Point-of-Care Ultrasound for the Neonatal and Pediatric Intensivist: A Practical Guide on the Use of POCUS

Foreword
Acknowledgments
Contents
Editors and Contributors
	Editors
	Contributors
List of Videos
Part I: Basics in Critical Care and Neonatal Point of Care Ultrasound
	Introduction to Point of Care Ultrasound
		Point of Care Ultrasound—Is It Time to Adopt in Routine Clinical Practice?
		References
	Physics, Knobology, and Transducers: Imaging Optimization
		Principles of Ultrasound
			Sound Is a Wave
			Sound Frequencies
			Piezoelectric Effect
			How Is an Image Formed?
			What Determines Echogenicity (Brightness)?
		Image Optimization and Knobology
			2D Gain
			Active Gain
			Depth
			Resolution
			Focal Zone
		Transducers
		Two-Dimensional Ultrasound
		Doppler Ultrasound
			The Doppler Effect
			Clinical Applications of Color Doppler
		Tissue Doppler
		Artifacts
			Gain Artifact
			Posterior Acoustic Shadowing
			Posterior Acoustic Enhancement
			Reverberation and Contact Artifacts
		References
Part II: Cardiovascular System Assessment
	Basic Echocardiographic Views for the Intensivist
		Introduction
		Basic Anatomy of the Heart for Cardiac Ultrasound
		Major Indications for Functional Echocardiography and Cardiac POCUS Assessment
		Echocardiography Windows and Basic Views for the Neonatal and Pediatric Intensivist
			Parasternal Window
			Apical Window
			Subcostal Window
			Suprasternal Window
		Conclusion
		References
	POCUS in Shock and Hypotension
		Introduction
		The Concept of Fluid Responsiveness
			Fluid Responsiveness Assessment Methods
				Static Parameters
				Dynamic Parameters
					Flow Velocity
					Fluid Challenge
		Integrating Fluid Responsiveness in the Hemodynamic Assessment of Shock
			Types of Shock and Ultrasound Assessment
			Clinical Considerations
		Conclusion
		References
	Echocardiographic Evaluation of Left Ventricular Function and Hemodynamic Status
		Introduction
		Left Ventricular Anatomy and Physiology
		Measurement of Cardiac Dimensions
		Evaluation of Left Ventricular Systolic Function
			Qualitative Assessment
			Quantitative Assessment
			Semi-quantitative Assessment
		Evaluation of Left Ventricular Diastolic Function
		Evaluation of Cardiac Output and Cardiac Index
		Conclusion
		References
	Focused Ultrasound in Right Ventricular Function and Pulmonary Hypertension
		Introduction
		Right Ventricular Morphology
		Importance of Point-of-Care Assessment of Right Ventricular Function
		Qualitative and Quantitative Assessment of the Right Ventricle
			TAPSE
			Fractional Area Change
			Tei Index
		Assessment of the Presence of Pulmonary Hypertension
			Pulmonary Artery Pressure Assessment
			Ductal Shunt
			Septal Assessment
			Assessment of Pulmonary Vascular Resistance
			Right Ventricular Function
		Conclusion
		References
	Focused Assessment of Pericardial Effusion and Cardiac Tamponade
		Anatomy of Pericardium
		Physiology
		Assessment of Pericardial Effusion on Ultrasonography
			Ultrasound (Echocardiography) Views
		Cardiac Tamponade
		Comprehensive Assessment of Cardiac Tamponade on Echocardiography Using 2D and M-Mode
		Doppler Echocardiography in Pericardial Effusion and Cardiac Tamponade
		Pericardiocentesis
		References
	Advanced Functional Echocardiographic Views Including PDA Assessment and Hemodynamic Evaluation
		Echocardiographic Diagnosis and Hemodynamic Evaluation of the Patent Ductus Arteriosus
			Echocardiographic Assessment of Ductal Ccharacteristics
				Measuring Transductal Diameter
				Direction of Shunt Across the Ductus Arteriosus
				Velocity of Shunt Across PDA and Its Significance
			Echocardiographic Evaluation of Pulmonary Over-Circulation
			Echocardiographic Evaluation of Systemic Hypoperfusion
		Advanced Hemodynamic Evaluation—Measurement of Blood Flow and Cardiac Output
		Assessment of Cardiac Output and Blood Flow on Echocardiography
			Estimation of Left Ventricular Output
			Estimation of Right Ventricular Output
		Limitations of LVO and RVO Measurement Using Echocardiography
		Superior Vena Cava (SVC) Blood Flow
		References
	Comprehensive Echocardiography and Diagnosis of Major Common Congenital Heart Defects
		Introduction
		Classification of Congenital Heart Defects
		Identifying Newborns with Critical Congenital Heart Disease
			1. Shock (The Grey Neonate)
				Common Key Echocardiography Feature: Poorly Functioning Left Ventricle
					HLHS Echo Features and Best Views (Figs. 4, 5, 6, and 7; Videos 1 and 2)
					Critical Aortic Stenosis (Figs. 8 and 9; Videos 1–4)
					Critical Aortic Coarctation (Figs. 10 and 11; Video 5)
					Interrupted Aortic Arch (Fig. 12)
			2. Cyanosis (The Blue Neonate)
				Ductal-Dependent Lesions
					Severe Pulmonary Valve Stenosis (Fig. 13; Video 6)
					Pulmonary Atresia with Intact Septum (Figs. 14, 15, and 16)
					Transposition of the great arteries (Figs. 17, 18, and 19)
				Non-ductal-Dependent Lesions
					Truncus Arteriosus (Figs. 20 and 21; Video 7)
					Tetralogy of Fallot (Figs. 22 and 23; Video 8)
					Total Anomalous Pulmonary Venous Return (TAPVR) (Figs. 24 and 25; Video 9)
					Tricuspid Atresia (Fig. 26; Videos 10 and 11)
			3. The Tachypneic Neonate (Respiratory Symptoms)
				Patent Ductus Arteriosus (Figs. 27 and 28; Video 12)
				Ventricular Septal Defect (Figs. 29, 30, 31, and 32; Videos 13 and 14)
				Atrial Septal Defect (Figs. 33 and 34; Videos 15 and 16)
				Atrioventricular Septal Defect (Fig. 35; Video 17)
		Conclusion
		References
Part III: Thoracic Assessment
	Basic Lung Ultrasound for the Intensivist
		Introduction
		Anatomic Considerations
		Ultrasound Transducer Selection, Orientation, and Performance
		Lung Sliding
		Common Ultrasound Artifacts
		Evaluation for Pleural Effusion
		Evaluation for Pneumothorax
		Differential Diagnosis of B-Lines
		Evaluation of Consolidated or Atelectatic Lung
		Summary
		References
	Airway Ultrasound
		Airway Ultrasound
			Applications
				Evaluation of Intubation
					Measurement of Tracheal Diameter
					Direct Visualization of Endotracheal Tube Cuff
					Direct Visualization of Endotracheal Tube Tip
					Diaphragmatic Ultrasound for Confirmation of Intubation
					Cricothyroid Imaging
				Vocal Cord Imaging
				Evaluating the Difficult Airway
		Conclusion
		References
	Diaphragmatic Ultrasound
		Functional Anatomy of the Diaphragm
		Diaphragmatic Dysfunction
		Ultrasound Views for Diaphragmatic Assessment
		Reference Values for Diaphragm Ultrasound in Children
			Assessment of Pathophysiology
				Assessment of Diaphragm Atrophy and Weakness
				Assessment of Diaphragm Paresis
				Assessment of Readiness for Weaning of Mechanical Ventilation
		Future Directions
		Conclusion
		References
	Clinical Applications in Lung Point-of-Care Ultrasound Assessment in Neonates
		Introduction
		Technical Considerations
		Clinical Applications of Lung Ultrasound for the Diagnosis of Neonatal Respiratory Diseases
			Transitional Period
				Transient Tachypnea of the Newborn
				Respiratory Distress Syndrome
				Lung Ultrasound in RDS and TTN
				Pneumothorax
				Meconium Aspiration Syndrome
				Pneumonia
				Bronchopulmonary Dysplasia
				Neonatal Acute Respiratory Distress Syndrome
				Congenital Lung and Airway Malformations
			Congenital Diaphragmatic Hernia
		Functional Use of Lung Ultrasound
			Lung Ultrasound Scores
			Lung Ultrasound Scores in RDS
				Lung Ultrasound Scores in BPD
			Integrating Lung Ultrasound into POCUS Protocols
		Conclusion
		References
Part IV: Abdominal Assessment
	Abdominal Point-of-Care Ultrasound in Neonatal and Pediatric Populations
		Introduction
			Upper Abdomen (Liver, Spleen, and Stomach)
				Liver
					Common Pathological Conditions
						Liver Congestion
						Liver Hematoma
						Liver Contusion
						Bile Duct Gas
						Portal Venous Gas
				Spleen
				Stomach
					Common Pathological Conditions
						Gastroesophageal Reflux (GER)
						Hypertrophic Pyloric Stenosis
			Lower Abdomen (Bowel, Peritoneal Cavity, and Abdominal Blood Vessels)
				Common Pathological Conditions
					Necrotizing Enterocolitis
					Food Protein-Induced Enterocolitis
					Hypoxic/Ischemic Bowel
					Henoch–Schönlein Purpura
					Atresia
					Malrotation
					Volvulus
					Hirschsprung Disease
					Meconium Ileus
					Intussusception
					Appendicitis
					Abdominal Bleeding
			Renal and Bladder Ultrasound
				Renal Ultrasound
				Bladder Ultrasound
		Conclusion
		Appendix: Intestinal Ultrasound Findings in Bowel Injury or Ischemia
		References
Part V: Neurosonology
	Focused Cranial Ultrasound for Neurointensive Care
		Introduction
		Transcranial Doppler Ultrasound
			Basic Principles and Techniques
				Basic Principles and Techniques for Imaging Duplex TCD
			Clinical Applications
				Traumatic Brain Injury: Prognosis
				Traumatic Brain Injury: Noninvasive Assessment of Intracranial Pressure (ICP)
				Traumatic Brain Injury: Noninvasive Assessment of Cerebral Perfusion Pressure (CPP)
				Screening for Vasospasm in Children
				Hypoxic-Ischemic Encephalopathy: Prognosis and Detection of Perfusion Disorders
				Cardiorespiratory Support with Extracorporeal Membrane Oxygenation: Changes Concerning Hemorrhage or Ischemia and Emboli Monitoring
				Arterial Ischemic Stroke: Progression or Regression of Steno-Occlusive Disease
				Bacterial Meningitis: Detection of Perfusion Disorders (Oligemia or Hyperemia)
				Cerebral Circulatory Arrest
				Midline Shift
			Limitations of TCD as a POCUS Tool
		Ocular Ultrasonography
			Basic Principles and Technique
				Clinical Applications: Optic Nerve Sheath Diameter to Investigate ICP
				Clinical Application: Identification of Retinal Trauma
		Neonatal Cranial Ultrasound
			Basic Principles and Technique
			Clinical Application
		POCUS Neurosonography Integration
		Conclusion
		References
	Cranial Ultrasound
		Introduction
			Technical Considerations
				Ultrasound Probe Selection for Neonatal Cranial Ultrasound
				Normal Neonatal Brain Anatomy
				Cranial Ultrasound Views
		Clinical Indications
			Cranial Ultrasonography in Brain Pathologies
				Intraventricular Hemorrhage
				Post-Hemorrhagic Ventricular Dilatation
				Periventricular Leukomalacia
				Sequelae in Periventricular Leukomalacia
				Perinatal Asphyxia and Hypoxic Ischemic Encephalopathy
				Neonatal Infections
		Conclusion
		References
Part VI: Use of Point of Care Ultrasound in Transport Setting
	Role of Point of Care Ultrasound in the Transport Setting for Evaluating Infants and Children with Shock
		Introduction
		Role of Point of Care Ultrasound in Critical Care Transport
			Diagnostic Role of Point of Care Ultrasound in Transport
			Role of Point of Care Ultrasound in Transport in Assessing Response to Intervention
			Procedural Role of Point of Care Ultrasound in Transport
			Role of Point of Care Ultrasound in Transport in Improving Communication Among the Teams
		The Ideal Ultrasound Device for Critical Care Transport
		Summary
		References
Part VII: Procedural Ultrasound
	Vascular Access Considerations in Children and Neonates
		Introduction
		Ultrasound-Guided Vascular Access: Basic Principles
			Probe Selection
			Probe Orientation
			Identification of Structures
			Assessment of Vessel Diameter
			Dynamic Needle Tip Positioning
		Central Venous Access
			Internal Jugular Vein
			Subclavian and Brachiocephalic Veins
			Axillary Vein
			Common Femoral Vein
			Epicutaneo-Caval Catheters and Peripherally Inserted Central Catheters
		Peripheral Venous Access
		Arterial Access
			Radial and Ulnar Arteries
			Dorsalis Pedis and Posterior Tibial Arteries
		Ultrasound-Guided Umbilical Venous Cannulation
		POCUS for Central Line Position Evaluation
		References
	Ultrasound-Guided Procedures Beyond Vascular Access
		Introduction
		Lumbar Puncture
		Thoracentesis
		Pericardiocentesis
		Paracentesis
		Suprapubic Bladder Aspiration and Urethral Catheterization
		Conclusion
		References
	Use of Ultrasound in ECMO
		Introduction
		Precannulation
			Venous Cannulation
			Arterial Cannulation
		Cannulation
		ECMO Complications
			Myocardial Function
			Tamponade
			Pulmonary Consolidation, Pneumothorax, and Effusions
			Thrombosis and Spontaneous Contrast
		De-Escalation of ECMO
		Conclusion
		References
Part VIII: Programmatic Considerations and Moving Forward
	POCUS Guidelines, Training Curriculum, and Education
		Introduction
		Problem Identification and General Needs Assessment
		Targeted Needs Assessment
		Goals and Objectives
		Educational Strategies
		Conclusion
		References
	Current and Future Challenges to Ultrasound Adoption in Clinical Practice
		Introduction
		The Technology: Learning from History
		The Processes: The Need for Programmatic Development
		Putting the Pieces Together: Credentialing, Privileging, and Outcomes
		How to Support the Individual Provider
		Exploring the Final Competency Domain: Treatment Methods and the Protocolization of Bedside Ultrasound
		References
Appendix: Learning Outcomes
	Basics in Critical Care and Neonatal Focused Ultrasound
	Cardiovascular System Assessment
	Thoracic Assessment
	Abdominal Assessment
	Neurosonology
	Procedural Ultrasound
	Focused Ultrasound in Transport Setting
	Programmatic Considerations and Moving Forward