Optimizing Hemodynamic Management In Critically Ill Neonates: Role of Targeted Neonatal Echocardiography
Susan Nicolson, Lindsey Loveland, Viviane Nasr, James DiNardo
Original article
Zhang K, Ray AM, DiNardo JA. Optimizing Hemodynamic Management in the Neonatal Intensive Care Unit: Leveraging Neonatal Echocardiography. J Cardiothorac Vasc Anesth. 2024 Mar 26:S1053-0770(24)00221-0. doi: 10.1053/j.jvca.2024.03.030. Epub ahead of print. PMID: 38834443.
Neonates navigate complex cardiopulmonary changes as they transition from fetal to postnatal circulation. This transition is more complex in preterm neonates with increased risk for hemodynamic compromise. Intensive care of neonates involves a delicate balance of monitoring, intervention, and adaptation, particularly in the face of hemodynamic instability. Traditional methods of bedside assessment, including heart rate, blood pressure, capillary refill time, urine output and serum lactate, are unable to provide a complete picture of tissue perfusion and oxygenation and provide no diagnostic insight. Targeted neonatal echocardiography (TNE) has been increasingly used at bedside to provide enhanced understanding of the pathophysiology causing hemodynamic instability and the response to treatment over time. TNE uses standardized imaging to characterize the rapidly changing hemodynamic status during the postnatal transition period and in common pathophysiologic states. It is imperative that congenital heart disease (CHD) is ruled out when using TNE, as pathophysiology varies substantially in the assessment and management of neonates with CHD. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus (PDA), evaluation of acute and chronic pulmonary hypertension (PH), of right and left ventricular systolic and/or diastolic function, of shock and screening for pericardial or pleural effusion.
Scope of Practice For Cardiac Point-of-Care Ultrasound
In contrast to TNE, cardiac point-of-care ultrasound (cPOCUS) refers to a basic, time-sensitive, and focused ultrasound assessment of the heart to assist in urgent or emergent clinical decision-making and guide resuscitation interventions. cPOCUS should not be used to appraise and target management of specific physiologic states over time. Typical indications for cPOCUS include evaluation of central catheter (arterial or venous) tip location, identification of pericardial or pleural effusions and differentiation of hypovolemia versus myocardial dysfunction.
Refer to the 2024 guidelines and recommendations for both disease and/or clinical-scenario- based indications for TNE and cPOCUS for neonates.1
Expanded Use of TNE
Undetected PDA closure in the presence of coarctation of the aorta can result in near complete or complete obstruction to distal aortic blood flow and cardiovascular collapse. Thomas et al. propose that incorporating serial TNE examinations in conjunction with upper and lower extremity blood pressure and pulse oximetry differentials during an “arch watch” can better track the evolution of aortic arch anatomy and blood flow dynamics and time starting or re-starting prostaglandins and/or surgical intervention.2
In addition to traditional echocardiographic parameters, novel techniques including tissue Doppler imaging, myocardial deformation analysis using speckle tracking echocardiography, and 3-D echocardiography continue to expand the diagnostic capabilities of TNE which in turn improve our understanding of neonatal cardiac anatomy, physiology and pathology.
Limitations and Opportunities
Several challenges limit universal use of TNE in clinical practice: limited availability of trained operators, variability in image quality and cost constraints. Interpretation of echocardiographic findings requires expertise and experience highlighting the need for standardized protocols and training programs to ensure consistency and accuracy. Interdisciplinary collaboration between neonatologists, pediatric cardiologists and echocardiographers is essential to maximize the use of both TNE and cPOCUS, to integrate it into routine clinical care pathways and to insure a platform for quality assurance. There is need to develop prospective studies and clinical trials to characterize the impact of TNE-guided care, both monitoring and treatment, on patient outcomes.
Conclusions
There is increasing evidence that TNE-guided care enables earlier detection and delineation of cardiovascular compromise and supports patient-tailored, physiology-based hemodynamic monitoring and management. The integration of echocardiography derived hemodynamic information, relevant to an individual situation and directed by a specific clinical question, offers a blueprint from which to formulate a physiology-based diagnostic impression, upon which cardiovascular support is based, and evaluate the response to the intervention (s).
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References
1. McNamara PJ, Jain A, El-Khuffash A, et al. Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr. Feb 2024;37(2):171-215. doi:10.1016/j.echo.2023.11.016
2. Thomas AR, Levy PT, Sperotto F, et al. Arch watch: current approaches and opportunities for improvement. Journal of perinatology : official journal of the California Perinatal Association. Mar 2024;44(3):325-332. doi:10.1038/s41372-023-01854-7