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Echocardiography in the critically ill child

Echocardiography in the critically ill child. What should paediatricians be doing? What must be left to the expert?. John Lawrenson Paediatric Cardiology Service Western Cape Department of Paediatrics and Child Health Stellenbosch University. Let’s start with the expert. 2007.

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Echocardiography in the critically ill child

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  1. Echocardiography in the critically ill child What should paediatricians be doing? What must be left to the expert? John Lawrenson Paediatric Cardiology Service Western Cape Department of Paediatrics and Child Health Stellenbosch University

  2. Let’s start with the expert 2007

  3. Why is echocardiography so difficult? • It isn’t but it takes practice • Not quite 10 000 hours • A trainee will spend 12 X 40 hour weeks doing echo • Machines are expensive and fragile • But are getting cheaper (cost of a good ventilator) • Machines are designed for adults • Cross platform units are hard to find

  4. Focused point-of-care echocardiography - Acronym soup • FEER Focused echocardiographic examination in resuscitation • BLEEP Bedside limited echocardiography by the emergency physician • RACE Rapid assessment by cardiac echo • FATE Focused assessed transthoracic echo • FAST Focused abdominal sonography in trauma (one subcostal look)

  5. Resucitation • German experience • Indications for emergency echo during resuscitation • Study needs to be 5 seconds long and part of the resuscitation and not prolong non flow intervals • 8 hour training • Helpful in ‘PEA’ and effusions

  6. In the ICU Seppelt 2007

  7. Impediments to ‘uptake’ (Seppelt 2007) • Cost • Senior ‘old dog’ clinicians • Lack of training • National program in France

  8. IVC Volume – subcostal • LV EF – standard • 2-D • 11 hrs training • 31 sick patients – reasonable results – checked by Cardiologist Tennessee

  9. The next stage in the ICU • Function • Systolic • RV function • Filling • Diastolic areas • Empty ventricles more reliable than full ventricles • IVC and change with inspiration (surrogate RA pressure) • Pressures - pulmonary • Output • Valves

  10. Neonatologists • There aren’t enough cardiologists in the World to meet the needs of neonatologists • ..in Cape Town… • Neonatologists have moved beyond the PDA to functional assessments • A special bond has to exist between cardiologists and neonatologists • Increasing numbers of neonatologists are skilled echocardiographers

  11. Sampson and Kumar 168/11000 - 83 patients

  12. Sampson and Kumar

  13. A Paediatrician for Polokwane or Fiji or wherever • Basics • Switch on machine • Recognise the bad stuff • Intermediate • Neonatal bad stuff • Rheumatic heart disease • Advanced • Congenital heart disease; refer for surgery

  14. Learning echo

  15. Do not forget to examine the patient first! Do not forget to examine the patient first! Do not forget to examine the patient first! Do not forget to examine the patient first! Do not forget to examine the patient first! Do not forget to examine the patient first!

  16. The future of echo for the non-cardiologist • Telemedicine • Good examples from Western Hemisphere • YouTube style studies • Dummy training using echo simulators • Smaller powerful laptop type machines • Hand held machines

  17. Thank You

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