Targeted Echocardiography in the Neonatal Intensive Care Unit

CORRESPONDENCE Targeted Echocardiography in the Neonatal Intensive Care Unit To the Editor: It has been more than a decade since the initial interest was expressed by neonatologists in acquiring basic skills in performing echocardiography.1 Their plea for a formalized training program has mostly been met with resistance, driving some to learn the technique through informal self-directed learning.2 The recent practice guideline and consensus statement by the Writing Group of the American Society of Echocardiography in collaboration with the European Association of Echocardiography and the Association for European Pediatric Cardiologists3 will be welcomed by neonatologists all over the world. The poor correlation of cardiac hemodynamics with clinical findings in premature newborns is now well known,4 and the increasing use of echocardiography for hemodynamic information can only improve patient care. Around-the-clock availability of cardiac sonographer to perform echocardiography in the neonatal intensive care unit (NICU) is currently not feasible in most environments, and management decisions can sometimes be delayed or altered depending on the time of day. A wealth of hemodynamic information derived from functional echocardiography will also drive research in the area of cardiovascular medicine in newborns, which is still at a very early stage. At the Boston Medical Center, two neonatologists with prior experience in echocardiography currently perform point-of-care functional echocardiography to check central line position, hemodynamic assessment of patent ductus arteriosus, and assessment of cardiac function in hypotensive newborns. The quality improvement initiative of using ultrasound to check central line positions has already resulted in a significant reduction of x-ray exposure to newborns (unpublished data). The echocardiographic images obtained by neonatologists are instantly loaded on a secure central server so that they can be read remotely by a cardiologist. All initial targeted echocardiographic studies are followed by detailed full echocardiographic assessments performed by cardiac sonographers and evaluated by pediatric cardiologists. This model can be used by other neonatologists who have acquired prior training to audit their own echocardiographic practice while providing 24-hour availability of echocardiography in the NICU. The development of formal guidelines governing the use and monitoring of echocardiography performed by neonatologists in the NICU will refine practice in the NICU, minimize interpretational errors, and allow patient care to proceed in the presence of a safety net. An understanding of the principles of echocardiography will allow neonatologists to ask appropriate, sometimes creative questions of sonographers and cardiologists. There is no more dedicated investigator than the physician involved in direct clinical care seeking to do the best for the patient.

Bharati Sinha, MD Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts Mark H. Mirochnick, MD Boston University School of Medicine and Boston Medical Center Boston, Massachusetts Sanjay Kumar, MCh, FRCS Yale University School of Medicine New Haven, Connecticut

Alan M. Fujii, MD Boston University School of Medicine and Boston Medical Center Boston, Massachusetts

REFERENCES 1. Skinner JR. Echocardiography on the neonatal unit: a job for the neonatologist or the cardiologist? Arch Dis Child 1998;78:401-2. 2. Evans N. Echocardiography on neonatal intensive care units in Australia and New Zealand. J Paediatr Child Health 2000;36:169-71. 3. Mertens L, Seri I, Marek J, et al., Writing Group of the American Society of Echocardiography; European Association of Echocardiography; Association for European Pediatric Cardiologists. Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. J Am Soc Echocardiogr 2011;24: 1057-78. 4. Osborn DA, Evans N, Kluckow M. Clinical detection of low upper body blood flow in very premature infants using blood pressure, capillary refill time, and central-peripheral temperature difference. Arch Dis Child Fetal Neonatal Ed 2004;89:F168-73. doi:10.1016/j.echo.2012.01.001

Neonatologists and Echocardiography: Time to Move On Author’s Response: We thank Dr. Sinha and colleagues for their interest in our recently published recommendations on targeted neonatal echocardiography (TNE).1 The authors nicely explain the way they developed a TNE service at the Boston Medical Center. This can serve as an example of how our practice guidelines can be implemented by neonatal intensive care units (NICU). Organizing a 24-hour service 7 days a week is an important challenge for most units, which should not be underestimated when starting a TNE program. Therefore, collaborating with existing resources has obvious logistic advantages. Wherever possible, this implies maximal integration within existing echocardiography services. As Sinha et al. correctly state, this integrated model also influences the quality of care and improves the safety of the TNE service. For NICUs in hospitals without pediatric cardiology services, telemedicine links are a good solution. This can consist of the transfer of images to a referral center, as in the Boston approach, or of more advanced solutions, such as a live-scanning approach with trained neonatologists scanning under remote supervision of pediatric cardiologists. This uses Internet transmission with a two-screen device, one connected to the ultrasound machine on site and the second to a camera observing the operator. This allows the reviewing physician to provide direct instructions to the operator while scanning. The success of a TNE program is critically dependent on the training of the operators. We agree with Sinha et al. that echocardiographic training of neonatologists should go beyond informal self-directed learning, and we hope that our more formal extensive training model will improve operators’ diagnostic skills. Because organizing a TNE service requires significant resources, there is a need to further scientifically prove the clinical benefit and demonstrate its impact on the clinical outcomes of patients admitted 361