Towards use of POCUS to evaluate hemodynamics in critically ill neonates: caution before adoption in this population

Abstract

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Letter to editor regarding “International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)” by Singh et al. Critical Care (2020) 24:65 We read with interest the article by Singh et al. which outlined the role of point-of-care ultrasound (POCUS) in neonatal/pediatric intensive care units [1]. While we commend the authors for their efforts to better standardize indications for POCUS, we have three concerns: First, the presentation of recommendations for POCUS in neonates as evidence-based, rather than as author consensus; second, the inclusion of recommendations for critically ill neonates with older children; and third, the proposal that “these ESPNIC guidelines are developed for use by any neonatologist or paediatric intensivist.” Our intent is not to dissuade readers away from the use of POCUS but to restore balance between the desired recommendations and strength of available evidence and to offer additional suggestions. (i) It is notable that only 2 recommendations achieve Quality of Evidence of A [(i)POCUS should not be used as a screen to diagnose congenital heart defects; (ii) assessment of ductus arteriosus patency], 4 reach level B (assessment of pulmonary artery pressures or pericardial fluid), while the remainder is classed as weak evidence. Surprisingly, the authors present strong agreement for all recommendations which creates an impression of greater validation than the evidence supports. (ii) We believe the approach may inadvertently equate neonates to “small children.” Appraisal of cardiovascular physiology in critically ill neonates is challenging due to the complexity of the transitional circulation, unique interplay with neonatal disease and developmental variability of cardiovascular drugs. In addition, the reliability of subjective assessment of heart function or chamber size is questionable. We strongly believe that recommendations for POCUS in neonates be developed separately. (iii) While availability of portable ultrasound machines has expanded, permitting the field to advance, related guidelines are incomplete. Published guidelines articulate the need for a well-defined training structure and guidelines for clinical practice [2–4]. Successful establishment of hemodynamic programs is attributed to the comprehensive nature of imaging protocols, exposure to higher case volume and organizational governance. The rates of attainment of imaging and interpretative competence are not congruent, and individual learning is also influenced by the complexity of pathophysiology and disease. A recent survey indicated that the establishment of hemodynamic programs is a high priority for neonatology leaders, as there is recognition that Open Access