www.jped.com.br
ORIGINAL
ARTICLE
Echocardiography
in
PICU:
when
the
heart
sees
what
is
invisible
to
the
eye
夽
Fatma
Rabah
∗,
Khalfan
Al-Senaidi,
Ismail
Beshlawi,
Alddai
Alnair,
Anas-Alwogud
Ahmed
Abdelmogheth
ChildHealthDepartment,SultanQaboosUniversityHospital,Muscat,Oman
Received26November2014;accepted6May2015 Availableonline11November2015
KEYWORDS
Echocardiography; Pediatriccardiology; Pediatricintensive care;
Clinicaldecision making
Abstract
Objective: Echocardiographyhasbecomeanindispensablebedsidediagnostictoolintherealm ofpediatricintensivecareunits(PICU).Ithasproventobeaninfluentialfactorintheformulaof clinicaldecision-making.Thisstudyaimedtodelineatetheimpactofechocardiographyonthe managementofcriticallyillpediatricpatientsinthePICUatSultanQaboosUniversityHospital, Oman.
Method: Thiswasaretrospectivecohortstudyconductedinafive-bedPICU.Patientsadmitted tothePICUfromJanuaryof2011toDecemberof2012werereviewed.Thosewhohave under-gonebedsideechocardiographyduringtheirICUstaywererecruited.Electronicpatientrecord wasusedasdatasource.
Results: Overa-24-monthperiod,424patientswereadmittedinthisPICU.Onehundredandone clinicallyindicatedtransthoracicechocardiogramswereperformed.81.8%ofthesepresented newfindings(n=82)thatsignificantlyimpactedtheclinicaldecisionofpatientmanagement, namely,alterationindrugtherapyandprocedure,whereasnodifferenceinthemanagement wasyieldedintheremaining17.8%ofthestudiedcases.
Conclusions: EchocardiographyhadasignificantimpactonthemanagementofPICUpatients. Such salutary effect was consequently reflectedon the outcome. Pediatricintensivists are encouragedtoacquiresuchbedsideskill.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:RabahF,Al-SenaidiK,BeshlawiI,AlnairA,AbdelmoghethA-A.EchocardiographyinPICU:whentheheartsees whatisinvisibletotheeye.JPediatr(RioJ).2016;92:96---100.
∗Correspondingauthor.
E-mail:fatmarabah@gmail.com(F.Rabah).
http://dx.doi.org/10.1016/j.jped.2015.04.011
PALAVRAS-CHAVE
Ecocardiografia; Cardiologia pediátrica; Cuidadointensivo pediátrico;
Tomadadedecisões clínica
EcocardiografianaUTIP:quandoocorac¸ãovêoqueéinvisívelaosolhos
Resumo
Objetivo: Aecocardiografiasetornouumaferramentadediagnósticorelevante,indispensável noâmbitodasunidadesdeterapiaintensivapediátrica(UTIP).Elasetornouumfatorinfluente natomada dedecisões clínicas.Oobjetivo desteestudo foidelinear oimpacto da ecocar-diografiasobreo manejode pacientespediátricosgravemente doentesnaUTIP doHospital UniversitárioSultanQaboos,emOmã.
Método: Esteéum estudo decoorte retrospectivorealizado em uma UTIPde cincoleitos. Foramanalisados pacientesinternadosnaUTIP entrejaneirode2011edezembro de2012. Foramrecrutadosospacientesquepassaramporecocardiografia durantesuainternac¸ãona UTI.Oregistroeletrônicodospacientesfoiutilizadocomofontededados.
Resultados: Em um período de 24 meses, 424 pacientes foram internados em nossa UTIP 101pacientesforamencaminhadosparaecocardiografiastranstorácicas.81,8%delastiveram novos achados (n=82) que afetaram significativamente a decisão clínica, como a terapia medicamentosaeprocedimentos,aopassoquenãohouvenenhumadiferenc¸anomanejonos outros17,8%doscasosestudados.
Conclusões: Aecocardiografia teveumimpactosignificativosobreomanejodepacientesda UTIP.Esseefeitorefletiu-senosresultados.Osintensivistaspediátricosdevemserincentivados aadquiriressahabilidaderelevante.
©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Managementofcriticallyillpediatricpatientsisa demand-ing task that requires proper prioritization and judicious timemanagement. Multi-systemaffection withoverlapof symptoms often complicates the clinical picture. Hemo-dynamic assessment has recently taken top priority in the management of critically ill patients.1 This is clearly
illustratedintheparadigmshiftfromABCtoCAB.2
Echocar-diography isan integral componentof theclinical service in the pediatric intensive care unit (PICU). It is consid-ered a handy bedside imaging modality, and an accurate diagnostic tool that explores a crucial body system.1 To
incorporate echocardiogram findings along with the clini-calsignsresultsinaclearimagedetailingthehemodynamic statusofthecriticallyillchild.This studyaimedto delin-eate the clinical usage of echocardiography in the PICU setting.
Methods
Thiswasaretrospectiveobservationalstudy.Patients admit-tedtooftheSultanQaboosUniversityHospitalPICUperiod fromJanuaryof2011toDecemberof2012wereassessed.
Thisisanopencombinedmedical-surgicalfive-bedPICU. Moreover,it is anintensivist-led PICU withthesupportof pediatric board-certified subspecialists. Apart from post-cardiothoracicoperativecases,allpost-traumatic,medical, andsurgicalcriticallyillchildrenareattendedtoatthisunit. Electronic patient records were reviewed to identify thosewhohadundergone transthoracicechocardiography. Thestudyprotocolwasapprovedbytheinstitutionalreview board.
The following data were collected; (1) age and sexof thepatientsat PICUadmission,(2)clinical indications for echocardiography,(3)echocardiographic findings,(4) clini-caldecisionorinterventionbasedontheechocardiographic findings.Intervention or managementalteration afterthe echocardiographywasclassifiedintofourmaincategories; (1)altereddrugtherapy,(2)alteredprocedure,(3)altered decision-making,and(4)others(theexactnatureofthese changeswasspecifiedindetails).
Statistical
analysis
Data were analyzed using SPSS version 17.0 (SPSS Inc. Released2008.SPSSStatisticsforWindows,Chicago,USA). Descriptivestatistics,such asmean(±standard deviation) for normallydistributed data or median and interquartile range(IQR)fornon-normallydistributedvariables,were cal-culatedforquantitativeparameters.Qualitativedatawere summarized as frequency and percentage for categorical variables.TheFisher’sexacttestwasusedtotestthe signifi-canceoftheresultsatthe5%level.Somedatawereviolated toaffirmfittingtheassumptionsrequiredbythestatistical analyses.
Results
Table1 Indicationfor101echocardiographyexams.
Characteristics n(%)
AssessmentofLVfunction 27(26.7)
Murmur 19(18.8)
SuspectedIEorPE 14(13.9) KnowncardiacorCHD 13(12.9) RefractoryhypoxiatoassessPApressure 10(9.9) Arrhythmiaortachycardia 7(6.9) Post-trauma/Post-arrest 6(5.9) Suspectedcardiomyopathy 3(3) Pre-/post-operative 2(2)
LV,leftventricular; IE,infective endocarditis; PE,pericardial effusion;CHD,congenitalheartdisease;PA,pulmonaryartery.
Table2 Echocardiographicfindingsin101exams.
Findings No(%)
Normalstudy 32(31.7)
CHD 25(24.7)
ReducedLVfunction,LVH/dilatation 21(20.8) Pericardialeffusion 10(9.9)
PulmonaryHTN 9(8.9)
Vegetation 4(4)
CHD,congenital heartdisease; LV, left ventricular; LVH,left ventricularhypertrophy;HTN,hypertension.
5years.Atotalof80patients weredischargedfromPICU (79.2%),whereas21patients(20.8%)died.
Tworegisteredcardiacsonographersandoneconsultant cardiologist(secondauthor)werethestaffthatcarriedout the echocardiographic examination. Interpretations were providedbyaboard-certifiedconsultantpediatric cardiolo-gist.IndicationsforechocardiogramsareshowninTable1. Over one-fourth of exams were conducted to assess left ventricularfunctioninhemodynamically unstablepatients (27exams,26.7%).Suspicionofcongenitalheartdiseasewas thesecondmostcommonindication(19exams,18.8%).
The findings were classified into categories of interest (Table2).Normalexamwasthemostcommonfinding(30%); 81 exams (81%) produced new findings that resulted in additionalclinical managementstepsofpotentialsalutary effect,and19(18.8%)yieldedclinicallyinsignificantfindings (Table3).Suchpost-echocardiographyclinicalmanagement alterationsaredetailedinTable4).Therewasasignificant positivecorrelationbetweenthefindingsofthestudiesand theclinicalinterventionortheclinicaldecision.Itis note-worthythatthep-valueofallresultswas<0.001.
Discussion
DeterminingtheimpactofechocardiographyinICUhaslong beenofinteresttoresearchandclinicalstudies.3---7Various
studies assessed the use of echocardiograms in adult ICU patients, yet few dealt with the pediatric population.8---12
Thepresentstudyhasclearlydemonstratedthesignificance of echocardiography in approximately 82% of the cases. Not onlyit supported theclinical decision in most of the
Table3 Impactofechocardiographyondecision-making.
Intervention n(%)
Altereddrugtherapy
Fluidloading 6(5.9)
Fluidrestriction 2(2) Reductionofinotropes 7(6.9) Initiationofinotropes 4(4) Increaseofinotropes 1(1) Initiationofdiuretics 5(5) Initiationofsildenafil 5(5)
InitiationofBB 5(5)
InitiationofACEI 4(4) Initiationofdigoxin 3(3) Initiationofacetylsalicylicacid 1(1) Correctionofelectrolytes 1(1)
Procedure
Follow-up 16(16)
RadiologyCTangio/bariumswallow 4(4) Referralforcardiothoracicsurgery 2(2)
CVLremoval 2(2)
Bronchoscopy 1(1)
Insertionofpericardialdrain 1(1) Removalofpericardialdrain 1(1)
Decision-making
Clearanceforsurgery/procedure 5(5) Limitationoftreatment 4(4) Adjustmentofventilation 1(1)
Nointervention 19(19)
BB, -adrenoreceptor blocker; ACEI, angiotensin-converting enzyme inhibitors; CT, computed tomography; CVL, central venousline.
cases,butitalsohelpedadjustingthemanagementofthose patients.Normalechocardiographicfindingswerethemost prevalentresult.Thisillustrateshowambiguousthecardiac conditioncouldbeintheeyesoftheclinicianwereitnotfor the echocardiography. Normalheart byechocardiographic examinationisaninvaluableinformationtobeincorporated intheassessmentofahypotensivepatient.Congenitalheart diseasewasthesecond mostcommonfinding,an observa-tionthatisuniquetothepediatricstudieswhencompared withadultstudies.
Assessmentoftheleftventricularfunctionisbyfarthe most common indication of echocardiograms across both adultandpediatricstudies.4---12Itisimperativeforthe
clini-ciantodefinethe cardiaccontributiontothehypotensive state of a critical patient. Sometimes, the clinical deci-sion is at the point of decision where the clinicianis not sure whethertoprimarily focusonsupportingthe cardiac function or to adopt fluid support with special consider-ationtosepsis.13Echocardiographymightbeaveryhelpful
indicatorinsuchcriticaltiming.Suchcrucialroleof echocar-diography could be sufficiently achieved even when it is notperformedbyacardiologist.3Interestingly,ithasbeen
Table4 Interventionsafterechocardiography.
Characteristics Altereddrug therapy(n=45)
Procedure (n=27)
Decision making(n=10)
Nodifference (n=19)
p-value
Normalstudy n 7 6 3 16 <0.001
% 15.6% 22.2% 30.0% 84.2%
CHD n 10 8 7 0 <0.001
% 22.2% 29.6% 70.0% 0.0%
PulmonaryHTN n 9 0 0 0 <0.001
% 20.0% 0.0% 0.0% 0.0%
ReducedLVfunction, LVH/dilatation
n 15 4 0 2 <0.001
% 33.3% 14.8% 0.0% 10.5%
Pericardialeffusion n 4 5 0 1 <0.001
% 8.9% 18.5% 0.0% 5.3%
Vegetation n 0 4 0 0 <0.001
% 0.0% 14.8% 0.0% 0.0%
CHD,congenitalheartdisease;HTN,hypertension;LV,leftventricular;LVH,leftventricularhypertrophy.
thatacriticalcarephysiciancouldbecapableofassessing LVfunction throughechocardiography,in goodcorrelation withthe cardiac index measured invasivelyby pulmonary catheterization.13
Pericardialeffusionwasonetheconcernsaddressedby the echocardiography in different ICU studies.4---6 Despite
havingdefinedclinicaldiagnosticcriteria,thesensitivityof thesefindingshighlighttheneedforechocardiographyfora firmdiagnosis.
Moreover, unexplained hypoxemiais not an uncommon ICUdilemma,especiallycomplicating thepictureof venti-latedpatients.Screeningfor pulmonaryhypertensionwith tricuspidregurge jetvelocityhas proven tobean invalu-able clue to explain defective oxygenation.13 Obviously,
theseimportantdiagnosticclueschangethemanagement. Echoingpreviousstudies,themostcommonresulting inter-ventionwasaltereddrugtherapy,mainlyinotropesandfluid management.4,14
The present study bears the limitations of the retro-spectiveobservationaldesign.Determinationofthecausal relationship and proper definition of the effect of con-founders were both restricted. Furthermore, this was a single-centerstudy withrelatively smallsample size.The fact that this study was neither randomized nor blinded hindered proper assessment of the impact of echocar-diography upon the outcome of critically ill children. Such limitations prevent the generalization of the study findings.
Additionally, candidate patientswho wouldmost prob-ably benefit from the echocardiography could not be identified. Nevertheless, those candidates might be the hemodynamically unstable patients, since the most com-monindicationsforechocardiographywerehypotensionand assessmentofleftventricularfunction.
Echocardiography is a noninvasive, accurate bedside exam in the PICU.Establishing intensivist-driven echocar-diogramsaffectsthemanagementofthecriticallyillpatient admitted to PICU. Large prospective clinical studies are neededtoproperlydefinetheindicationsandeffectsofsuch handyprocedureinthePICUsetting.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
The authors aregrateful toDr. Ismail El-Beshlawi for his adviceonthepreparationandwritingofthismanuscript.
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