role of neonatal cardiac ultrasound in guiding...
TRANSCRIPT
![Page 1: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/1.jpg)
Department of Newborn Care
Role of Neonatal Cardiac
Ultrasound in Guiding
Cardiovascular Support.
Nick Evans
Neonatal Medicine
Royal Prince Alfred Hospital
Sydney
![Page 2: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/2.jpg)
Department of Newborn Care
Lack of Evidence
• Almost no outcome based evidence to
guide circulatory support.
• Blood pressure has been the input and
the outcome in most trials.
• Role for cardiac ultrasound
– Pathophysiology based treatment.
• Define the haemodynamic.
• Apply logical treatment to correct that
haemodynamic.
![Page 3: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/3.jpg)
Department of Newborn Care
Blood Pressure and the Circulation
Pressure = Flow x Resistance
Circulatory
determinant of
tissue oxygen
delivery.
Volume
or Filling
Myocardial or
Pump function
![Page 4: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/4.jpg)
Department of Newborn Care
Low Systemic Blood Pressure
Pressure = Flow x Resistance
Can only resolve with a measure of pressure and flow
![Page 5: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/5.jpg)
Department of Newborn Care
When to use cardiac ultrasound to
guide support.
• Reactively:
– Any clinical evidence of circulatory compromise
including hypotension.
• Prospectively in high risk situations mostly
within first 12 postnatal hours
– Very preterm (<28 weeks or 28/29 weeks if sick)
– Term with hypoxic respiratory failure/PPHN
– Asphyxia
– Sepsis (anytime)
![Page 6: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/6.jpg)
Department of Newborn Care
What information do we need?
• An impression of cardiac filling
• Subjective ventricular filling
• A measure of cardiac function
–Subjective and/or fractional shortening
• A measure of systemic blood flow
–MPA Velocity, RV Output, SVC flow
• Blood pressure
![Page 7: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/7.jpg)
Department of Newborn Care
Scenario:
• 25 weeker, 10 hours old, MBP 35mmHg
RV Output = 100 mls/kg/min
NR 150-300
![Page 8: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/8.jpg)
Department of Newborn Care
Scenario:
• 27 weeker, 7 days old, MBP 18mmHg on
maxiumum inotropes.
RV Output = 600 mls/kg/min
NR 150-400
![Page 9: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/9.jpg)
Department of Newborn Care
WHAT’S THE CARDIAC FILLING?
![Page 10: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/10.jpg)
Hypovolaemia
![Page 11: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/11.jpg)
After 20mls/kg volume
![Page 12: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/12.jpg)
Department of Newborn Care
Myocardial or Pump Function?
![Page 13: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/13.jpg)
Department of Newborn Care
Poor Apparent Myocardial
Function
• Can result from:
–Low Pre-load.
–Sick or immature myocardium.
–High afterload or obstruction.
![Page 14: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/14.jpg)
Department of Newborn Care
Immature Fetal Myocardium
25 weeks Term
![Page 15: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/15.jpg)
If myocardial function looks good….
It probably is good.
![Page 16: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/16.jpg)
If myocardial function looks bad
It probably is bad.
![Page 17: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/17.jpg)
Department of Newborn Care
LV Ejection Fraction and Fractional
Shortening.
• Essentially calculated from the difference
between the end-diastolic (LVED) and
end systolic (LVES) dimension.
![Page 18: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/18.jpg)
LV Ejection Fraction and Fractional
Shortening.
RV
LV
LA
RV
LV
![Page 19: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/19.jpg)
LV Ejection Fraction and Fractional
Shortening.
LV End-Diastolic Diameter
LV End-Systolic Diameter
FS = (LVED – LVES)/LVED
EF = (LVED3 – LVES3)/LVED3
LV
RV
![Page 20: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/20.jpg)
External Impacts on Pump
Function: Tamponade
![Page 21: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/21.jpg)
External Impacts on Pump
Function: Tamponade
![Page 22: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/22.jpg)
External Impacts on Pump
Function: Obstruction
![Page 23: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/23.jpg)
Department of Newborn Care
SYSTEMIC BLOOD FLOW
MEASURES
The purpose of myocardial function is
to generate flow.
![Page 24: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/24.jpg)
Department of Newborn Care
Physics of fluid flow volumes
Flow = Velocity of fluid
x
Cross-sectional area of flow
•Can be measured
with Doppler.
•Needs flow direction
close to 0o or 180o.
•Can be derived from
diameter measurement
using r2.
•Needs to view vessel at
right angles. (90o)
![Page 25: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/25.jpg)
Department of Newborn Care
RA LA
RV LV
DUCT
Lungs
RV
Output
LV
Output
Body
Why do shunts
confound
ventricular
outputs as
estimates of
systemic flow?
Ventricular output is often not
systemic blood flow!
![Page 26: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/26.jpg)
Right Ventricular OutputDiameter measurement-2D view.
Mean 5.0 mm (SD 0.5 mm)(range 0.35 - 0.68)
Babies < 30weeks.
![Page 27: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/27.jpg)
Right Ventricular OutputVelocity Time Integral (VTI) measurement.
![Page 28: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/28.jpg)
Department of Newborn Care
Measure cardiac input rather than
output?
SVC Flow
• Not bad angle for insonation.
• OK window for diameter (early on).
• Not corrupted by intra-cardiac shunts.
![Page 29: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/29.jpg)
Measure Cardiac Input: Superior vena cava flow; good window for
velocity.
![Page 30: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/30.jpg)
SVC diameter
Max
MinSVC
RA
SVC
![Page 31: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/31.jpg)
Department of Newborn Care
Calculations.
• Stroke volume = VTI x ( x Diam2/4)
• Cardiac output (mls/min) = Stroke volume x Ht Rate
• Cardiac index (mls/kg/min) = Cardiac output / BW (kg)
![Page 32: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/32.jpg)
Department of Newborn Care
What’s normal?
RV Output
mls/kg/min
SVC Flow
mls/kg/min
Normal 150 - 300 50 - 100
Low <150 <50
Very Low <100 <40
![Page 33: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/33.jpg)
Department of Newborn Care
Screening for Low Systemic Blood
Flow: MPA Velocity
Vmax
![Page 34: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/34.jpg)
Department of Newborn Care
When do you see low flow?
• Preterm babies:
– Within first 12 hours of life, improves after that
time.(Arch Dis Child 2000)
– Strong association with IVH when flow improves.(Arch
Dis Child 2000, Pediatrics 2004)
• Term babies:
– Post Asphyxia
– With severe respiratory problems again within the first
24 hours. (Arch Dis Child 1996)
• In all babies:
– Low flow is poorly predicted by blood pressure. (J Pediatr
1996 and Arch Dis Child 2000)
![Page 35: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/35.jpg)
Department of Newborn Care
When do you see high flow?
• With shunts:
• Inter-atrial and VSDs increase RV Output.
• PDA increases LV Output.
• With vasodilation.
• Septic shock
• Late/resistant shock in premature babies
• With A-V malformations
![Page 36: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/36.jpg)
Department of Newborn Care
Possible Haemodynamics
Filling Pump
Function
Systemic
Blood Flow
Blood
Pressure
Hypovolaemia Low Normal or
Low
Low Low
Pump failure Normal
or dilated
Low Low Low
Vasoconstrictive Normal Normal or
low
Low Normal or
high
Vasodilatory Normal Normal or
High
Normal or
high
Low
![Page 37: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/37.jpg)
Department of Newborn Care
Other considerations
• Interaction between pulmonary and systemic
circulations.
– Pulmonary BF will be low if Systemic BF is low but
– Low PBF with primary PPHN can restrict SBF,
particularly if ductus is closed.
• Ductal and atrial shunts
– Right to left shunt will support systemic BF
– Left to right shunt may drain systemic BF
![Page 38: Role of Neonatal Cardiac Ultrasound in Guiding ...neokw.com/presentations/evans/kuwait-2019-role-of-cardiac-ultrasou… · Department of Newborn Care Lack of Evidence • Almost no](https://reader036.vdocument.in/reader036/viewer/2022081611/5f03bcbe7e708231d40a858a/html5/thumbnails/38.jpg)
Department of Newborn Care
Conclusions
• Cardiac Doppler ultrasound allows
estimated of global haemodynamic
status through:
– Estimation of volume status
– Exclusion of structural problems
– Estimation of pump function
– Estimation of systemic and pulmonary
blood flow.
– Estimation of resistance using blood
pressure and blood flow.