Linking To And Excerpting From “International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)”

Today, I review, link to, and excerpt from International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Crit Care. 2020 Feb 24;24(1):65. doi: 10.1186/s13054-020-2787-9.

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Abstract

Background: Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

Methods: Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

Results: Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

Conclusions: Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Keywords: Children; Neonatal intensive care unit (NICU); Neonate; Paediatric intensive care unit (PICU); Point of care ultrasound (POCUS); Ultrasound.

Table 1.

Summary of recommendations on the use of POCUS in the neonatal and paediatric critical care

No.	Recommendation	Level of agreement	Quality of evidence
1.	POCUS should not be used as a screening tool for diagnosing congenital heart defects in neonates and children, unless neonatologists/paediatric intensivists have received an advanced echocardiography training specifically for this purpose	Strong agreement	A
2.	POCUS may be helpful to assess cardiac filling (preload assessment) and intravascular volume status in neonates and children	Strong agreement	D
3.	POCUS may be helpful to assess fluid responsiveness in neonates and children	Strong agreement	D
4.	POCUS may be helpful for qualitative assessment of cardiac function on visual inspection in neonates and children	Strong agreement	D
5.	POCUS is helpful for semi-quantitative assessment of cardiac function in neonates and children [however, a detailed functional assessment should be performed by a person with advanced echocardiography training]	Agreement	C
6.	POCUS is helpful for assessment of pulmonary artery systolic pressure in pulmonary hypertension in neonates and children	Strong agreement	B
7.	POCUS is helpful for semi-quantitative assessment of pulmonary hypertension in neonates and children	Strong agreement	B
8.	POCUS is helpful to diagnose pericardial effusion in neonates and children	Strong agreement	B
9.	POCUS is helpful to guide pericardiocentesis in neonates and children	Strong agreement	B
10.	POCUS should be used to assess the patency of ductus arteriosus in neonates and children	Strong agreement	A
11.	POCUS may be used to detect vegetation to make or exclude the diagnosis of endocarditis [however, a definitive diagnosis requires a detailed assessment by a paediatric cardiologist].	Disagreement	D
12.	POCUS is helpful to distinguish between respiratory distress syndrome (RDS) and transient tachypnoea of the neonate (TTN)	Agreement	B
13.	POCUS is helpful to detect pneumonia in neonates and children	Agreement	B
14.	POCUS is helpful to semi-quantitatively evaluate lung aeration and help the management of respiratory intervention in acute respiratory distress syndrome (ARDS) in neonates and children	Agreement	B
15.	POCUS is helpful to recognise meconium aspiration syndrome (MAS)	Agreement	C
16.	POCUS is helpful for descriptive purposes in viral bronchiolitis but cannot provide a differential aetiological diagnosis	Strong agreement	C
17.	POCUS is helpful to accurately detect pneumothorax in neonates and children	Strong agreement	B
18.	POCUS is helpful to insert chest tube or perform needle aspiration in neonatal tension pneumothorax	Strong agreement	B
19.	POCUS is helpful to detect pleural effusions in neonates and children	Strong agreement	B
20.	POCUS is helpful to guide thoracentesis in neonates and children	Strong agreement	B
21.	POCUS is helpful to evaluate lung oedema in neonates and children	Agreement	C
22.	POCUS is helpful in detecting anaesthesia-induced atelectasis in neonates and children	Agreement	C
23.	POCUS-guided technique should be used for internal jugular vein (IJV) line placement in neonates and children	Strong agreement	A
24.	POCUS-guided technique is helpful for subclavian vein line placement in neonates and children	Strong agreement	B
25.	POCUS-guided technique is helpful for femoral line placement in neonates and children	Strong agreement	B
26.	POCUS-guided technique is helpful for arterial catheters placement in children	Agreement	B
27.	POCUS-guided technique is helpful for peripherally inserted central catheters in children	Agreement	B
28.	POCUS is helpful to locate catheter tip position in neonates and children	Strong agreement	C
29.	POCUS is helpful to detect cerebral blood flow changes in neonates and children	Agreement	B
30.	POCUS should be used to detect germinal matrix and intraventricular haemorrhage (IVH) in neonates	Strong agreement	A
31.	POCUS is helpful to detect cerebral blood flow patterns suggesting the presence of cerebral circulatory arrest in children with fused skull bones	Agreement	C
32.	POCUS is helpful to detect cerebral blood flow changes secondary to vasospasm in patients with traumatic brain injury and non-traumatic intracranial bleeding.	Agreement	C
33.	POCUS is helpful to detect changes in optic nerve sheath diameter (ONSD) indicative of raised ICP in children with fused skull bones	Agreement	B
34.	POCUS is helpful to detect cerebral midline shift in neonates and children	Agreement	C
35.	POCUS is helpful for detection of free intra-abdominal fluid in neonates and children	Strong agreement	C
36.	POCUS may detect parenchymal changes of abdominal organs in neonates and children [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist]	Agreement	D
37.	POCUS may detect obstructive uropathy in neonates and children [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist]	Agreement	D
38.	POCUS may assess bowel peristalsis in neonates and children	Agreement	D
39.	POCUS may recognise hypertrophic pyloric stenosis [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist]	Disagreement	D
40.	POCUS my guide peritoneal drainage or aspiration of peritoneal fluid in neonates and children	Strong agreement	D
41.	POCUS is helpful to detect signs of necrotising enterocolitis [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist or a person with specific advanced ultrasound training]	Agreement

 

Table 2.

Semi-quantitative systolic ventricular function measures that might be used by the clinician with more evolved training in cardiac POCUS. Normative values are taken from the available literature on the topic [32–45] and represent the best reference data available so far, although, in some cases, specific level for a different class of patients’ age are lacking

Parameter	View	Measurement	Reference values
LV fraction shortening (FS%)	PSAX, PLAX, (2D or M mode)	LV intraluminal diameter change	28–46% for all ages
LV ejection fraction (Simpson’s method)	A4C, A2C	Percentage change of LV volume between end-diastole and end-systole	55–80% for all ages
E-point septal separation (EPSS)	PLAX (2D or M mode)	Distance between anterior leaflet of the mitral valve and intraventricular septum during the diastolic phase. This measurement is associated with LV systolic volume.	> 7 mm in adults predictive of severe LV dysfunction *
LV output (stroke volume)	A5C, PLAX	Product of VTI measured by pulse wave Doppler at LVOT in A5C and LVOT cross-sectional area measured in PLAX	Z-scores available for different ages and should be used; neonates: 150–400 ml/kg/min
Mitral annular plane systolic excursion (MAPSE)	A4C	Systolic excursion of lateral (or medial) mitral annulus toward apex to assess LV systolic function.	Z-scores available for different ages and should be used; term neonates: > 8 mm (8–11 mm) Adults 12–14 mm (< 8 mm predictive of severe LV dysfunction)
RV output (stroke volume)	PSAX or sweep PLAX	Product of VTI measured by pulsed-wave Doppler at RVOT and RVOT cross-sectional area	Z-scores available for different ages and should be used; neonates: 150–400 ml/kg/min
Tricuspid annular plane systolic excursion (TAPSE)	A4C	Systolic excursion of lateral (or medial) tricuspid annulus toward apex to assess RV systolic function.	Term neonates: > 8 mm (8–11 mm) Children–Z-score available; generally > 12 mm (12–17 mm) Adults or grown-up children > 17 mm (17–25 mm)

A4C Apical 4 chamber view, A5C Apical 5 chamber view, A2C Apical 2 chamber view, PSAX parasternal short-axis view, PLAX parasternal long-axis view, M mode motion mode, LV left ventricle, LVOT left ventricular outflow tract, VTI velocity time integral

*No data are available in neonates or children

Recommendations for use of lung POCUS

1. POCUS is helpful to distinguish between respiratory distress syndrome (RDS) and transient tachypnoea of the neonate (TTN)—agreement (quality of evidence B). RDS is characterised by a poorly aerated lung with the absence of A-lines, presence of small “subpleural” consolidations and diffuse white lung (confluent B-lines). Conversely, in TTN, the interstitial pattern alternates with areas of near-normal lung (with A-lines). Pleural line thickening might be seen in late preterm and term babies [53–61]. The double lung point has been proposed as a pathognomonic finding [62, 63] but it is debated, as it does not seem necessary for TTN diagnosis if normal lung areas are evident [64]. High inter-observer agreement between physicians with different lung ultrasound (LUS) expertise has been reported, which makes the differential diagnosis between RDS and TTN reliable, irrespective of the operator [65]. In preterm neonates with RDS, various studies showed that a semiquantitative ultrasound evaluation of lung aeration is very predictive of the need for surfactant [66, 67] and, therefore, this POCUS tool is helpful to decide about surfactant replacement and improve its timeliness [68].
2. POCUS is helpful to detect pneumonia in neonates and children—agreement (quality of evidence B). LUS signs of pneumonia are the presence of consolidations and dynamic air bronchograms, B-lines and pleural effusion. Abnormal pleural line and decreased lung sliding may be observed [58, 65]. LUS has been reported to have higher diagnostic accuracy compared with chest X-rays for the diagnosis of pneumonia [69]. However, there is no defined threshold for consolidation size or a consensual method of measurement.
3. POCUS is helpful to semi-quantitatively evaluate lung aeration and help the management of respiratory intervention in acute respiratory distress syndrome (ARDS) in neonates and children—agreement (quality of evidence B). LUS in neonatal and paediatric ARDS shows bilateral diffuse areas of reduced lung aeration with areas of the interstitial syndrome and consolidations, pleural line abnormalities and pleural effusion [70–73]. Although current diagnostic criteria for ARDS do not yet include LUS, it represents a useful tool for its detection [73, 74]. Several LUS aeration scores are used to semi-quantitatively measure the effect of fluid restriction, alveolar recruitment and surfactant administration [75–79]. Scores based on the main lung ultrasound semiology (including A lines, alveolar-interstitial pattern and presence of consolidations) should be preferred over the simple B lines count, as they describe better the lung aeration and have been validated with various techniques [80].
4. POCUS is helpful to recognise meconium aspiration syndrome (MAS)—agreement (quality of evidence C). MAS is now recognised as a cause of neonatal ARDS [73] and shares the same LUS findings. However, this LUS pattern is dynamic and changes with the spread of meconium plugs during mechanical ventilation [81, 82].
5. POCUS is helpful for descriptive purposes in viral bronchiolitis but cannot provide a differential aetiological diagnosis—strong agreement (quality of evidence C). LUS signs in viral bronchiolitis consist of pleural line irregularities, “sub-pleural” consolidations and areas with interstitial pattern [83–85]. Good concordance between operators has been shown in wheezing infants [86]. LUS findings in viral bronchiolitis are similar to those seen during influenza outbreaks [87] but it is not currently possible to differentiate between different forms of viral respiratory infections.
6. POCUS is helpful to accurately detect pneumothorax in neonates and children—strong agreement (quality of evidence B). In adults, LUS has a high diagnostic accuracy for the diagnosis of pneumothorax [88, 89] and has been reported to be more sensitive than conventional radiology [90]. Neonatal data confirm this high diagnostic performance for tension pneumothorax [91].
7. POCUS is helpful to insert chest tube or perform needle aspiration in neonatal tension pneumothorax—strong agreement (quality of evidence B). LUS should not only be used to diagnose pneumothorax but also to provide static guidance for pleurocentesis [91]. Thus, POCUS should be used to identify lung margin, hemidiaphragm and sub-diaphragmatic organs throughout the respiratory cycle before needle or tube insertion to safely avoid them.
8. POCUS is helpful to detect pleural effusions in neonates and children—strong agreement (quality of evidence B). Policy statements in adults recommend the use of LUS for the detection of effusions and evaluation of pleural fluid volume to guide management [55, 92, 93]. In children, LUS shows high accuracy in the diagnosis of pneumonia-related pleural effusion [47].
9. POCUS is helpful to guide thoracentesis in neonates and children—strong agreement (quality of evidence B). Ultrasound-guided thoracentesis reduces the risk of complications and increases success rates [55, 92, 93]. It should be used to identify lung margin, hemidiaphragm and sub-diaphragmatic organs throughout the respiratory cycle before needle or tube insertion to safely avoid them.
10. POCUS is helpful to evaluate lung oedema in neonates and children—agreement (quality of evidence C). Although LUS is accurate in detecting extra-vascular lung fluid [94], it cannot distinguish between cardiogenic and non-cardiogenic oedema [55, 94]. LUS has been used in children to evaluate cardiogenic lung oedema, by assessing extravascular lung fluid counting numbers of B-lines after cardiac surgery [79]. However, extravascular lung water may obviously be affected by the pressure delivered during mechanical ventilation. Thus, in these conditions, LUS globally evaluates the lung aeration rather than extravascular lung fluid.
11. POCUS is helpful in detecting anaesthesia-induced atelectasis in neonates and children—agreement (quality of evidence C). LUS may be used to monitor this complication during anaesthesia that may potentially lead to hypoxemia [95].

Recommendations for use of vascular POCUS in line placement

1. POCUS-guided technique should be used for internal jugular vein (IJV) line placement in neonates and children—strong agreement (quality of evidence A). Robust paediatric data favour ultrasound guidance for IJV cannulation compared to landmark technique [96–100]. Multiple studies have repeatedly shown decreased risk of cannulation failure and arterial puncture, higher success rates on first attempt and decreased incidence of complications [100–104].
2. POCUS-guided technique is helpful for subclavian venous line placement in neonates and children—strong agreement (quality of evidence B). The subclavian and brachiocephalic veins have been cannulated in children and neonates (including preterm ones) with in-plane visualisation, and this seems the easiest approach [105–107]. However, there is no firm consensus about the best technique, i.e., supra-clavicular vs infra-clavicular, or in-plane vs out-of-plane [101, 108]. Multiple cases series of children and neonates reported higher success rates and decreased incidence of complications favouring ultrasound use compared to landmark technique. Therefore, ultrasound-guided subclavian cannulation in neonates and children is safe, doable and is advised over a blind cannulation technique [101, 107–112].
3. POCUS-guided technique is helpful for femoral line placement in neonates and children—strong agreement (quality of evidence B). Paediatric trials comparing US-guided femoral line placement with landmark technique showed higher overall success rate and on the first attempt as well as fewer needle passes [113–116].
4. POCUS-guided technique is helpful for arterial catheters placement in children—agreement (quality of evidence B): a few high-quality studies have found that US-guided arterial line placement is faster (shorter time to success and lower number of attempts) and has higher first-attempt cannulation rates regardless of the location [117, 118].
5. POCUS-guided technique is helpful for peripherally inserted central catheters (PICC) in children—agreement (quality of evidence B). A paediatric RCT comparing US-guided versus landmark PICC placement showed higher first-attempt cannulation rate, successful PICC positioning rate and shorter time to success when ultrasound was used [119]. Similar findings are supported by adult literature [120].
6. POCUS is helpful to locate catheter tip position in neonates and children—strong agreement (quality of evidence C). A trial and two observational studies in the paediatric and neonatal population have suggested that US may decrease radiation and number of line manipulations by confirming PICC tip position after placement [121–123] and could be considered a complement to conventional radiography [124].

Recommendations for use of cerebral POCUS

1. POCUS is helpful to detect cerebral blood flow changes in neonates and children—agreement (quality of evidence B). Children are especially amenable to cranial ultrasound since their skulls remain not yet ossified and their fontanelles open [125, 126]. Alterations in cerebral blood flow allow inferences to be made regarding brain pathology and raised intracranial pressure (ICP) [127, 128]. Estimation of flow velocities and calculation of pulsatility (PI) and resistance indexes (RI) are useful tools for non-invasive monitoring of ICP [129]. Age-dependent normal values of blood velocities in different vessels and indexes have been previously published [130]. Paediatric data are not yet sufficient to support its use and caution must be taken when interpreting results [131, 132].
2. POCUS should be used to detect germinal matrix and intraventricular haemorrhage (IVH) in neonates—strong agreement (quality of evidence A). Intraventricular haemorrhage and parenchymal bleeding remain a frequent and serious complication in extremely preterm infants. POCUS is a useful clinical tool to detect IVH and parenchymal changes [133], and assesses the severity according to Papile’s classification [134, 135]. In environments where imaging resources are limited, brain POCUS should be used for the diagnosis of IVH which may aid in the redirection of care.
3. POCUS is helpful to detect cerebral blood flow patterns suggesting the presence of cerebral circulatory arrest in children with fused skull bones—agreement (quality of evidence C). Transcranial doppler has been used to establish the presence of cerebral circulatory arrest [135, 136] by evaluation of the middle cerebral (MCA) and basilar artery. The following patterns are compatible with cerebral circulatory arrest [126, 136]: (a) oscillating waveform or sustained reversal of diastolic flow, (b) small systolic spikes and disappearance of all intra-cranial flow, (c) no flow in MCA, (d) reversal of diastolic flow in extracranial Internal Carotid Artery (ICA) and (e) mean velocity in MCA less than 10 cm/s for more than 30 min. However, interpretation of this assessment must be done with caution.
4. POCUS is helpful to detect cerebral blood flow changes secondary to vasospasm in patients with traumatic brain injury and non-traumatic intracranial bleeding—agreement (quality of evidence C). Vasospasm of cerebral arteries results in increased flow velocities. The Lindegaard ratio (LR) is calculated by dividing mean velocity in MCA by mean velocity in ipsilateral extracranial ICA. As hyperaemia may also increase mean velocities, LR is useful to distinguish between hyperaemia and vasospasm (3:6 ratio is considered a sign of mild vasospasm, and > 6 a sign of severe vasospasm) [136].
5. POCUS is helpful to detect changes in optic nerve sheath diameter (ONSD) indicative of raised ICP in children with fused skull bones—agreement (quality of evidence B). Measurement of the ONSD is suggestive of papilledema and increased ICP [137, 138]; however, data conflict on threshold measurements [137–140] and papilledema may persist despite normalisation of intracranial pressure. Therefore, it must be reminded that this technique may have relevant measurement errors because of the narrow margins that distinguish pathological from normal.
6. POCUS is helpful to detect cerebral midline shift (MLS) in neonates and children—agreement (quality of evidence C). Measurement of the distance from both temporal bones to the centre of the third ventricle through the temporal acoustic window determines the presence of MLS [141, 142]. Minimal shifts (less than 5 mm) in adults have proven to identify abnormal conditions [143]. Yet, normative values for MLS identification in children have not been reported, and this may reduce the helpfulness of this application.

• E.

  Recommendations for abdominal POCUS

  1. POCUS is helpful for the detection of free intra-abdominal fluid in neonates and children—strong agreement (quality of evidence C). Abdominal POCUS is widely used as a clinical tool for the management and diagnosis of patients with abdominal pathology [144–148]. Evaluation of free fluid is particularly useful when sudden clinical deterioration and hypotension occur and may provide insight into the ongoing pathophysiologic process [149, 150].
  2. POCUS may detect parenchymal changes of abdominal organs in neonates and children [although for a definite diagnosis a detailed assessment should be performed by a paediatric radiologist]—agreement (quality of evidence D). Basic ultrasound knowledge of abdominal organ anatomy is essential during POCUS examination. Furthermore, a detailed assessment should be performed by a paediatric radiologist if abnormal abdominal organ structures are detected by POCUS [151, 152].
  3. POCUS may detect obstructive uropathy in neonates and children [although for a definite diagnosis a detailed assessment should be performed by a paediatric radiologist]—agreement (quality of evidence D). A renal ultrasound is useful to easily detect the presence of hydronephrosis even by novices [152–154]. Urinary retention can be evaluated by POCUS assessing postvoid residual volumes. In the case of anuria, a simple obstruction requiring a urinary catheter placement can be ruled out.
  4. POCUS may assess bowel peristalsis in neonates and children—agreement (quality of evidence D). Bowel POCUS may be used to assess peristalsis [155] but insufficient data yet exist correlating peristalsis with feeding tolerance. However, the presence of peristalsis has strong negative predictive value in adults for ileus and gut ischemia in adults [156].
  5. POCUS may recognise hypertrophic pyloric stenosis [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist]—disagreement (quality of evidence D )[157]
  6. POCUS may guide peritoneal drainage or aspiration of peritoneal fluid in neonates and children—strong agreement (quality of evidence D). A paracentesis may be required for either diagnostic or therapeutic purposes. POCUS should be used for pre-procedural planning, identification of epigastric vessels and real-time ultrasonographic guidance. In adult studies, the use of ultrasound has been shown to decrease both bleeding complications and the overall cost of care for patients undergoing in-hospital paracentesis [158].
  7. POCUS is helpful to detect signs of necrotizing enterocolitis (NEC) [although for a definitive diagnosis a detailed assessment should be performed by a paediatric radiologist or a person with specific advanced ultrasound training]—agreement (quality of evidence C). Ultrasound may be a useful adjunct detecting changes consistent with NEC even when radiographs are inconclusive [159, 160]. Furthermore, radiographs have poor sensitivity in the diagnosis of NEC [161, 162]. POCUS can provide prognostic value identifying free fluid, bowel wall thickness, pneumatosis intestinalis, portal venous gas and vascular perfusion [159, 163–166]. The International Neonatal Consortium’s NEC subgroup recently revisited the necrotizing enterocolitis (NEC) pathogenesis and new diagnostic criteria were proposed [167]. These were based on the so-called ‘two out of three’ model which includes pneumatosis intestinalis or portal venous gas by abdominal X-rays and/or POCUS. POCUS was included since various studies demonstrated that it outperformed conventional radiology to this end [159].

  Discussion

  There remains a significant variation in clinical practice—in indications, training program and clinical governance. The application of POCUS in clinical practice is dependent on many factors including availability of ultrasound machines, providers, hospital setting, local patient population and specialty. Even within a unit, practice varies among clinicians and their expertise. We subdivided POCUS recommendations according to the estimated level of training required for their use (Fig. 2), and this may be helpful for their implementation.

   

  

  Estimated level of training required for the implementation of POCUS recommendations. Recommendations are listed according to their progressive number for each section