Hemodynamics and Cardiology

Neonatology Questions and Controversies

Istvan Seri

• Publisher: Elsevier
• Year: 2018
• ISBN:
  9780323568432
• Edition: 3
• Topic: Medicine
• Subtopic: Perinatology & Neonatology

Dr. Richard Polin's Neonatology Questions and Controversies series highlights the most challenging aspects of neonatal care, offering trustworthy guidance on up-to-date diagnostic and treatment options in the field. In each volume, renowned experts address the clinical problems of greatest concern to today's practitioners, helping you handle difficult practice issues and provide optimal, evidence-based care to every patient.

• Stay fully up to date in this fast-changing field with Hemodynamics and Cardiology, 3rd Edition.
• A new editorial team and a completely redesigned volume with state-of-the-art chapters on neonatal hemodynamics.
• New chapters on the role of delayed cord clamping/cord milking, the relationship between neonatal transition and brain injury, the hemodynamics of the asphyxiated neonate, the hemodynamic impact of therapeutic hypothermia, and practical physiology-based approaches to the diagnosis and treatment of neonatal hypotension, PPHN and PDA.
• A new section discusses comprehensive real-time monitoring of neonatal hemodynamics, and its role in the establishment of precision medicine in neonatology and the prediction of neonatal sepsis using mathematical modelling of heart rate variability.
• Expanded sections review the clinical application of the tools available for bedside monitoring of systemic and organ blood flow and oxygen delivery and the approaches to the pathophysiology-based treatment of neonatal shock and outcomes.
• Consistent chapter organization to help you find information quickly and easily.
• The most authoritative advice available from world-class neonatologists who share their knowledge of new trends and developments in neonatal care.

Purchase each volume individually, or get the entire 7-volume set! Gastroenterology and Nutrition Hematology, Immunology and Genetics Hemodynamics and Cardiology Infectious Disease and Pharmacology New Volume! Nephrology and Fluid/Electrolyte Physiology Neurology The Newborn Lung

Diagnosis of Neonatal Cardiovascular Compromise: Methods and their Clinical Applications

Outline

1. Section C1. Assessment of Systemic Blood Flow and Cardiac Function: Ultrasound
   1. Chapter 10. Point of Care Ultrasound in the Assessment of the Neonatal Cardiovascular System
   2. Chapter 11. Assessment of Systemic Blood Flow and Myocardial Function in the Neonatal Period Using Ultrasound
   3. Chapter 12. Tissue Doppler Imaging
   4. Chapter 13. Speckle Tracking Echocardiography in Newborns
2. Section C2. Assessment of Systemic Blood Flow and Cardiac Function: Other Methods
   1. Chapter 14. Assessment of Cardiac Output in Neonates: Techniques Using the Fick Principle, Indicator Dilution Technology, Doppler Ultrasound, Thoracic Electrical Impedance, and Arterial Pulse Contour Analysis
   2. Chapter 15. Cardiac Magnetic Resonance Imaging in the Assessment of Systemic and Organ Blood Flow and the Function of the Developing Heart
3. Section C3. Assessment of Organ and Peripheral Blood Flow
   1. Chapter 16. Methods to Assess Organ Blood Flow in the Neonate
   2. Chapter 17. Near-Infrared Spectroscopy and Its Use for the Assessment of Tissue Perfusion in the Neonate
   3. Chapter 18. Clinical Applications of Near-Infrared Spectroscopy in Neonates
   4. Chapter 19. Assessment of the Microcirculation in the Neonate
4. Section C4. Comprehensive and Predictive Monitoring
   1. Chapter 20. Heart Rate and Cardiorespiratory Analysis for Sepsis and Necrotizing Enterocolitis Prediction
   2. Chapter 21. Comprehensive, Real-Time Hemodynamic Monitoring and Data Acquisition: An Essential Component of the Development of Individualized Neonatal Intensive Care

Section C1

Assessment of Systemic Blood Flow and Cardiac Function: Ultrasound

Outline

Chapter 10. Point of Care Ultrasound in the Assessment of the Neonatal Cardiovascular System

Chapter 11. Assessment of Systemic Blood Flow and Myocardial Function in the Neonatal Period Using Ultrasound

Chapter 12. Tissue Doppler Imaging

Chapter 13. Speckle Tracking Echocardiography in Newborns

Chapter 10

Point of Care Ultrasound in the Assessment of the Neonatal Cardiovascular System

Nicholas Evans, and Martin Kluckow

Abstract

There is a progressive adoption of point of care ultrasound (POCU) performed by acute care physicians in many clinical areas including the neonatal intensive care unit. There has been some resistance to POCU from consultative ultrasound specialties, much of which is due to misunderstanding the goals of POCU. Clearly there is a need for equipment, training, and accreditation structures in neonatal POCU. These structures need to be workable, relevant, and, most importantly, controlled from within the specialty of neonatology. There is a range of clinical situations in neonates where POCU can add invaluable and, at times, lifesaving diagnostic information. Understanding individual patient physiology, targeting treatment, and obtaining longitudinal feedback are important aspects of the use of neonatal POCU. Neonatal POCU is not just about the heart, but embraces the study of a range of organ systems including the brain, lungs, abdominal organs, and blood vessels for line localization.

Keywords

accreditation; cardiac ultrasound; infant newborn; point of care ultrasound; transitional circulation

• The use of point of care ultrasound (POCU) in the care of sick and preterm neonates is rapidly expanding.

• The benefits of a portable, bedside technique that is able to provide real time, longitudinal data regarding the physiology of individual patients allowing more targeted treatment is being progressively recognized as we move towards the era of personalized medicine in neonatology.

• POCU has an important role in managing the transitioning term or preterm infant, the septic/asphyxiated infant, the shocked or hypotensive infant and infants with suspected PPHN or congenital heart disease.

• POCU is usually a predominantly ‘rule in’ diagnostic modality and does not aim to ‘rule out’ all diagnoses whereas consultative ultrasound should also be a ‘rule out’ diagnostic modality.

• With the acceptance of the usefulness of ultrasound in the clinical setting, the need for appropriate training programs and accreditation increases.

• Approaches to training and accreditation vary across different countries.

It is a limitation in the intensive care of the newborn infant that we have few tools with which to monitor cardiovascular and hemodynamic function. There is usually the ability to continuously monitor invasive blood pressure and heart rate and that’s about it. Beyond that, reliance is placed on rather inaccurate measures of contemporaneous hemodynamic well-being such as skin capillary refill time and urine output and measures that do not reflect the changes in the hemodynamic status in real time, such as the acid-base status. Near-infrared spectroscopy (NIRS) is evolving as a potentially useful monitoring tool¹ for the real-time assessment of tissue oxygenation of the organ interrogated (brain, kidney, muscle, or intestines; see Chapters 16 to 18). As for measuring cardiac output, there is little outcome-based validation for tools designed to measure cardiac output (see Chapters 14 and 21). The difficulties of small patient size and a smaller commercial market limit neonatology access to a range of tools for monitoring cardiac output which are available for the intensive care of the older subject, such as thermodilution, electrical impedance velocimetry, continuous Doppler methodologies, and derivations from blood pressure waveforms.

Doppler cardiac ultrasound provides a noninvasive, albeit noncontinuous, technique from which it is possible to derive estimates of a wide range of hemodynamic parameters as well as information on structure and function of the organ that drives the circulation, the heart. Integration of cardiac ultrasound into routine neonatal intensive care has been limited by the concentration of the necessary skills in specialist groups who work predominantly outside the neonatal intensive care unit (NICU). This results in information that is often neither timely nor particularly well focused on hemodynamics. From a research perspective, it meant that there were assumptions derived from a limited number of snapshots rather than serial studies to document natural history.

Neonatology, like many acute care specialties, has recognized the limitations of an external consultative ultrasound model and neonatologists are increasingly develo...