neonatologist & clinical associate professor university of ... · hemodynamics –changing...
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Dr Sumesh Thomas
Neonatologist & Clinical Associate ProfessorUniversity of Calgary (Canada)
Director – Southern Alberta Neonatal Transport ServiceAlberta Health Service
MD, FRCP(Edin), FRCPCH, FRCPC
POCUS in Neonatology, Neonatal Transport
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Value of early ECHO in ELBW neonates
NEOCON Hyderabad Dec 2019
Dr Sumesh Thomas MB.BS, DCH(UK), FRCPCH (UK), FRCP (Edin), FRCPC – Director SCAN program
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>1200 babies admitted to Tertiary Care NICU annually
ELBW babies – 120 annually
22,500 births in Southern Alberta
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Foothills Medical Centre
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What is ‘value’ to an ELBW infant?
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Neonatology -Timelines
1900s – Incubator shows
1950s – Silverman showed benefits
thermoregulation
60’s Basic &
experimental
Focus on lung
Surfactant deficiency identified
70’s
32-36 wks Assisted Ventilation
Establishment of NICUs
80’s
28-32 wks
Surfactant Technologic advances Brain injury
90’s
24-28 wks VentilatorsOutcomes
IVF
Parental role
Post 2000
23-25 wks
Functional outcomes
Cultural diversity
Parent driven
Internet Information
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Accepted strategies aimed at Neuroprotection
• Minimal Handling
‘less is better’
• Gentle ventilation
• Optimal growth and nutrition
Avoidance of iatrogenic harm
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Typical indications for early ECHO
• Neonatal Hypotension
• Hemodynamically significant PDA
• Pulmonary Hypertension of the Newborn (PPHN)
• Central Line Placement
• Suspected Effusions
• Congenital Heart Disease – cardiologist
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POC Neonatal UltrasoundResults: 321 articles – 6 Dec 2019 ( 26 articles on Feb 2014)
1. Investigating the European perspective of neonatal point-of-care echocardiography in the neonatal intensive care unit--a pilot study
Roehr CC et al Eur J Pediatr. 2013 Jul;172(7):907-11
2. Confirmation of correct tracheal tube placement in newborn infants
Schmölzer GM et al . Resuscitation. 2013 Jun 84(6):731-7
3. Utility of targeted neonatal echocardiography in the management of neonatal illnessHarabor A, Soraisham AS J Ultrasound Med 2015; 34(7);1259-63
4. Ultrasound assessment of umbilical venous catheter migration in preterm infants: a prospective study.
Franta J, Harabor A, Soraisham AS. Arch Dis Child Fetal Neonatal Ed. 2017 May;102(3):F251-F255
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Targeted examination – ‘minimal handling’
• Evaluate a specific clinical question
• Focused examination with essential views and measurements
Not a ‘fishing’ exercise
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Routine ECHO
• Non-focused examination
• Significantly longer examination
Could result in further interventions and or evaluation with limited benefits / potential harm
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Neither approach is a substitute for knowledge of ‘neonatal transitional physiology’
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PDA – to treat or not to treat?Determining hemodynamic significance (HS)
Indicators of pulmonary over-circulation• Pulmonary hemorrhage• Failed extubation/inability to wean ventilation• Worsening of oxygenation and/or CO2 retention• CXR : cardiomegaly and pulmonary congestion
Indicators of systemic hypo-perfusion• Diastolic BP < 3rd percentile for GA• Systolic and diastolic BP < 3rd percentile for GA with the requirement for
inotropic support• Lactic acidosis unexplained by other causes • Renal impairment with oliguria
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Complete Left to Right
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Hs PDA
• Identify PDA and determine size
• Determine direction of flow and max velocity across shunt
• Evaluate for left sided volume overload
• Assess end organ perfusion (SMA/CA/MCA)
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Pulmonary hypertension
Right ventricular hypertrophy
Deviation of IVS to the Left/flattening
Tricuspid regurgitation (TR)
Right to left or bidirectional shunting at PFO / PDA
Rt. V systolic pressure calculationBernoulli equation4v2 + Right atrial pressure (~4mmHg),v = maximal velocity of the TR jet in m/s.
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RVH / Septal deviation
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Tricuspid Regurgitation
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Peak tricuspid regurgitation (TR) velocity 3.9 m/sec
Bernoulli equation4v2 + Right atrial pressure (~4mmHg),v = maximal velocity of the TR jet in m/s.
Gradient across the tricuspid valve 63 mmHg. Pulmonary artery pressure estimated at 68-73 mmHg
Systemic BP 54/32 Mean 41mmHg
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Cardiac Contractility
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UVC position
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Cardiac Tamponade
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Value? – Food for thought
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Hemodynamics – changing practices
• Delayed cord clamping when feasible
• Cautious use of inotropes – consider bedside ECHO• hyperinflation and iatrogenic hypotension / raised SVC pressure
• Fluid status / potential insensible water losses
• Cautious use of fluid boluses – consider bedside ECHO if considering >10ml/kg volume in the absence of supportive history
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Position
Stimulation
Assessment of breathing at 30 seconds
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I need my blood!!
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Take home message
• There is a place for early ‘focused’ ECHO examinations – to support clinical decision making and improve procedural success
• Interpretation of ECHO finding requires • In-depth understanding of neonatal transitional physiology
• Recognition of iatrogenic contribution from medical interventions
• Awareness of current controversies regarding treatment options
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Physiological changes…in nature
• Infant cries
• Functional Residual Capacity
• Pulmonary Vascular Resistance
• RV Output, PVD & Lung perfusion
• Blood return to LA
• LV filling & output
• PDA flow
• Cord is severed
Net effect systemic perfusion Drawings by A.M. Rudolph Circ Res, 57:811, 1985
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• In the Vent-1st
group, HR and RVO remain stable throughout
Both Groups: HR & RVO
Bhatt et al. J Physiol 2013; 591:2113-26; Figure
courtesy: Dr. Stuart Hooper
“Vent first”
“Clamp first”
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Immediate cord clamping
• UV clamped
• Right ventricle (RV) preload
• UA clamped
• Increase in LV after-load
• No lung expansion
• Pulmonary perfusion and pulmonary venous return to LA
• RV output to LA
Net Effect systemic perfusion