Echocardiography in the critically ill child

What should paediatricians be doing? What must be left to

the expert?

John Lawrenson

Paediatric Cardiology Service Western Cape

Department of Paediatrics and Child Health Stellenbosch University

Let’s start with the expert

2007

Why is echocardiography so difficult?

• It isn’t but it takes practice – Not quite 10 000 hours– A trainee will spend 12 X 40 hour weeks

doing echo • Machines are expensive and fragile

– But are getting cheaper (cost of a good ventilator)

• Machines are designed for adults• Cross platform units are hard to find

Ultrasound examination of the heart

Paediatric Cardiologist

NeonatologistPoint of Care

Emergency/ICUAnaesthetic use

Ultrasound examination of the heart

Paediatric Cardiologist

NeonatologistEmergency/ICU

Anaesthetic use

diagnosisPDA/

pulmonary hypertension

functional Point of Care haemodynamicresearchHaemodynamicResidual defects

Focused point-of-care echocardiography - Acronym

soup• FEER Focused echocardiographic

examination in resuscitation• BLEEP Bedside limited echocardiography

by the emergency physician• RACE Rapid assessment by cardiac echo• FATE Focused assessed transthoracic

echo• FAST Focused abdominal sonography in

trauma (one subcostal look)

Resucitation

• German experience• Indications for emergency echo

during resuscitation• Study needs to be 5 seconds long

and part of the resuscitation and not prolong non flow intervals

• 8 hour training• Helpful in ‘PEA’ and effusions

Seppelt 2007

In the ICU

• Impediments to ‘uptake’ (Seppelt 2007)– Cost– Senior ‘old dog’ clinicians– Lack of training

• National program in France

•IVC Volume – subcostal

•LV EF – standard

•2-D

•11 hrs training

•31 sick patients – reasonable results – checked by Cardiologist

Tennessee

The next stage in the ICU

• Function – Systolic– RV function

• Filling– Diastolic areas– Empty ventricles more reliable than full

ventricles– IVC and change with inspiration (surrogate RA

pressure)• Pressures - pulmonary• Output• Valves

Neonatologists

• There aren’t enough cardiologists in the World to meet the needs of neonatologists

• ..in Cape Town…• Neonatologists have moved beyond the

PDA to functional assessments• A special bond has to exist between

cardiologists and neonatologists • Increasing numbers of neonatologists are

skilled echocardiographers

168/11000 - 83 patients

Sampson and Kumar

Sampson and Kumar

A Paediatrician for Polokwane or Fiji or wherever

• Basics – Switch on machine– Recognise the bad stuff

• Intermediate– Neonatal bad stuff– Rheumatic heart disease

• Advanced– Congenital heart disease; refer for surgery

Learning echoThe wish to learnThe need to learn

Introduction and help from expert

Time

Additional learning

Going solo!

Do not forget to examine the patient first!

Do not forget to examine the patient first!

Do not forget to examine the patient first!

Do not forget to examine the patient first!

Do not forget to examine the patient first!

Do not forget to examine the patient first!

The future of echo for the non-cardiologist

• Telemedicine– Good examples from Western

Hemisphere– YouTube style studies

• Dummy training using echo simulators• Smaller powerful laptop type

machines• Hand held machines

Thank You