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
