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17653

Clinical Utility of Echocardiography In the Pediatric Intensive Care Unit

Friday, October 19, 2012
Room 275-277 (Morial Convention Center)
Jonah E. Attebery, MD1, Emily M. Yeager, BA, BS2, Edward J. Truemper, MD, MA3, Ling Li, MD, PhD4, James M. Hammel, MD5, David A. Danford, MD4 and Shelby Kutty, MD4, (1)Pediatrics, University of Nebraska Medical Center/Creighton University/Children's Hospital and Medical Center, Omaha, NE, (2)Creighton University School of Medicine, Omaha, NE, (3)Division of Pediatric Critical Care, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, NE, (4)Division of Pediatric Cardiology, University of Nebraska Medical Center/Creighton University/Children's Hospital and Medical Center, Omaha, NE, (5)Division of Cardiothoracic Surgery, University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, NE

Purpose: Although transthoracic echocardiography (ECHO) is commonly performed in the pediatric intensive care unit (PICU), its utility is not specifically known.  We sought to evaluate the clinical impact of ECHO in the PICU in terms of frequency of unanticipated findings and the nature of clinical management changes attributed to the results of ECHO.

Methods: This prospective study was conducted in a 21-bed combined medical-surgical-cardiac PICU at a tertiary care children’s hospital.  All patients undergoing clinically indicated ECHO were included. Data included indications, pre-ECHO assessment of anticipated ECHO findings, primary diagnosis, age, and urgency (stat vs. routine) of ECHO.  Patients were classified as cardiac or non-cardiac.  Interpretations were provided by board certified pediatric cardiologists.  Input of the attending multidisciplinary team allowed classification of results as confirming the pre-ECHO clinical impression, altering the pre-ECHO impression regarding the indication for the test, or altering the impression by virtue of new findings unrelated to the specific indication.  The nature of new findings were listed and categorized.  The team recorded clinical management changes made in response to the ECHO results; the nature of these were categorized.   Univariate comparisons between categorical variables and outcomes were made.

Results: ECHOs (n=416) were performed in 132 patients (7/2011-4/2012).  Of these, 244 (59%) were ordered on males, 31% were <30 days old, median age 103 days, 379 (91%) had a primary cardiac diagnosis, and 92 (22%) were ordered stat.  63% of ECHOs confirmed and 24% altered the pre-ECHO impression regarding the indication; 13% introduced new findings unrelated to the indication.  The distribution of unexpected findings and the ECHO-associated management changes are summarized (Table). Surgical revision was required in 26 patients (6.3%). Stat ECHOs were more likely to alter pre-ECHO assessment than routine ECHOs (p<0.001).  Management changes were more commonly associated with stat ECHOs (p=0.002) and those with new unexpected findings (p<0.001), but had no demonstrable association with age <30 days (p=0.332).

Conclusion: Unanticipated ECHO results are common in the PICU, and often alter the clinical impressions that prompted the ECHO or introduce new findings unrelated to the reason for which the ECHO was recorded.  Clinical management changes attributable to ECHO findings are frequent, including occasional surgical intervention.  ECHO adds diagnostic value and contributes to the management approach in the PICU, accounting for its frequent use.

Diagnostic efficacy          ECHOs  n(%)
Confirmed pre-ECHO impression 263 (63)
Altered pre-ECHO impression 99 (24)
New findings unrelated to indication 55 (13)
   Ventricular function    18 (33)
   New anatomic lesion    16 (29)
   Central line issue    11 (20)
   Pulmonary artery pressure    4 (7)
   Pericardial effusion    4 (7)
   Ductus patency    2 (3.5)
Management changes
   ECHOs resulting in intervention    132 (31.6)

   Inotrope adjustment

   44 (33.3)
   Surgical revision    26 (19.6)
   Vasodilator adjustment    18 (13.6)
   Fluid/diuretic adjustment    13 (9.8)
   PGE1 adjustment    8.3 (8.3)
   Other

   25 (18.9)