POCUS em UTI Neonatal - Revisão sobre Aplicações e Benefícios

REVIEW Pointofcare ultrasound in the neonatal ICU Laura E Millera Jason Z Stollerbc and Maria V Fragabc Purpose of review Pointofcare ultrasound POCUS is an emerging clinical tool in the neonatal intensive care unit NICU Recent literature describing the use of POCUS for various applications in the NICU has garnered increased interest among neonatologists Recent findings Diagnostic applications for POCUS in the NICU include the evaluation and serial monitoring of common pulmonary diseases hemodynamic instability patent ductus arteriosus PDA persistent pulmonary hypertension of the newborn PPHN necrotizing enterocolitis NEC and intraventricular hemorrhage IVH among others Procedural applications include vascular access endotracheal intubation lumbar puncture and fluid drainage Summary Experience with POCUS in the NICU is growing Current evidence supports the use of POCUS for a number of diagnostic and procedural applications As use of this tool increases there is an urgent need to develop formal training requirements specific to neonatology as well as evidencebased guidelines to standardize use across centers Keywords diagnostic pointofcare ultrasound neonatal ICU pointofcare ultrasound ultrasound guidance INTRODUCTION Pointofcare ultrasound POCUS is performed and interpreted by the bedside clinician with the intent of either answering a focused clinical question or achieving a specific procedural goal 1 Use of POCUS by critical care providers has increased in recent years however neonatologists have been slower to integrate this tool into practice POCUS has a number of benefits applicable to the neonatal intensive care unit NICU population Critically ill premature and lowbirthweight LBW infants often cannot be safely transported out of the NICU for external radiology studies POCUS is performed at the infants bedside and typically can be done faster facilitating prompt diagnosis and intervention POCUS can also be used to enhance the safety and efficiency of procedures such as peripherally inserted central catheter PICC placement Finally use of POCUS may reduce exposure to ionizing radiation from radiographs and computed tomography 23 Evidence is emerging to support the use of POCUS in the NICU for a number of diagnostic and procedural applications Table 1 45 which will now be described DIAGNOSTIC APPLICATIONS Diagnostic POCUS can complement the history and physical examination providing realtime information on common neonatal pulmonary cardiac abdominal and neurologic diseases Pulmonary Lung ultrasound LUS is not an intuitive imaging modality given that air reflects ultrasonic sound waves The artifacts caused by this process however can be used to identify both healthy lung and pathologic processes These sonographic signs were initially described in adults 6 and were found to be highly sensitive and specific for the diagnosis of various pulmonary diseases 7 Neonatology and perinatology KEY POINTS POCUS is increasingly recognized as a valuable clinical tool in the NICU Available evidence largely supports the use of POCUS for a number of procedural and diagnostic applications in critically ill neonates Future efforts should focus on the development of NICUspecific training requirements and evidencebased guidelines Subsequent observational studies have shown that these same signs are present in neonates Table 2 and Fig 1 710 and distinct patterns can be used to identify neonatal pulmonary diseases 11 Experience with LUS in the NICU has grown in recent years and a 2019 expert international panel proposed comprehensive LUS protocols and guidelines to facilitate standardization of this tool 12 Pneumothorax Pneumothorax is a relatively common complication of neonatal lung disease particularly in the setting of positive pressure ventilation Rapid clinical deterioration can result therefore timely diagnosis is crucial Chest radiographs are typically used for diagnosis though may miss smaller pneumothoraces particularly in LBW infants Several casecontrol studies have shown that LUS is as accurate and more sensitive than radiographs for the diagnosis of pneumothorax in neonates 131415 and can be performed more quickly There are several LUS signs seen in pneumothorax Normal lung sliding Supplemental Video 1 Lung ultrasound appearance of lung sliding Sagittal view of the chest showing a horizontal shimmering pleural line representing the visceral pleura sliding along the parietal pleura during the respiratory cycle httplinkslwwcomMOPA41 or a shimmering appearance of the visceral pleura as it slides along the parietal pleura with respiration is typically absent Supplemental Video 2 Lung ultrasound sagittal view appearance Table 1 Potential pointofcare ultrasound applications in the NICU Diagnostic Procedural Pulmonary Vascular access Pneumothorax Peripheral intravenous lines Pleural effusion Peripherally inserted central catheters Respiratory distress syndrome Umbilical venous and arterial catheters Transient tachypnea of the newborn Central venous catheters internal jugular subclavian brachiocephalic or femoral Meconium aspiration syndrome Peripheral arterial catheters Pneumonia Endotracheal tube localization Pulmonary hemorrhage Lumbar puncture Diaphragm dysfunction Fluid drainage Atelectasis Thoracentesis Paracentesis Pericardiocentesis Cardiac Suprapubic bladder aspiration Hemodynamic assessment contractility cardiac filling cardiac output superior vena cava flow Patent ductus arteriosus Persistent pulmonary hypertension of the newborn Abdominal Necrotizing enterocolitis Intestinal dysmotility Anuria Neurology Intraventricular hemorrhage Hypoxic ischemic encephalopathy Cerebral perfusion Hydrocephalus NICU neonatal intensive care unit Table 2 Description of common lung sonographic signs Alines Echogenic equidistant parallel horizontal lines located below the pleural line Blines Echogenic vertical lines starting at the pleural line and extending to the edge of the screen without fading Zlines Echogenic small vertical lines starting at the pleural line that do not obscure Alines Sliding lung sign Sliding of visceral pleura on parietal pleura during respiration Alveolarinterstitial syndrome 3 Blines in every examined area White lung Compact Blines in every examined area Consolidation Hepatization of the subpleural lung tissue Shred sign Irregular interface between relatively aerated lung and consolidated lung Lung point Interface between lung sliding and lack of lung sliding Lung pulse Lack of lung sliding with appearance of pulsation of lung synchronized with cardiac contraction Double lung point sign Sharp cutoff point between aerated upper lung and coalescent Blines representing edema in the lower lung Pleural effusion Anechoic collection bordered by the diaphragm and pleura of pneumothorax The pleural line on the right side of the video shows an absence of lung sliding A lung point and normal lung sliding can be seen coming into view on the left side during respiration httplinkslwwcomMOPA42 In time motion mode Mmode the stratosphere or barcode sign reflects the absence of normal lung inflation over time Fig 2a The lung point sign is one of the most specific signs of pneumothorax This sign indicates the interface between lung sliding and absent lung sliding in the area of the pneumothorax Fig 2a and b Supplemental Video 2 Lung ultrasound sagittal view appearance of pneumothorax The pleural line on the right side of the video shows an absence of lung sliding A lung point and normal lung sliding can be seen coming into view on the left side during respiration httplinkslwwcomMOPA42 1415 Finally in the area of the pneumothorax there is often an absence of both Blines and lung FIGURE 1 Lung ultrasound signs Sagittal view of the right chest showing the pleural line open arrowhead Aline closed arrowhead and occasional Blines arrow FIGURE 2 Lung ultrasound appearance of pneumothorax a By Mmode imaging the lung point arrows is observed at the junction between the seashore closed arrowhead and barcode open arrowhead patterns b Sagittal view of the left chest showing a lung point closed arrowhead The pleural line open arrowhead is indicated r rib rs rib shadow FIGURE 3 Lung ultrasound appearance of respiratory distress syndrome Coronal view of the right chest showing confluent Blines white lung a pleural line abnormality arrow and absent Alines pulse Absent lung pulse is defined as the lack of lung sliding combined with the appearance of pulsation of the lung in synchrony with cardiac contraction Respiratory distress syndrome and transient tachypnea of the newborn Respiratory distress syndrome RDS and transient tachypnea of the newborn TTN are common but distinct disease processes with similar clinical and radiographic features Whereas RDS is caused by deficiency or inactivation of pulmonary surfactant TTN is because of delayed or inadequate clearance of fetal alveolar fluid These distinct pathophysiologic processes result in distinct ultrasonographic patterns Therefore when the diagnosis is uncertain LUS may be a useful adjunct in differentiating between them 1617 LUS is highly sensitive and specific for the diagnosis of both RDS and TTN performing better than radiography 18 Sonographic findings in RDS include consolidation or bilateral white lung air bronchograms pleural line abnormalities and absent Alines Fig 3 1920 In TTN characteristic findings include the doublelung point sign pulmonary edema alveolarinterstitial syndrome compact Blines and a regular pleural line without subpleural consolidation 21222324 The doublelung point DLP sign refers to a sharp cutoff point between the relatively normal LUS signs in the aerated upper lung fields and coalescent Blines representing retained alveolar fluid in the lower lung Though it is highly specific for TTN its sensitivity is variable 212223 A recent multicenter longitudinal study found that a regular pleural line without subpleural consolidation was a more consistent finding than the DLP in TTN 24 Finally after the diagnosis of either RDS or TTN is made LUS can be used to monitor the progression of disease In RDS specific LUS patterns describing lung aeration accurately predict need for surfactant 2526 Pneumonia Delayed diagnosis of pneumonia can lead to bacteremia and septic shock LUS has the potential to aid in the prompt identification of neonatal pneumonia Sonographic findings are consistent across all age groups and include large areas of consolidation with irregular margins dynamic air bronchograms and pleural line abnormalities 2728 In studies of neonates and older pediatric patients LUS is reported to be more sensitive than chest radiography for the diagnosis of pneumonia 2729303134 Pulmonary hemorrhage Neonatal pulmonary hemorrhage is a serious complication associated with a high mortality rate Diagnosis is made using nonspecific radiographic abnormalities and clinical manifestations such as bloodtinged endotracheal tube secretions LUS can aid in the identification of pulmonary hemorrhage Findings include the shred sign consolidation with air bronchograms pleural line abnormalities and disappearing Alines 35 The shred sign results from the contact of aerated lung with consolidated lung producing an irregular shredded border In a casecontrol study that included 57 neonates with pulmonary hemorrhage the shred sign was the most common LUS finding and alone had a sensitivity of 912 and specificity of 100 35 Pleural effusions Pleural effusions are easily identified on LUS as a hypoechoic collection between the parietal and visceral pleura Fig 4 Supplemental Video 3 Lung ultrasound appearance of pleural effusion Hypoechoic pleural fluid is visualized above the diaphragm and surrounding the lung as the sonographer slides the transducer from the lung base to the apex httplinkslwwcomMOPA43 Quantitative assessment and serial monitoring of effusion volume is a well established use of POCUS 6 Furthermore when thoracentesis is indicated POCUS can be used for procedural guidance identifying the lowest intercostal space above the diaphragm where the procedure can be safely performed 36 In adults use of ultrasound guidance for thoracentesis has been shown to reduce the rate of complications and is now considered standardofcare 37 Although less data are available in neonates ultrasoundguided thoracentesis may decrease complication rates in this population as well 38 FIGURE 4 Lung ultrasound appearance of pleural effusion View of the chest showing hypoechoic pleural fluid pf above the diaphragm arrow and surrounding the lower lobe of the lung lu FIGURE 5 Cardiac ultrasound pathology a Longitudinal IVC view showing IVC collapse arrow consistent with a low intravascular volume status b Subcostal view showing a large pericardial effusion lv liver ra right atrium Cardiac Echocardiograms ECHOs can provide critical timesensitive information on the structure and function of the newborn heart Initial ECHOs are typically used to assess cardiac structure that is to evaluate for congenital heart disease CHD with subsequent studies focused on function Serial measurements are useful to monitor hemodynamic changes associated with extrauterine transition or acute disease states such as shock persistent pulmonary hypertension PPHN or patent ductus arteriosus PDA Frequently repeated ECHOs are not feasible or costeffective within a traditional consultative model This need has triggered the emergence of focused pointofcare ECHOs performed by neonatologists Cardiac POCUS is used primarily to assess hemodynamic instability PDA significance and PPHN Importantly it does not aim to evaluate for CHD which requires pediatric cardiology expertise Hemodynamic instability Traditional cardiovascular metrics such as blood pressure correlate poorly with cardiac output and endorgan perfusion in neonates 3940 Cardiac POCUS can provide objective data in the evaluation of undifferentiated hypotension or hypoperfusional states 41 conditions often associated with severe illness Important echocardiographic components in the evaluation of hypotension include preload and afterload qualitative and quantitative biventricular function and evaluation of a pericardial effusion Fig 5a and b Supplemental Videos 46 Subcostal view showing a large pericardial effusion httplinkslwwcomMOPA44 Parasternal long axis view showing hyperdynamic cardiac function with complete collapse of the left ventricular cavity during systole httplinkslwwcomMOPA45 Parasternal long axis view showing severe biventricular cardiac dysfunction httplinkslwwcomMOPA46 Additional metrics such as superior vena cava SVC flow have shown promise as surrogates for systemic blood flow correlating with both neurologic outcomes and survival 424344 Together these realtime echocardiographic indices can provide a comprehensive individual hemodynamic profile used to target therapies and monitor response over time Patent ductus arteriosus PDA management is one of the most controversial topics in neonatology Although it is not clear which patients benefit from ductal closure serial monitoring of ductal patency ductal size and associated hemodynamic parameters provides important data as intervention is considered or undertaken PDA evaluation begins with a formal ECHO by cardiology to exclude ductaldependent CHD Cardiac POCUS can subsequently monitor hemodynamic significance over time using three components ductal diameter markers of increased pulmonary flow and evidence of diastolic steal 45 This tool may also aid in the postoperative management of neonates who undergo PDA ligation with the goal of preventing postligation cardiac syndrome 4647 Jain et al 47 found that LV output less than 200 mlkgmin 1 h after PDA ligation accurately predicted the development of hypotension and need for inotropes Persistent pulmonary hypertension of the newborn Infants with PPHN are often severely ill requiring significant respiratory and hemodynamic support POCUS can be used to diagnose PPHN quantify severity using estimations of pulmonary artery systolic pressure PASP target treatment such as inhaled nitric oxide and vasopressors and monitor response by serial assessment 4849 Useful ECHO parameters in PPHN include PASP estimation by measuring gradients across the tricuspid valve directionality of intracardiac and extracardiac shunts ventricular size and function and septal flattening The primary limitation to the use of cardiac POCUS for PPHN is significant interobserver variability for qualitative assessments such as right ventricular size and function 50 Abdominal Abdominal radiographs have poor sensitivity for the diagnosis of necrotizing enterocolitis NEC particularly in preterm infants 5152 Furthermore multiple radiographs are often needed to diagnose or serially monitor infants with NEC Abdominal ultrasound can be a useful adjunct detecting changes consistent with NEC even when the radiograph is inconclusive 5354 Ultrasound can identify typical indicators of NEC such as pneumatosis intestinalis Fig 6 free air and portal venous gas Unlike radiographs however ultrasound can also characterize intraabdominal fluid Fig 7 and bowel wall perfusion Furthermore certain sonographic findings have prognostic value in NEC predicting surgery or death 535556 To date research on the use of abdominal ultrasound for the diagnosis or monitoring of NEC has focused on traditional consultative ultrasound More experience is needed to determine its utility and feasibility at the pointofcare FIGURE 6 Ultrasound appearance of pneumatosis intestinalis Echogenic intramural air visualized in longitudinally a and transversely b oriented loops of bowel FIGURE 7 Abdominal ultrasound appearance of ascites Transverse view of the abdomen showing ascites and a loop of bowel arrow Doppler ultrasound of the epigastric artery and vein is shown FIGURE 8 Peripherally inserted central catheter tip localization by ultrasound a High parasternal longitudinal superior vena cava view showing an upper extremity PICC tip open arrowhead at the junction of the superior vena cava arrow and right atrium ra b Longitudinal IVC view showing a lower extremity PICC tip open arrowhead in the IVC arrow just below its junction with the right atrium lv liver FIGURE 9 Umbilical catheter tip localization by ultrasound a Modified longitudinal IVC view showing the UVC tip open arrowhead inferior to the junction of the ductus venosus and right atrium ra b Longitudinal view of the descending aorta da showing the UAC tip open arrowhead just above the origins of the celiac closed arrowhead and superior mesenteric arrow arteries lv liver FIGURE 10 Normal lumbar spine ultrasound Saggital view of the lumbar spine showing the conus medullaris cauda equina ce vertebral bodies vb and CSF arrow time it is still a considerable investment particularly for NICUs in resourcelimited settings Furthermore options for formal training specific to neonatology are limited and no formal curriculum or accreditation process exists Second many NICUs do not have an ultrasound machine with neonatal probes dedicated to pointofcare use Third available evidence from RCTs particularly for procedural applications may be limited by a lack of equipoise among neonatologists to randomize infants given the favorable safety and efficacy data in older children and adults To date studies on diagnostic POCUS in the NICU are mostly limited to case reports and singlecenter observational studies involving highly experienced POCUS operators More robust data are needed to determine whether POCUS can be effectively implemented across centers and if routine use favorably impacts clinical outcomes Finally as use of POCUS continues to grow it will be critically important to delineate scope of practice develop evidencebased guidelines for use and establish mechanisms for quality assurance Acknowledgements None Financial support and sponsorship None Conflicts 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and improves success rates ULTRASSOM POINTOFCARE POCUS NA UTI NEONATAL INTRODUÇÃO O POCUS consiste na utilização do equipamento à beira do leito com o intuito de propiciar um diagnóstico mais imediato bem como trazer mais conforto a pacientes que não podem realizar o deslocamento até a unidade de imagem A interpretação da imagem ultrassonográfica é feita logo que a imagem é processada pelo médico assistente devidamente preparado Esse sistema pode ser utilizado para fornecer maior segurança na realização de procedimentos invasivos como a punção da veia subclávia A implantação do POCUS nas UTIs neonatais tem sido lenta mesmo que haja claros benefícios aos pacientes internados nessas unidades Fonte siemens healthineers APLICAÇÃO DE DIAGNÓSTICO O POCUS pode ser utilizado como ferramenta complementar à anamnese e ao exame físico Algumas sinais percebidos previamente em adultos foram observados em recémnascidos Um exemplo da aplicação do POCUS é a ultrassonografia pulmonar LUS do inglês Lung Ultrasound Score APLICAÇÃO DE DIAGNÓSTICO Na UTI neonatal essa ferramenta pode ser utilizada para auxiliar no diagnóstico de síndromes em diferentes órgãos e sistemas como Cardíaco Avaliação hemodinâmica persistência do canal arterial Pulmonar Pneumotórax derrame pleural Digestório Enterocolite necrotizante Vascular Inserção de cateteres Neurológico Perfusão cerebral hemorragia intraventricular APLICAÇÃO DE DIAGNÓSTICO PNEUMOTÓRAX Essa é uma complicação comum das doenças pulmonares em neonatos O POCUS favorece o diagnóstico oportuno o que contribui para a redução dos impactos dessa condição O LUS é mais sensível que o diagnóstico radiográfico em neonatos São sinais deslizamento pulmonar normal linha pleural horizontal parietal brilhante sinal do ponto pulmonar APLICAÇÃO DE DIAGNÓSTICO SÍNDROME DO DESCONFORTO RESPIRATÓRIO SDR E TAQUIPNEIA TRANSITÓRIA DO RN TTN Processos patológicos comuns em RNs mas que se diferenciam SDR Deficiência ou inativação do surfactante pulmonar TTN Depuração retardada ou inadequada do líquido alveolar LUS permite o diagnóstico diferencial e é mais específico que a radiografia APLICAÇÃO DE DIAGNÓSTICO PNEUMONIA E HEMORRAGIA PULMONAR Pneumonia Diagnóstico tardio pode levar a choque séptico LUS é mais sensível que a radiografia Hemorragia pulmonar Complicação grave associada a elevada taxa de mortalidade A LUS teve sensibilidade de 912 na identificação de hemorragia pulmonar em estudo realizado com 57 neonatos APLICAÇÃO DE DIAGNÓSTICO DERRAME PLEURAL Facilmente identificados na LUS É visível como uma coleção hipoecóica entre a pleura parietal e a pleura visceral POCUS pode ser utilizado para guiar a punção durante a toracocentese APLICAÇÃO DE DIAGNÓSTICO MANIFESTAÇÕES CARDÍACAS Instabilidade hemodinâmica O POCUS cardíaco é capaz de fornecer dados sobre a hipoperfusão Persistência do Canal Arterial Com a tecnologia POCUS é possível realizar a monitorização do paciente portador de PCA antes e após a cirurgia com a intenção de prevenir complicações Hipertensão pulmonar persistente do recémnascido O POCUS pode ser utilizado para identificar e caracterizar a gravidade do quadro APLICAÇÃO DE DIAGNÓSTICO MANIFESTAÇÕES ABDOMINAIS A radiografia abdominal possui baixa sensibilidade para auxiliar no diagnóstico de patologias como a enterocolite necrotizante A ultrassonografia torna o diagnóstico mais específico pois é capaz de identificar pequenas alterações mesmo com radiografia inconclusiva A imagens obtidas têm valor preditivo de indicação cirúrgica ou do risco de morte APLICAÇÃO DE DIAGNÓSTICO NEUROLOGIA A ultrassonografia é realizada através das fontanelas abertas e possibilita a identificação de condições como hemorragia intraventricular e hidrocefalia Ideal para quando há descompensação do paciente ou ausência de suporte radiológico Também pode ser utilizado na monitorização da perfusão cerebral do RN APLICAÇÕES PROCESSUAIS Acessos vasculares O POCUS pode ser utilizado como ferramenta guia para a realização de acessos centrais de inserção periférica PICCs os quais são utilizados frequentemente em UTIs neonatais Nesse contexto a ultrassonografia permite o correto posicionamento do cateter que deve ser na junção do átrio direito com a veia cava superior ou com a inferior Intubação endotraqueal O POCUS permite o correto posicionamento da sonda utilizada no procedimento Punção lombar A coleta de líquido cefalorraquidiano é um procedimento comum nas UTIs neonatais Dessa forma a ultrassonografia permite a identificação de estruturas anatômicas capazes de orientar o local mais adequado para punção REQUISITOS TÉCNICOS Diferentes transdutores podem ser utilizados Recomendase a utilização da frequência de 15 MHz com uma área pequena para uso do equipamento em RNs com a intenção de auxiliar em acessos vasculares Já transdutores de 312 MHz podem ser utilizados para a ultrassonografia cardíaca e para a ultrassonografia craniana Fonte siemens healthineers CONCLUSÃO As evidência atuais indicam as contribuições do POCUS nas UTIs neonatais Há ponderações realizadas quanto à Experiência do profissional Treinamento da equipe Preço Consenso entre neonatologistas Fonte siemens healthineers REFERÊNCIAS Fonte siemens healthineers