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
Neonatologist
Point of Care
Emergency/ICU
Anaesthetic use
Ultrasound
examination
of the heart
Paediatric
Cardiologist
diagnosis
research
Neonatologist
PDA/
pulmonary
hypertension
functional
Emergency/ICU
Point of Care
haemodynamic
Anaesthetic use
Haemodynamic
Residual 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
In the ICU
Seppelt 2007
• 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
Tennessee
•31 sick patients – reasonable results – checked by
Cardiologist
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
Sampson and Kumar
168/11000 - 83 patients
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 echo
The wish to learn
The 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 noncardiologist
• Telemedicine
– Good examples from Western Hemisphere
– YouTube style studies
• Dummy training using echo simulators
• Smaller powerful laptop type machines
• Hand held machines
Thank You