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Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children
Pui Yin Florence Ip1,2, Uvaraj Periasamy2,3,4, Steven J Staffa2,3
1Department of Medicine, Boston Children's Hospital, Boston, MA.
Insights
Echocardiography guides management changes in critically ill children. For those with depressed cardiac function, switching from vasoconstrictors to inotropes shortens intensive care duration.
Area of Science:
- Pediatric critical care medicine
- Cardiology
- Echocardiography in pediatric intensive care
Background:
- Formal echocardiography is crucial for assessing cardiac function in critically ill children.
- Management decisions in pediatric intensive care units (ICUs) often require precise cardiac status evaluation.
Purpose of the Study:
- To evaluate the impact of management changes guided by echocardiography on outcomes in critically ill children.
- To assess the association between cardiac function status and subsequent treatment strategies and patient outcomes.
Main Methods:
- Retrospective cohort study of critically ill children (1-18 years) admitted to a tertiary care children's hospital between 2011 and 2020.
- Patients were stratified into near-normal or depressed cardiac function groups based on echocardiography performed within 72 hours of ICU admission, while intubated and on vasoactive infusions.
- Clinical data and management strategies (vasoactive and fluid) were analyzed in relation to echocardiography timing and patient outcomes.
Main Results:
- In children with depressed cardiac function, vasoconstrictor use correlated with poorer lactate clearance and oxygen extraction, increased lung water, and worse oxygenation (SpO2/FiO2).
- Echocardiography revealing depressed cardiac function often led to a shift towards inotropes and conservative fluid management.
- Patients with depressed cardiac function switched to inotropes experienced shorter durations of mechanical ventilation and vasoactive support compared to those remaining on vasoconstrictors.
Conclusions:
- Echocardiography-guided management adjustments in critically ill children with depressed cardiac function are associated with reduced intensive care interventions.
- Timely assessment and modification of treatment strategies based on echocardiographic findings can optimize patient recovery in the pediatric ICU.
Objectives:
To evaluate management changes and outcomes in critically ill children after formal echocardiography.
Design:
Retrospective cohort study between January 1, 2011, and December 31, 2020.
Setting:
Tertiary care children's hospital.
Patients:
Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function.
Methods:
Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes.
Interventions:
None.
Measurements And Main Results:
Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Sp o2 /F io2 . An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors.
Conclusions:
Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.
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