Focused Cardiac Ultrasound in the Pediatric Perioperative Setting: A Comprehensive Review

Abstract

Focused cardiac ultrasound (FoCUS) has emerged as a valuable tool for perioperative assessment in pediatric patients. This review article explores the role of FoCUS in the pediatric perioperative setting, encompassing its applications, clinical utility, and impact on patient care. We discuss the indications for FoCUS, including the evaluation of hemodynamic instability, assessment of cardiac function, and diagnosis of perioperative complications. The review delves into the specific techniques and views utilized in pediatric FoCUS, emphasizing the importance of operator expertise and image interpretation. We also examine the evidence supporting the use of FoCUS in various perioperative scenarios, including cardiac surgery, non-cardiac surgery, and critical care. Finally, we discuss the limitations of FoCUS and the ongoing research directions in this rapidly evolving field. This review aims to provide a comprehensive overview of FoCUS in the pediatric perioperative setting, highlighting its potential to improve patient safety and optimize perioperative care.

Introduction

Pediatric perioperative medicine encompasses a wide range of surgical and anesthetic procedures performed on children. Ensuring patient safety and optimizing perioperative outcomes are paramount concerns. Traditional clinical assessments, while valuable, may have limitations in accurately assessing cardiac function and hemodynamic status in children. Focused cardiac ultrasound (FoCUS), a bedside echocardiographic technique, has emerged as a valuable tool for perioperative clinicians.

FoCUS provides real-time, dynamic visualization of cardiac structures and function, allowing for rapid assessment of key parameters such as cardiac size, ventricular function, valvular function, and the presence of pericardial effusions. This information can significantly enhance clinical decision-making, guide therapeutic interventions, and improve patient outcomes.

This review article provides a comprehensive overview of FoCUS in the pediatric perioperative setting, exploring its applications, clinical utility, and impact on patient care.

Principles of FoCUS

FoCUS utilizes portable ultrasound systems with high-frequency transducers to obtain rapid, limited echocardiographic views. Key principles of FoCUS include:

• Limited scope: Focuses on specific clinical questions and avoids comprehensive echocardiographic examinations.

• Rapid acquisition: Emphasizes rapid image acquisition and interpretation to facilitate timely clinical decision-making.

• Operator dependence: Relies heavily on the operator's knowledge, experience, and ability to acquire and interpret images.

• Clinical correlation: FoCUS findings must always be interpreted in the context of the patient's clinical presentation and other relevant clinical data.

FoCUS Techniques in Pediatrics

• Standard views: Common views utilized in pediatric FoCUS include:

  • Parasternal long-axis (PLAX) view: Assesses left ventricular (LV) size, systolic function, and valvular function (mitral and aortic valves).

  • Parasternal short-axis (PSAX) view: Assesses LV size, systolic function, and septal motion.

  • Apical four-chamber (A4C) view: Assesses LV and right ventricular (RV) size and function, as well as interventricular septal motion.

  • Subcostal four-chamber (S4C) view: Provides a good view of the right ventricle and can be useful for assessing pericardial effusions.

• Specialized views:

  • Depending on the clinical scenario, additional views may be obtained, such as suprasternal views for assessing the aortic arch and pulmonary arteries.

Applications of FoCUS in the Pediatric Perioperative Setting

• Preoperative assessment:

  • Risk stratification:

    • Assess cardiac function in patients with known or suspected cardiac disease.

    • Identify patients at increased risk for perioperative complications.

  • Optimize anesthetic management:

    • Guide the choice of anesthetic agents and techniques based on cardiac function.

    • Identify patients who may require closer hemodynamic monitoring or require optimization of comorbidities (e.g., hypertension, diabetes) before surgery.

• Intraoperative monitoring:

  • Assess hemodynamic stability:

    • Evaluate cardiac function in response to anesthetic agents, surgical manipulation, and fluid administration.

    • Diagnose and manage hemodynamic instability, such as hypotension, hypertension, and arrhythmias.

  • Guide therapeutic interventions:

    • Guide fluid administration, vasopressor support, and inotropic therapy.

    • Assess the effectiveness of therapeutic interventions.

• Postoperative monitoring:

  • Evaluate the recovery of cardiac function:

    • Assess myocardial contractility and assess for the development of postoperative complications, such as myocardial ischemia or pericardial effusion.

  • Guide extubation decisions:

    • Assess cardiac function before extubation to minimize the risk of hemodynamic instability.

Clinical Utility of FoCUS in Pediatric Perioperative Care

• Improved diagnostic accuracy: FoCUS can provide valuable information that may not be readily apparent from clinical examination alone.

• Enhanced clinical decision-making:

  • Enables clinicians to make more informed decisions regarding patient management, including anesthetic choices, fluid administration, and the need for further investigations.

• Early identification of complications:

  • Allows for early detection and management of perioperative complications, such as myocardial ischemia, pericardial effusion, and cardiac tamponade.

• Reduced reliance on invasive monitoring:

  • In some cases, FoCUS may reduce the need for invasive hemodynamic monitoring, such as arterial lines and pulmonary artery catheters.

FoCUS in Specific Perioperative Scenarios

• Cardiac surgery:

  • Preoperative assessment of cardiac function and anatomy.

  • Intraoperative monitoring of cardiac function during cardiopulmonary bypass.

  • Postoperative assessment of myocardial function and the presence of complications.

• Non-cardiac surgery:

  • Evaluation of cardiac function in patients with known or suspected cardiac disease undergoing major non-cardiac surgery.

  • Assessment of hemodynamic stability during and after surgery.

• Critical care:

  • Assessment of cardiac function in critically ill children, such as those with sepsis, respiratory failure, and trauma.

  • Diagnosis and management of hemodynamic instability in the pediatric intensive care unit (PICU).

Limitations of FoCUS

• Operator dependence: The accuracy and clinical utility of FoCUS depend heavily on the operator's expertise and experience.

• Limited depth of penetration: FoCUS may have limitations in visualizing deep cardiac structures.

• Artifact:

  • Motion artifacts from patient movement can degrade image quality.

  • Lung artifacts can interfere with the visualization of cardiac structures.

• Limited quantitative assessment:

  • While qualitative assessment of cardiac function is possible, quantitative measurements may be challenging.

Training and Education

• Hands-on training:

  • Hands-on training programs are essential for developing the necessary skills and knowledge to perform and interpret FoCUS examinations.

• Simulation-based training:

  • Simulation-based training can provide a safe and controlled environment for practicing FoCUS techniques and developing clinical decision-making skills.

• Continuing education:

  • Ongoing education and mentorship are crucial to maintaining and improving FoCUS skills and knowledge.

Future Directions

• Integration of AI and machine learning:

  • AI algorithms can be used to assist with image interpretation, improve diagnostic accuracy, and provide real-time feedback to operators.

• Development of standardized protocols:

  • The development of standardized protocols for FoCUS acquisition and interpretation can improve consistency and enhance the reliability of results.

• Integration of FoCUS into perioperative care pathways:

  • Further integration of FoCUS into perioperative care pathways can lead to improved patient outcomes and reduced healthcare costs.