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Updated: Mar 20, 2026
Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Pilot study on the feasibility of limited focused real-time echocardiography during pediatric renal transplantation
Katherine Taylor1,2, Armando Lorenzo3,4, Luc Mertens5,6
1Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Supraphysiological blood pressure and central venous pressure (CVP) targets are not essential for optimal pediatric renal transplant graft perfusion. Echocardiography (ECHO) confirmed adequate cardiac index increases, even when CVP and blood pressure targets were unmet.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Cardiovascular Physiology
Background:
- Current pediatric renal transplantation protocols often recommend supraphysiological blood pressure and central venous pressure (CVP) to optimize graft perfusion.
- However, ideal CVP and blood pressure targets in pediatric patients remain uncertain and challenging to achieve without causing morbidity.
Purpose of the Study:
- To assess the feasibility of using intraoperative echocardiography (ECHO) to evaluate intravascular volume status during pediatric renal transplantation.
- To correlate ECHO findings with standard hemodynamic monitoring (CVP, SBP, DBP) at critical intraoperative stages.
- To determine if achieving specific CVP and blood pressure targets is necessary for adequate graft perfusion.
Main Methods:
- A pilot feasibility study involving real-time, limited ECHO imaging during four critical phases of pediatric renal transplantation.
- Simultaneous measurements of CVP, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were recorded with ECHO images.
- Surgeons blinded to ECHO data assessed graft perfusion quality.
Main Results:
- Echocardiography demonstrated an increase in cardiac index (CI) in all 13 patients (9 TTE, 4 TEE) upon vascular clamp removal and post-resuscitation (average 20% increase).
- CVP, SBP, and DBP measurements were inconsistent, yet ECHO confirmed appropriate CI augmentation.
- Surgeons reported satisfactory graft perfusion in 12 out of 13 cases.
Conclusions:
- Fixed targets for CVP and blood pressure may not be necessary to enhance cardiac index and promote good renal perfusion in pediatric renal transplantation.
- Intraoperative ECHO can provide valuable real-time assessment of intravascular volume and cardiac function, guiding management effectively.
- This study suggests a more flexible approach to hemodynamic management may be beneficial in pediatric renal transplantation.
Abstract:
Pediatric renal transplantation protocols describe supraphysiological blood pressure and CVP to optimize graft perfusion. Ideal CVP and blood pressure targets in children are uncertain and difficult to achieve and/or sustain without incurring morbidity. We correlated intra-operative ECHO with standard monitoring to assess intravascular volume at critical intra-operative stages. A feasibility pilot study of real-time limited ECHO images during four critical stages of pediatric renal transplantation (baseline; venous and arterial clamps on; clamps off; 5-10 min post-clamp release) was conducted. Simultaneous CVP, SBP and DBP measurements were obtained with ECHO images. A surgeon blinded to the ECHO study assessed the quality of graft perfusion. Thirteen patients (nine TTE and four TEE) were enrolled. The CI increased in all patients at vascular clamp removal and the post-resuscitation period (average increase in CI 20%, range 8-49%). SBP, DBP and CVP were inconsistent. ECHO data confirmed an appropriate CI increase even when the targeted CVP and BP values described in protocols were not achieved. The surgeons were satisfied with graft perfusion in 12 of 13 cases, with one locally obstructed vessel. We suggested that aiming for fixed targets in CVP and BP is not necessary to augment CI and encourage good renal perfusion.
