Page 42 - Fall2020

POINT-OF-CARE ULTRASONOGRAPHY IN NEONATES
manipulations, and a decrease in the number of required radiographs to confirm placement. Linear array or micro- linear probes with high-frequency transducers (up to 25 MHz) are most often utilized in the placement and evalua- tion of these superficial structures. Radiographs have been shown to have a low sensitivity in identifying the tip of the line compared with ultrasound evaluation (see Multime- dia 3 at acousticstoday.org/ruossmm; Miller et al., 2019).
Evacuation of Life-Threatening Abnormal Fluid Collections
POCUS is strongly recommended for needle-assisted drain- age of fluid around the heart (pericardiocentesis), from the chest (thoracentesis), and from the abdomen (paracentesis). Fluid, blood, or air can surround and compress the heart, resulting in cardiac failure and death. POCUS can rapidly confirm the diagnosis before other clinical features appear and can be used to guide emergent pericardiocentesis (see Multimedia 4 at acousticstoday.org/ruossmm). Accumu- lation of fluid or air between the chest wall and lungs can cause severe issues with breathing and death if not there is no intervention. Fluid is characterized by hypoechoic or anechoic signals below the pleural line with absent rever- beration artifacts in the area of the fluid collection, and, in some cases, the lung is collapsed and can be visualized as a hyperechoic object moving in the anechoic area (see Multi- media 5 at acousticstoday.org/ruossmm). Accumulation of air in the chest cavity is displayed as absent lung move- ment with preserved reverberation artifacts from the pleural line in B-mode and a barcode sign in M-mode. Ultrasound can identify smaller amounts of fluid than plain film radiography and can be used to guide needle drainage of the fluid or air collection while avoiding an unintended injury to organs in close proximity. Evacua- tion of peritoneal fluid (fluid in the abdominal cavity) for emergent or diagnostic purposes with POCUS improves the efficacy of the procedure (Singh et al., 2020).
Establishment of Point-of-Care Ultrasound Programs
The establishment of a neonatal-focused POCUS pro- gram requires multidisciplinary collaboration between neonatology, radiology, and cardiology. Evidence and an international multidisciplinary pediatric and neonatal group consensus support that POCUS has a diagnostics and procedural role in the NICU (Singh et al., 2020). POCUS aims to enable nonradiologists to use bedside ultrasound to answer specific questions in real time,
assist in procedures, and decrease radiation exposure in neonates. Although the need for POCUS differs between NICUs depending on the availability of pediatric-trained subspecialists and technologists, there are multiple common barriers (cost, training, and quality improve- ment) to developing a program. Finally, clinicians need to be aware of the technique limitations, their own limita- tions, and the scope of their practice when using POCUS, with continued referral to radiology or cardiology for more detailed and comprehensive assessments.
Conclusion
POCUS applications in newborn medicine are growing, with increasing evidence to support its use for a variety of neonatal applications. Comprehensive understanding of the diagnostic and procedural implications as well as the limitations and considerations is a prerequisite to widespread implementation of POCUS in critically ill neonates. It is now imperative to further define the scope of POCUS in the NICU through formal training, accreditation guidelines, and a close multidisciplinary collaboration within pediatrics. Neonatologists should be honest with families about the advantages and limitations of POCUS in the NICU and adopt a culture of research that will support development and labeling of new preci- sion diagnostics and therapeutic interventions.
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