017 to February 2020 were retrospectively collected to analyze the types of lung diseases diagnosed and the reliability of LUS for diagnosing NLDs. RESULTS: (1) During this period, 1381 newborn infants with dyspnea were admitted to our NICU, accounting for 41.2% of all hospitalized children. (2) Among the 1381 infants, 17 patients with respiratory distress were confirmed as having severe heart disease by echocardiography, while the remaining 1364 patients had different kinds of lung diseases: pneumonia (697 patients, 51.1%), respiratory distress syndrome (251 patients, 17.4%), transient tachypnea of the newborn (197 patients, 13.3%), atelectasis (89 patients, 5.6%), pneumothorax (46 patients, 3.2%), pulmonary hemorrhage (69 patients, 4.5%), severe pleural effusion (18 patients, 1.32%), congenital pulmonary sequestration (3 patients, 0.22%), bullae of the lung (2 patients, 0.15%), and congenital cystic adenomatoid malformation (2 patients). (5) Among the 1381 infants, 217 received CXR examination before admission, which resulted in misdiagnosis in 45 patients (20.7%) and missed diagnosis in 12 patients (5.5%); the missed diagnosis and misdiagnosis rate was 26.3%. CONCLUSION: Our 3-year clinical practice experience indicated that LUS could completely replace chest X-ray for the diagnosis and differential diagnosis of NLDs in the NICU. Compared with X-ray, LUS had higher accuracy and reliability in diagnosing NLDs.

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

Ultrasound to Localize the Peripherally Inserted Central Catheter Tip Position in Newborn Infants.

OBJECTIVE: This study aimed to evaluate the application of ultrasound for the localization of the tip position of peripherally inserted central catheters (PICCs) in newborn infants. STUDY DESIGN: This study was a retrospective analysis on ultrasonic localization for PICC placement conducted in our department over the past 2 years. Ultrasonic localization was performed immediately after PICC placement in all neonatal patients. Successful PICC placement was confirmed if the PICC tip position was located at the inferior/superior cavoatrial junction. Chest X-ray localization was performed on 32 infants immediately after ultrasound examination to compare the accuracy of ultrasound localization. RESULTS: Of the 186 patients, 174 (93.5%) had successful PICC placement on the first attempt. In 11 (5.9%) patients, the catheter tip was placed beyond the ideal location as follows: too deep (in the right atrium) in 4 patients, too shallow in 4 patients, and malpositioned in 3 patients. Both the sensitivity and the specificity of ultrasound for identifying PICC tip localization were 100%. Complications occurred in 2.7% of this group of patients. CONCLUSION: Ultrasonic localization of the PICC tip position is a timely, accurate, and reliable method and can identify the catheter tip with high accuracy. This method could be widely applied in neonatal wards.

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

Efficacy of Bronchoalveolar Lavage as Adjunct Therapy in the Treatment of Neonatal Severe Pneumonia: A Prospective Case-Control Study.

OBJECTIVE: The aim of this study was to investigate the efficacy and safety of bronchoalveolar lavage (BAL) in the treatment of neonatal severe pneumonia (NSP). METHODS: One hundred patients with severe pneumonia were randomly divided into two groups, the BAL and control groups, with 50 patients in each group. In the BAL group, normal saline was instilled into the endotracheal tube for BAL. Before and after lavage, lung ultrasound (LUS) monitoring was performed to observe the lung pathological changes. Conventional treatment was administered in the control group. The need for and duration of invasive mechanical ventilation, the complication rate, the duration and cost of hospitalization and the mortality rate were compared between the two groups. RESULTS: The results of this study showed that there were 35 (70%) patients who meet the indications of the invasive mechanical ventilation (IMV) at admission in the BAL group, while there were only 15 (30%) patients still requiring IMV after BAL therapy. The duration of IMV was 41.7 ± 7.5 vs. 97.7 ± 12.9 h in BAL and controls, the incidence rate of complications was 8.0% vs. 20.0% in both groups, the length of hospital stay was 9.2 ± 1.9 vs. 14.1 ± 2.1 days in both groups, and the expense of hospital cost was 12 557 ± 832 vs. 19 121 ± 929 Chinese Yuan in both groups. All patients had stable vital signs during lavage, and no significant adverse side effects were observed. CONCLUSION: BAL was significantly beneficial for NSP with no significant adverse side effects; LUS is a useful tool for the timely detection of BAL effects.

The new application of point-of-care lung ultrasound in guiding or assisting neonatal severe lung disease treatment based on a case series.

Objective: Lung ultrasound (LUS) has been successfully used for neonatal lung disease diagnosis, as a non-invasive, free of radiation tool, the application of point-of-care LUS (POC-LUS) to diagnose lung disease has become a new trend worldwide. This paper was to introduce the new application of LUS to guide or assist the neonatal lung diseases treatment.Methods: Based on case series of our daily routine clinical work, in combining with the latest literatures, we introducing the new using field of POC-LUS in guiding the treatment of uninflated lung disease by bronchoalveolar lavage (BAL), guiding the treatment of severe pleural effusion and pneumothorax, guide the use of and weaning from mechanical ventilation, and in assessing the efficacy of exogenous pulmonary surfactant (PS) therapy.Results: The results of this study showed that the using rate of invasive ventilation and PS were decreased significantly, the duration of invasive ventilation was shortened significantly, the recovery of pleural effusion and pneumothorax were more quickly and safety, and finally a significantly shortened length of hospitalizations was obtained.Conclusions: LUS monitoring had significant effects in guiding the management of neonatal severe lung diseases, which with the worthy of extensive clinical application.

POC-LUS guiding pleural puncture drainage to treat neonatal pulmonary atelectasis caused by congenital massive effusion.

Point of care lung ultrasound (POC-LUS) has played important roles in diagnosing neonatal lung diseases and assisting in their treatment. A newborn infant with severe respiratory distress diagnosed as pulmonary atelectasis caused by congenital massive pleural effusion, whose consolidated lung recruitment after pleural puncture drainage under POC-LUS guidance. Lung ultrasound can be performed easily and timely at bed-side with free of radiation exposure, thus it should be used extensively in the neonatal department.

Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus.

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Lung ultrasonography to diagnose pneumothorax of the newborn.

OBJECTIVE: To explore the reliability and accuracy of lung ultrasound for diagnosing neonatal pneumothorax. METHODS: This study was divided into two phases. (1) In the first phase, from January 2013 to June 2015, 40 patients with confirmed pneumothorax had lung ultrasound examinations performed to identify the sonographic characteristics of neonatal pneumothorax. (2) In the second phase, from July 2015 to August 2016, lung ultrasound was undertaken on 50 newborn infants with severe lung disease who were suspected of having pneumothorax, to evaluate the sonographic accuracy and reliability to diagnose pneumothorax. RESULTS: (1) The main ultrasonic manifestations of pneumothorax are as follows: ① lung sliding disappearance, which was observed in all patients (100%); ② the existence of the pleural line and the A-line, which was also observed in all patients (100%); ③ the lung point, which was found in 75% of the infants with mild-moderate pneumothorax but not found to exist in 25% of the severe pneumothorax patients; ④ the absence of B-lines in the area of the pneumothorax (100% of the pneumothorax patients); and ⑤ no lung consolidation existed in the area of the pneumothorax (100% of the pneumothorax patients). (2) The accuracy and reliability of the lung sonographic signs of lung sliding disappearance as well as the existence of the pleural line and the A-line in diagnosing pneumothorax were as follows: 100% sensitivity, 100% specificity, 100% positive predictive value, and 100% negative predictive value. When the lung point exists, the diagnosis is mild-moderate pneumothorax, whereas if no lung point exists, the diagnosis is severe pneumothorax. CONCLUSION: Lung ultrasound is accurate and reliable in diagnosing and ruling out neonatal pneumothorax and, in our study, was found to be as accurate as chest X-ray.

Lung ultrasonography to diagnose pulmonary hemorrhage of the newborn.

OBJECTIVES: This study was aimed to investigate the application of lung ultrasound for the diagnosis of pulmonary hemorrhage of the newborn (PHN). METHODS: From July 2013 to June 2016, 157 neonates were enrolled in the study. They were divided into two groups: a study group of 57 neonates, who were diagnosed with PHN according to their medical history, clinical manifestations and chest X-ray findings, and a control group of 100 neonates with no lung disease. All subjects underwent bedside lung ultrasound in a quiet state in a supine, lateral or prone position, performed by a single expert physician. The ultrasound findings were compared between the two groups. RESULTS: The lung ultrasound main findings associated with PHN included lung consolidation with air bronchograms with an incidence of 82.5%, a shred sign with an incidence of 91.2%, pleural effusion with an incidence of 84.2% (pleurocentesis confirmed the fluid was really bleeding), atelectasis with a incidence of 33.3%, pleural line abnormalities, as well as disappearing A-lines with an incidence of 100%, and 11.9% of these patients had the main manifestations of alveolar-interstitial syndrome (AIS). The shred sign exhibited a sensitivity of 91.2% and a specificity of 100% in diagnosing PHN. CONCLUSIONS: Lung ultrasonography is useful and reliable for diagnosing PHN, which is suitable for routine application in the neonatal intensive care unit.

Bronchoalveolar lavage for the treatment of neonatal pulmonary atelectasis under lung ultrasound monitoring.

OBJECTIVE: Pulmonary atelectasis (PA) is a common clinical complication among newborns, and it is one of the most common causes of neonatal dyspnea, a condition with no specific effective treatment. This study examined the effectiveness and security of bronchoalveolar lavage (BL) regarding the treatment of neonatal PA under ultrasound monitoring. METHODS: A total of 57 patients diagnosed with PA via lung ultrasound (LUS) were included in this study. All patients received BL via a tracheal intubation injection of lavage fluid. The LUS was conducted immediately after each lavage to understand the conditions of lung re-expansion. Irrigation was repeated two to three times as one course of treatment. BL was provided as one to two courses of treatment daily for several days according to atelectasis and lung recruitment status. RESULTS: Of the 57 patients, BL was very effective in 44 cases (77.2%), marginally effective in nine cases (15.8%) and ineffective in four cases (7.0%), showing a total effective rate of 93.0%. The four ineffective cases showed a long disease duration and severe pulmonary consolidation. CONCLUSIONS: BL showed significant effectiveness for the treatment of neonatal PA under ultrasound monitoring. This treatment is easy to operate, and no adverse side effects were observed. Thus, BL should be considered for clinical application.

Two spatially and temporally distinct Ca2+ signals convey Arabidopsis thaliana responses to K+ deficiency.

In plants, potassium (K+ ) homeostasis is tightly regulated and established against a concentration gradient to the environment. Despite the identification of Ca2+ -regulated kinases as modulators of K+ channels, the immediate signaling and adaptation mechanisms of plants to low-K+ conditions are only partially understood. To assess the occurrence and role of Ca2+ signals in Arabidopsis thaliana roots, we employed ratiometric analyses of Ca2+ dynamics in plants expressing the Ca2+ reporter YC3.6 in combination with patch-clamp analyses of root cells and two-electrode voltage clamp (TEVC) analyses in Xenopus laevis oocytes. K+ deficiency triggers two successive and distinct Ca2+ signals in roots exhibiting spatial and temporal specificity. A transient primary Ca2+ signature arose within 1 min in the postmeristematic stelar tissue of the elongation zone, while a secondary Ca2+ response occurred after several hours as sustained Ca2+ elevation in defined tissues of the elongation and root hair differentiation zones. Patch-clamp and TEVC analyses revealed Ca2+ dependence of the activation of the K+ channel AKT1 by the CBL1-CIPK23 Ca2+ sensor-kinase complex. Together, these findings identify a critical role of cell group-specific Ca2+ signaling in low K+ responses and indicate an essential and direct role of Ca2+ signals for AKT1 K+ channel activation in roots.

Calcineurin B-like protein CBL10 directly interacts with AKT1 and modulates K+ homeostasis in Arabidopsis.

Potassium transporters and channels play crucial roles in K+ uptake and translocation in plant cells. These roles are essential for plant growth and development. AKT1 is an important K+ channel in Arabidopsis roots that is involved in K+ uptake. It is known that AKT1 is activated by a protein kinase CIPK23 interacting with two calcineurin B-like proteins CBL1/CBL9. The present study showed that another calcineurin B-like protein (CBL10) may also regulate AKT1 activity. The CBL10-over-expressing lines showed a phenotype as sensitive as that of the akt1 mutant under low-K+ conditions. In addition, the K+ content of both CBL10-over-expressing lines and akt1 mutant plants were significantly reduced compared with wild-type plants. Moreover, CBL10 directly interacted with AKT1, as verified in yeast two-hybrid, BiFC and co-immunoprecipitation experiments. The results of electrophysiological analysis in both Xenopus oocytes and Arabidopsis root cell protoplasts demonstrated that CBL10 impairs AKT1-mediated inward K+ currents. Furthermore, the results from the yeast two-hybrid competition assay indicated that CBL10 may compete with CIPK23 for binding to AKT1 and negatively modulate AKT1 activity. The present study revealed a CBL-interacting protein kinase-independent regulatory mechanism of calcineurin B-like proteins in which CBL10 directly regulates AKT1 activity and affects ion homeostasis in plant cells.

[Research on isolation and purification of total iridoid glycosides from herbal Lamiophlomis rotata].

OBJECTIVE: Enriching the hemostatic active part total iridoid glycosides from the aqueous extract of herbal Lamiophlomis rotata. METHOD: First derivative spectrophotometry was used as the detection method and the content of total iridoid glycosides was used as tracking target. The abilities of absorption and anti-absorption of ten different types of macroreticular resin were compared, after being used to absorb the iridoid glycosides from aqueous extract of herbal L. rotata. The best purification process was optimized. RESULT: With the optimized purification process, the content of total iridoid glycosides was 67.53%. CONCLUSION: XDA-1 macroreticular resin has good ability of absorption and anti-absorption for iridoid glycosides and 50% ethanol was the best solvent for anti-absorption. The macroreticular resin could be reused.