Abstract
PurposeTo determine the feasibility of using the Ultrasound Cardiac Output Monitor (USCOM) as an adjunct during hemodynamic assessments by a pediatric medical emergency team (PMET).MethodsPediatric in-patients at McMaster Children’s Hospital aged under 18 years requiring urgent PMET consultation, were eligible. Patients with known cardiac outflow valve defects, Pediatric Critical Care Unit in-patients, and those in cardiorespiratory arrest, were excluded. The primary outcome was feasibility, and the ease of USCOM transport and application as assessed by a self-administered user questionnaire. Secondary outcomes included the quality of USCOM measurements, and agreement in clinical versus USCOM-derived assessments.ResultsForty-one patients from 85 eligible PMET consultations were enrolled between March and August 2011. A total of 55 USCOM assessments were performed on 36 of 41 (87.8%) participants. USCOM could not be completed in 5 (12.2%) participants due to patient agitation (n = 4) and emergent care (n = 1). USCOM was reported as easy to transport and apply by 97.4% and 94.7% of respondents respectively, not obstructive to patient care by 94.7%, and yielded timely measurements by 84.2% respondents. USCOM tracings were of good quality in 41 (75.9%) assessments. Agreement between clinical and USCOM-derived hemodynamic assessments by two independent raters was poor (Rater 1: κ = 0.094; Rater 2: κ = 0.146).ConclusionUSCOM can be applied by a PMET during urgent hemodynamic assessments in children. While USCOM has been validated in stable children, its role in guiding hemodynamic resuscitation and informing therapeutic goals in a hemodynamically unstable pediatric population requires further investigation.
Highlights
Recognition and early resuscitation of pediatric patients according to their hemodynamic physiology and goaldirected endpoints improves survival and functional outcomes in children with shock [1,2,3,4]
Complete Ultrasound Cardiac Output Monitor (USCOM) measurements were obtained during initial pediatric medical emergency team (PMET) assessments in 36 of the 41 (87.8%) participants, and in 19 of 22 (86.4%) scheduled follow-up visits (Figure 1)
This is the first study to our knowledge to evaluate the urgent use of USCOM for hospitalized children outside of a pediatric critical care unit (PCCU) setting, and by non-physician clinicians. This has significant implications, given that early recognition and prompt reversal of cardiorespiratory decompensation improves clinical outcomes and survival amongst children with septic shock [29,30,31]. We hypothesized that both physician and non-physician PMET members can be trained in operating USCOM, and this study revealed that these PMET members demonstrated similar
Summary
Recognition and early resuscitation of pediatric patients according to their hemodynamic physiology and goaldirected endpoints improves survival and functional outcomes in children with shock [1,2,3,4]. There are currently several adjunctive methods of assessing a patient’s hemodynamic status, such as pulmonary artery catheters, pulse contour cardiac output, 2D echocardiography, and central venous oximetry [2,6]. These tools are limited by their need for invasive access, inability to provide real-time measurements, the prerequisite expertise and setting required to conduct some of these measurements (i.e. an intensive care unit), and limited evidence of efficacy on clinically important outcomes [6,7,8]. Children requiring hemodynamic resuscitation outside the pediatric critical care unit (PCCU) remain primarily dependent on the clinical assessment. A reliable, non-invasive, objective method of assessing hemodynamic physiology that can be and rapidly applied in a broad range of children within and beyond the PCCU would be a valuable adjunct to optimizing the resuscitation of children in shock [9,10]
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