Enhancing Management of Circulatory Instability in Neonates

Transcription

1 Associate Scientist Enhancing Management of Circulatory Instability in Neonates Patrick McNamara Associate Professor of Pediatrics

2 The Vulnerable Neonate How will you ensure cardiovascular stability?

3 Myths & Magical numbers & Cook books

4 Metabolic Homeostasis Hemoglobin Anemia Hemorrhage Cellular Metabolism Oxygen Saturation Lung disease Shunts Heart Rate arrhythmia Preload Volume status Diastolic function Pericardial effusion Afterload SVR, pericardial P Oxygen Delivery Cardiac Output Contractility Catecholamines, sepsis Cardiomyopathy, acidosis SVR BP Oxygen Consumption Work Breathing, growth, trauma catabolism, fever Basal Metabolism Pain, sedation, anxiety thermogenesis

5 The Changing NICU Cost-effectiveness Optimal Outcome

6 What is Targeted Neonatal Echocardiography? Extension of the clinical examination - not confined to organs (Assessment phase) Hemodynamics, Organs, Catheters Ductal evaluation, Pulmonary hemodynamics, LV performance Relate physiologic and hemodynamic data to the clinical problem (Integration phase) Focused clinical decision making Response to intervention (Response)

7 Scenario I 19 day old male, born at 24 weeks gestation (650 gms), with a large HSDA (3.2 mm) referred for surgical ligation (failed 2 courses of indomethacin) E Coli sepsis, bilateral IVH Lung disease: HFOV 9 cm H 2 0, FiO2 0.4 Uneventful procedure (52 mins duration)

8 Blood Pressure BP [mmhg] Dobut. 5 mcg/kg/min Dobut. 10 Dobut Time [hrs] Heart rate FiO MAP ph LAC

9 Issues Problem: Systemic hypotension & low output state secondary to LV dysfunction and mechanical compression effects of extracardiac effusion Issue: : Reason for clinical deterioration different from presumed physiology Potential for cardiorespiratory arrest high without timely and appropriate intervention

10 Scenario II 40 week male, 3.3 kg with antenatal diagnosis of CDH & suspected aortic arch hypoplasia Severe oxygenation failure from birth Prostaglandin infusion (0.05) commenced No response to inhaled Nitric Oxide Postnatal echo equivocal

11 BP 31/23 (26) 43/30 (35) 39/30 (34) 43/32 (35) 56/32 (46) HR Lactate U.O. (mls/kg/hr) hrs 12hrs 24 hrs 36hrs PGE 1 ino Dopamine Epinephrine Milrinone, wean PGE 1 /pressors ppm 15 µg/kg/min 0.03 mg/kg/mi 0.66 mg/kg/min

12 Issues: Problem: Low systemic blood flow 2 to hyperinotropy and excessive L-R transductal shunting Danger: Complication of therapy Cardiotropic agents (e.g. dopamine, epinephrine) which increase myocardial contractility impair diastolic performance and low cardiac output state. Pressor agents further exacerbate the transductal shunt low cardiac output state Impact: Functional USS may help identify to origin of the low output state (e.g. myocardial dysfunction, transductal shunting) facilitating the choice of cardiotropic agent (pressor vs vasodilator)

13 Merits of TnECHO Provides timely hemodynamic information to confirm or question the presumed pathophysiology Earlier identification of neonatal disease e.g. HSDA, pericardial effusion, CHD Delineates need for treatment and assists with selection of desirable therapy e.g. ino or cardiotrope, vasodilator or vasopressor Facilitates monitoring the response to therapy Seghal & McNamara 2008

14 Emergence of Point of Care USS s: 1 st ultrasound equipment, restricted use: not portable 1970s: Cranial USS performed by neonatologists in Europe, Australasia Levene 1982 Arch Dis Child Echo performed by radiology until late 1970s (TURF War I) Point of Care ultrasound used by adult intensivists, OBG nurses (hemorrhage, fetal well-being), ER physician (abominal aneurysm) & surgeons (acute abdomen, scrotum) Australasian Society for Ultrasound Certificate in Clinician performed USS

15 ECHO in the NICU, ASE writing group 2010 Canadian fecho Network 40% centers with trained neonatologist 2009 PAS, AAP workshops in fecho 2007 CCPU, Australasia 2005 RCPCH, UK fecho manadated for tertiary level neonatologists 2005 Toronto fecho training program 2003 Toronto fecho in clinical care Ward 2001 Errors in neonatal echo in ANZAC Evans 2000 Survey of neonatal fecho practice in ANZAC Pre-2000 Ad-hoc fecho practice in ANZAC, UK & Europe

16 Traditional Echocardiography Model Clinical question by neonatologist Ultrasound performed by technician Image interpretation Report generation

17 Issues Disconnect between clinical question and study interpretation Information missing with need for repeat of study Temporal delay in acquisition of information Limited ability to perform sequential studies Out-of-hours studies limited to cases where likelihood of CHD high

18 Refining Therapeutic Decision-Making

19 Clinical Problem Functional Evaluation Hemodynamic Problem Anatomic Problem Medical decision Cardiology Consultation

20 TnECHO - Indications Is their a hemodynamically significant ductus arteriosus? Size of the shunt, effect on myocardial performance and end-organ perfusion Evaluation of pulmonary hemodynamics Degree of pulmonary hypertension vs. impact on myocardial performance Presence or absence of shunt Troubleshooting systemic hypoperfusion or hypotension Systolic vs. diastolic performance (afterload effect?) Low SVC flow, low cardiac output Miscellaneous Confirmation of line placement (assist insertion) Presence or effusions or thrombi

21 Defining the Nature of the Problem Preload Myocardial Function Afterload Heart Problem Rhythm problem Hypovolaemia Prematurity < 48 hours of life HSDA SVT Overinflation Sepsis / NEC PDA Ligation Coarctation Complete heart block Adrenal suppression Adrenal suppression Pulmonary hypertension HLHS IDM Aortic stenosis

22 Is the neonatologist reliable? Does TnECHO improve outcomes?

23 Challenges Validity of some measurements Collaboration with Pediatric Cardiologists Income streams Misdiagnosis & Maltreatment Terms/Level of Engagement Standards for training Access to equipment (Ownership) Data storage

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25 Diagnostic Errors 47/110 (44%) Ward 2001 J Pediatr Child Health

26 Neonatologist & CHD Samson 2004 Card Young

27 Drawing Parallels: Antenatal Diagnosis of CHD 626, 781 live births 4295 cases of CHD 451 major cardiac defects 238 (52.8%) cases detected antenatally Chew 2007 Ultrasound Obs Gyn

28 EVIDENCE FROM ADULT TRAINING Target group Duration Assessment Accuracy Focused Assessment with Sonography for Trauma 15 scans: 50 scans: Trauma assessment sensitivity 90%, accuracy 99% sensitivity 96%, accuracy 100% McCarter 2000 Ann Surg Limited Echo Assessment Project (LEAP): Residents 20 hours LV function & pericardial effusion High Alexander 2001 Circulation Medical students 20 hours LV function & pericardial effusion Complete echo: 97% Accuracy: 80% Alexander 2001 Circulation Non-cardiologist 10 hours LV assessment Accuracy 87% Manasia 2004 J Cardiovasc Anesth Non-cardiologist 4 hours LV function Sensitivity 77% Specificity 94% Melamed 2004 Chest Residents 20 hours Complete assessment Accuracy 93% Croft 2006 Echo

29 PDA Detection Didactic: 2 hours lectures Observation: 8 studies Practice: 3 studies Echo course, DVD & 3 hours with pediatric cardiologist Lee 2007 J Perinat Our study shows that it is possible to predict ductal patency without extensive echocardiography training. It also shows us that a neonatology based screening programme for pre-symptomatic arterial ducts in very low birth weight infants would be feasible. Walsh 2006 Ir Med J

30 Is the neonatologist reliable? Does TnECHO improve outcomes?

31 Efficacy of GDFI in adult care Manasia 2004 J Cardiovasc Anesth Changes in clinical care in 53% of patient Gorcsan 2001 JAMSE diagnostic accuracy (50%) in RCT of goal directed echo for hypotensive patients in ER Jones 2005 Crit Care Med

32 Focused Echocardiography in Resuscitation Setting Breitkrutz 2005 Crit Care Med

33 PDA Echocardiography research Neonatology Cardiology Number of publications present Time period

34 Early Detection & Outcome Era I Era II Intraventricular Hemorrhage Gestation [weeks] PDA diagnosis [days] 26.1[ ] 26.6 [ ] 4 [2-13] 3 [3-4] * IVH Gd III/IV PDA treatment I [days] 5 [3-25] 3 [3-7] * % PDA treatment II [days] Ventilation [days] 12 [9-14] 8 [7-9] * 13 [0-66] 9 [1-66] * 10 0 Before Era After O Rouke 2008 Acta Paed

35 Duration of Indomethacin Treatment of the Preterm PDA as Directed by Echocardiography Premature infants with HSDA fecho guided intervention Conventional group Carmo J Pediatr 2009

36 Duration of Indomethacin Treatment of the Preterm PDA as Directed by Echocardiography Reduction in indomethacin administration from a median of 3 doses (1-12) to 1 dose (1-15) using fecho directed therapy No increased in need for subsequent indomethacin or PDA ligation Carmo J Pediatr 2009

37 Toronto Crisis Waiting time for PDA ligation 2-3 weeks Delayed time of intervention Inconsistent referral pattern Post-ligation Cardiac Syndrome (PLCS) common

38 Enhancing PDA Care Creation of PDA ligation team Comprehensive TnECHO before intervention Categorisation system for PDA Early postoperative TnECHO to guide neonatal care

39 Year PDA Ligation [Toronto] 100 Triaging system 80 TnECHO 60 Rate TnECHO - postop

40 Dealing with Education and Accreditation

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42 First symposium on fecho Oct 08 M. Kluckow

43 Recent Initiatives Establishment of np-fecho working group for Canadian Neonatologists (Calgary 2010) American Society of Echocardiography Writing group 2010 Guidelines for ECHO in the NICU Cardiologists, Neonatologists

44 Use of npfe - Guiding Principles Echocardiography information dependant on quality of images and reliability of interpretation (Competence) Hemodynamic information should only be used in the context of the clinical scenario (Logic and Reason)

45 np-fecho evaluations must be performed by personnel who have completed a recognised training program, met basic criteria for image acquisition and interpretation.

46 Established Standby Interest Calgary Winnipeg Montreal Toronto (n=3) Hamilton London Vancouver Halifax Edmonton Quebec city

47 Toronto TnECHO Model of Care Neonatal Cardiology Specialist Archiving & Reporting Imaging Equipment Neonatal Cardiology Consult Model Clinical Practice Guidelines Training Program

48 CLINICAL RESEARCH EDUCATION Neonatal cardiovascular consult model of care - Guidelines &Referral process - 3 trained fellows Neonatal Cardiology Fellowship (TBA) 1 year Elective opportunities Portable laptop systems HSC / Sunybrook Roving machine 1 site Standardized image acquisition and protocols Electronic reporting Prospective observational human studies PDA Ligation physiology experiments Milrinone pharmacokinetics Surfactant hemodynamics Furosemide and blood transfusion Translational Sciences Asphyxial cardiac arrest and vasopressin - piglet Pulmonary Hypertension collaborations neonatal rodents Echocardiography training - Phase I (3 months) - Phase II (3-6 months) Completed by 16 fellows In progress 4 fellows Resources: Publications, WINFOCUS, Evans DVDs Elective opportunities - 4 neonatologists (2 4/52) - 1 sabbatical - 6 fellows, next 12 months Ancillary Resources - Online npfecho teaching module - Competency evaluation & OSCE development (Finan) Archiving - ECHOPAC Archiving - ECHOPAC Archiving - ECHOPAC Ligation rates & PLCS ECMO-medical rare Developmental Hemodynamics group Global Workshops PAS, India, Saudi Arabia, AAP

49 TnECHO Sonographers TnECHO Sonographers Year Year

50 TnECHO training module Phase I: Didactic sessions Hands-on supervised sessions (12 weeks) Equipment Landmarks & standard views Goal directed assessments Ongoing scanning (12 weeks ) : Logbook Phase II: Independent scanning: Neocardiac rotations /formal review Formal evaluation

51 Training Modules 1. Physics of Ultrasound 2. 2D, M-mode and Doppler imaging 3. Orientation and image acquisition for basic transthoracic cardiac views 4. Evaluation of left ventricular systolic and diastolic performance 5. Evaluation of pulmonary hemodynamics 6. Evaluation of the ductus arteriosus 7. Evaluation of systemic hemodynamics 8. Evaluation of indwelling catheters, brain parenchyma, effusions and bladder. Maintain logbook - completed a minimum of 50 complete echocardiograms of which 25 are ductus arteriosus evaluations.

52 Challenges Learning curve for functional echocardiography Standardized echocardiography approach Quality assurance for imaging Therapeutic protocol consistent approach

53 Scenario III Term 40 wks gestation; Bwt Kg Severe uncontrolled maternal IDDM SVD Resp distress intubated & surfactant good response ventilated on AC on 22/6 in 25% oxygen Severe hypoglycemia 120ml/kg/day Insulin level 571 UVC high slightly high on Xray adjusted Murmur ECHO; severe septal hypertrophy with mid cavity gradient To treat as HOCM if symptomatic

54 Case Progression Day 3 extubated in LF Sugars stable D20W at glucagon Day 5 Glucose 6 at 0600 hrs Inc to 10 (0900), 14 (1200) 18 (1400) Lactate 6 8 Poor perfusion, reduced urine output Increasing resp distress CXR rpt Inc cardiomegaly + UVC migrated deep in RA TnECHO performed

55 Echo clip #1 Echo clip #2

56 Effusion (TPN) drained under Echo guidance Echo next day showed thin rim of effusion and well filled heart Extubated to low flow oxygen Off glucagon over the next 3 days Transferred to L2 for establishing feeds

57 Take Home Messages Targeted Neonatal Echo should be used in combination with clinical acumen and not as replacement The focus is to provide longitudinal hemodynamic information in critically ill neonates This information either compliments what is clinically suspected or provides novel physiologic insights Catalyst for prospective physiology based research Issues related to training, accreditation and standards need to be addressed locally and in collaboration with our cardiology colleagues

58 Information Age Reinvigoration of the physical assessment The role of goal directed ultrasound is not to replace or detract from a complete echocardiogram performed by the pediatric cardiologist but to enhance the physical examination by providing additional real-time physiologic information

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60 Point of Care ultrasound at 20 hrs: Large effusion pleural effusion with severe LV dysfunction Chest drain inserted and 40 mls of straw colored fluid [100% lymphocytes]

61 RV PA PDA LV AO LA Point of Care ultrasound Hypercontractile myocardium with unrestrictive L-R transductal flow PGE1 & pressors weaned

62 Dopamine and Afterload Group 1 Dopamine 8 µg/kg/min Group 2 Dopamine 6 µg/kg/min Zhang 1999 Arch Dis Child

63 Clinical Dilemma e.g. hypotension, ductus arteriosus Ultrasound as a research tool Ultrasound as a clinical tool? Improved Clinical Care

64 Pillars of Training Credentialing committees for each country. Development and maintenance of standards for both trainees and trainers. Ongoing support for trainees (experienced mentor). OSCE a useful method for assessment of skills Regular re-accreditation of trainees. Quality control including a requirement for log books supported by comparison with gold standards.

65 Sick Neonate Cyanosis (SpO 2 65%)? Ebsteins Heart & lung assessment Preload Contractility HSDA CHD Effusion Heart & lung assessment PPHN Dilated SVC with turbulent flow Brain assessment? Hemorrhage MCA Doppler Brain assessment Vein of Galen malformation Abdominal assessment? Ascites Bladder Renal, mesenteric, celiac Doppler? Organs present Abdominal assessment Normal

66 TnECHO in Canada 2008 fecho is used less often in Canada. (79% vs. 91%, p=0.01) 86% of respondents reported that average time to obtain echo was close to 6hrs Most common indications were Exclude PPHN Confirm PPHN Assess response to treatment Others (serial functional assessment, target therapy, aid weaning) Proportion of respondents (%) Comparison of professionals performing FECHO # Canada(n=89) Aus-NZ(n=98) Neonatologist Cardiologist Others Professional # p<0.05 significant #

67 Delivery room echocardiography Post- SRT Asse ssments Pre- SRT Assessment Clinical 2D echo ABG A-II Clinical 2D echo A-III Clinical 2D echo ABG A-III Clinical 2D echo ABG 0 hrs SRT 30 min 1 hr 1 hr

68 Surfactant Hyperoxia Hypocapnia / Alkalosis Placenta elimination Hyperoxia Hypothermia PVR +++ PDA Ao SVR Ao Left Ventricle

69 0 mins 30 mins 60 mins p LVEDD [mm] 7.1 (6.9, 7.4) 7.4 (7.2, 8.4) 7.5 (7.4, 8.3) * 0.03 Fractional shortening [%] 27.4 ± ± 8.2 * 36.4 ± 7.8 * LA : Ao ratio 1.3 ± ± 0.1 * 1.44 ± 0.09 * <0.001 LV output [mls/kg/min] ± ± ± 29.9 * 0.04 RV output [mls/kg/min] 37.7 ± ± 10.4 * 69.1 ± 12.2 * < Systemic vascular res. [Woods units] 26.2 (22.3, 37.6) 36.2 (28.1, 59.1) 38.3 (35.8, 62.6) 0.09

70 Surfactant administration is followed by Increased systolic but decreased diastolic BP. Increased ductal size and exclusive left-to-right transductal flow within the first hour of life. Extremely low pulmonary and systemic blood flow in first hour of life Redistribution of the amount of pulmonary and systemic blood flow resulting in increased Qp:Qs

71 PVR RVO LVO SVR

72 Japanese Experience TnECHO Delivery room and 8 hourly until 96 hours Day 7 & 10 Weekly evaluation x 6 weeks, & discharge Strict Protocols with management approach

73 Merits All doctors trained 24/7 coverage Dedicated up-to-date equipment Challenges Lack of scientific validation for many hemodynamic markers (e.g. IVC diameter, ESWS) Ad-hoc Echocardiography training Standardized image acquisition and protocols Brief study (10-15 mins) Electronic reporting and archiving system