Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes

Neonatologists first need to define which POCUS diagnostic applications would be most beneficial and impactful in their practice environment and apply for POCUS privileges in those specific areas.²⁰  If they have not received previous certification, a transition period of education and training under supervision of an expert team is suggested that are compliant with quality assurances previously outlined in the accompanying clinical report²¹  for POCUS development. Data obtained from POCUS studies ought to be integrated within the clinical context and used as an adjunct to confirm diagnoses obtained from clinical examination, laboratory tests, and previously available and concurrent imaging.⁶  If these results are not congruent, clinicians may consider requesting more detailed studies by radiologists or cardiologists, not limited to US but possibly CT and/or MRI.

Critical and lifesaving situations in which POCUS needs to be performed immediately include:

• Infant is not responding to the Neonatal Resuscitation Program protocol without an identifiable reason for the unresponsiveness.²²  (Focused cardiac US.)

• Unexplained acute respiratory failure or worsening hypoxemia unresponsive to usual respiratory support.²³  (Focused lung US.)

• Unexplained acute circulatory shock, defined as blood pressure <10th percentile for corrected gestational age or worsening hypotension, worsening lactic acidosis, and unexplained oliguria unresponsive to initial resuscitation maneuvers, such as volume expansion and cardiovascular medication.^14,24  (Focused cardiac US.)

• Unexplained drop in hemoglobin >20% in 24 hours with suspicion of acute bleeding (ie, intracranial hemorrhage, hemopericardium, hemothorax, subcapsular, abdominal, or splenic hemorrhages).²⁵ 

The next section of this technical report describes diagnostic POCUS applications by organ system, followed by an algorithm for systematic multiorgan interpretation of POCUS as a novel approach in decompensating infants.

In the last 10 years, research studies have shown that lung US is an accurate, noninvasive method for predicting respiratory failure and offers certain advantages over chest radiography, including a reduction in radiation exposure.^22,26  Lung US is a good tool for use in emergency situations, because it is rapid, portable, repeatable, accurate, noninvasive, and radiation free. Assessment of lung US is based on detection of the following air-fluid interface related artifacts: A-lines, which reflect aeration; B-lines, which reflect thickened septa by interstitial or alveolar fluid; and air bronchograms, which can be seen in atelectasis and, when associated with hypoechoic areas and pleural irregularities, reflect consolidation. The commonly used protocol is to scan a total of 6 lung zones—3 on the right lung and 3 on the left lung; zone 1 is the upper lung, zone 2 is the lower lung, and zone 3 is the lateral lung (axillary area).²⁷  Lung US usually is performed with the patient supine. Lung US can be performed also from the back in prone position, but this body position needs to be maintained for at least 1 hour to allow lung fluids to settle with gravity.²⁸  A high-frequency linear probe is preferred, although any probe can be used with adjusted image depth and gain to show clear air-fluid interface patterns. Four patterns of lung findings are described with graded severity score; the lowest score is 0 and the highest is 3 for each zone, and the total lung score is the sum of the 3 lung zones on both right and left sides. Figure 1 shows different lung US patterns and a commonly used lung US scoring system.²⁹ Figure 2 shows the clinical applications, therapeutic interventions, and interpretation of lung US severity score.

1. Lung US for the diagnosis of respiratory distress syndrome (RDS) and guiding the need for surfactant administration.

Lung US can accurately and reliably diagnose transient tachypnea of the newborn (TTN) and offers value in differentiating TTN from RDS.³⁰  Also, the use of lung US severity score may be used as a guide for early surfactant administration in preterm infants³¹  (Table 1A).

2. Lung US in pneumothorax.

Evidence has shown that lung POCUS has high diagnostic accuracy in detecting pneumothorax, similar to chest radiography, and that the time to diagnosis can be shorter.³²  Visualization of the following combined lung US patterns can accurately diagnose pneumothorax: (1) absence of sliding sign of the pleural line; (2) complete absence of B lines (ie, only A-lines); (3) presence of a lung point; and (4) presence of a barcode sign in M-mode imaging (Table 1B).

3. Lung US in lung consolidation.

Lung consolidation is characterized by the presence of a nonaerated area or lung parenchymal portion filled with fluid, as seen in Fig 1D. The most common causes are atelectasis, inflammatory processes attributable to pneumonia, severe pulmonary edema, or acute pulmonary hemorrhage. The sonographic appearance of the consolidated area usually looks like hepatic tissue, with an abnormal pleural line and bronchograms. Meta-analysis of studies of lung US for consolidations in children of all ages has shown an 84% specificity when compared with clinical assessment and chest radiography together. Although the heterogeneity of the studies in terms of imperfect reference standards (clinical and/or radiography and outcomes), limited use of CT, and low sample sizes limits the generalization of the results, it is encouraging that high accuracy was achieved even when the performing physician had limited experience.³³  As has been done in adult critical care, the global loss of lung aeration can be accurately described by using easy semiquantitative scores specifically adapted to neonates.^33,34  Those scores are easy to calculate even in emergencies (Fig 1).

4. Lung US in postnatal diagnosis of congenital diaphragmatic hernia (CDH).

Relying only on chest radiography for postnatal diagnosis of CDH could delay the diagnosis in some cases, and confirmation with US, CT, or MRI may be needed in atypical cases. Lung POCUS may assist in early diagnosis of these cases. The diagnostic criteria include absence of the diaphragmatic echogenic line, absence of A-lines, absence of the pleural line and lung sliding on the side of the CDH, presence of bowel loops with peristalsis, and possible detection of liver or spleen in the hemithorax, as illustrated in Table 1C.^35–37 

5. Lung US in pleural effusion.

In assessing infants with pleural effusion by US, a clinician would visualize an anechoic (black) space between the parietal and visceral pleura in the most dependent areas. Additionally, lung POCUS has the potential for evaluating the characteristics of the fluid (simple anechoic, granular, fibrinous, septated, loculated, etc) and diagnosing the nature of the effusion. However, thoracentesis remains a valuable test to differentiate between transudate, exudate, or hemorrhage. The pleural effusion may have as underlying etiology central line malposition, pleural hemorrhage, exudate secondary to pneumonia, acute chylothorax,^38,39  or anasarca or hydrops fetalis (Table 1D).

6. Diaphragmatic motion assessment by US.

Diaphragmatic paralysis or paresis can be a clinically undetectable etiology of respiratory failure. Diaphragmatic excursion can be qualitatively and quantitatively assessed by monitoring the diaphragmatic movement via the US probe placed subcostally at the anterior axillary line for the right hemidiaphragm and subcostally at the posterior axillary line for left hemidiaphragm. In newborn infants, a transverse subxiphoid view is also useful. M-mode can be used for quantitative assessment of excursion with 0.5 to 1 cm as acceptable range in neonates.^40,41 

Figure 3 shows a proposed algorithm for lung POCUS interpretation.

Cardiac POCUS was described in the 1980s by emergency physicians to improve diagnostic capabilities and initiate therapy based on pathophysiologic findings. In the event of acute decompensation, the goal of cardiac POCUS is to assess pericardial effusion, global systolic myocardial function, heart filling, and ventricular symmetry.⁴²  For the last 20 years, cardiac POCUS is increasingly being used in NICUs to provide information in real time to aid clinical decision making.⁴³  The aim for basic cardiac POCUS differs from a comprehensive structural echocardiogram performed by a pediatric cardiologist or from an advanced hemodynamic evaluation performed by a neonatologist referred to as targeted neonatal echocardiography.⁴⁴  The principal role of cardiac POCUS is the time-sensitive assessment of the symptomatic patient and the immediate identification of pathologic processes that can be diagnosed rapidly with standard basic echocardiographic views, including pericardial effusions, catheter malposition, global systolic myocardial dysfunction, pulmonary hypertensive crisis, and hypovolemia with underfilling of the heart.⁴⁵  Early recognition and triage of pathologic conditions by US can guide lifesaving resuscitative interventions and would benefit from ubiquitous adaptation.^14,24,46 

Cardiac POCUS curricula have been developed locally at some institutions across the world with the goal of training more providers in basic and life-saving US applications, differing in limitations of practice and guidelines for advanced hemodynamics training.⁴⁷  Cardiac POCUS is not used as a screening tool for detection of congenital heart disease (CHD); therefore, the role of cardiac POCUS during the neonatal period needs to be clearly defined. Cardiac POCUS does not involve a comprehensive structural assessment on initial evaluation.⁴⁷  However, studies have demonstrated that with training and standardized protocols, cardiac POCUS could identify subtle abnormalities that prompt immediate and early access to pediatric cardiology to rule out underlying CHD.⁴⁸ 

With the additional complexity of neonatal transition and developmental factors related to immaturity, which could influence operator reliability and impact on its clinical value, training and standardized protocols for neonatal cardiac POCUS are imperative to ensure quality studies and interpretation in both resource-abundant and resource-limited countries.

The following are indications for cardiac POCUS in neonates:

1. Cardiac tamponade and pericardial effusion.

   Cardiac POCUS can be used to detect cardiac tamponade and large pericardial effusions leading to hemodynamic impairment^6,20,49  and can be lifesaving in critically ill infants. When cardiac tamponade is detected, POCUS allows for direct visualization to perform and safely guide pericardiocentesis.^50,51  The recommended views are subcostal 4-chamber, apical 4-chamber for semiquantitative assessment of effusion volume and also to guide pericardiocentesis, and parasternal long axis view to differentiate pericardial from pleural effusions, as shown in Table 1E.

2. Assessment of umbilical venous catheter and central lines position.

   Cardiac POCUS can be used to check the position of the umbilical venous catheter (UVC), peripherally inserted central catheters (PICCs), and epicutaneo-caval catheters (ECCs) in neonates. Assessment needs to include the evaluation of central line-related complications (ie, pericardial effusions, air embolism, or thrombus at the tip of the catheter). Adjustment of the tip position can be performed in real time, guided by POCUS.^52–54  Central line-related air embolism, although rare, could be an undetectable cause of clinical deterioration. Air emboli usually occur in the pulmonary artery, completely or partially blocking the right ventricular (RV) outflow tract and may cause acute hypoxemia and even sudden death. An air embolism appears on US as a bright or echogenic artifact, usually in proximity to the pulmonary valve.^15,55  The recommended views for central line tip assessment are subcostal 4-chamber view, bicaval long axis view for PICC or ECC line assessment, long axis view of the ductus venosus, and inferior vena cava for UVC assessment.^44,56 

3. Assessment of global cardiac systolic function.

   Cardiac POCUS can be applied to assess global cardiac systolic function on visual inspection “eyeballing.” The main goal is to assess whether cardiac contractility is good or impaired.²⁴  A detailed quantitative assessment is beyond the scope of cardiac POCUS, but suspicion of impaired cardiac function ought to lead to urgent consultation with a neonatologist with expertise in advanced hemodynamics assessment or a pediatric cardiologist if CHD or cardiomyopathy is suspected. Basic recommended views for eyeballing needs to include left, right, or global ventricular performances and subcostal 4-chamber, apical 4-chamber, and parasternal long and short axis views.⁴³ 

4. Assessment of cardiac filling and fluid status.

   Cardiac POCUS can provide information on cardiac filling through “eyeballing” (qualitative assessment) an underfilled heart (decreased preload) or volume overload (increased preload). In addition, serial assessments with cardiac POCUS can help in assessing response to fluid therapy. A qualitative volume status assessment is based on detection of low ventricular volume at the end of systole when the ventricular walls are touching each other, and the ventricular cavity is collapsing. Underfilling of the heart or low volume status is going to be interpreted and managed according to the clinical context. Common causes are dehydration attributable to loss of volume or hemorrhage, third space losses, compression by high mean airway pressure, or severe pulmonary hypertension. The latter is characterized by underfilling of the left ventricle with a dilated right heart, giving the impression of ventricular asymmetry. Useful views for volume assessment are apical 4-chamber view and parasternal long and short axis views, as shown in Table 1F.⁴⁷ 

5. Assessment of pulmonary hypertension on cardiac POCUS.

   Cardiac POCUS can be used to suspect or rule out severe pulmonary hypertension (PH). Although a detailed assessment of PH or RV function is out of the scope of cardiac POCUS, it can be used for evaluation of PH and RV function on visual inspection and semiquantitative assessment, in cases of worsening hypoxemia, simply based on ventricular asymmetry with dilated RV compared with the left ventricle, and paradoxical movement and shape at the end of systole of the interventricular septum. The recommended views are apical 4-chamber and long and short axis parasternal views, illustrated in Table 1G.⁵⁷ 

6. Suspicion of unanticipated CHD.

   If the clinician suspects CHD using cardiac POCUS, referral to a pediatric cardiology is mandatory. This diagnosis needs to be considered in the presence of ventricular or atrial asymmetry, single ventricle, large interatrial or interventricular septum defect, abnormally looking valves, or great arteries.⁴³ 

A wide spectrum of critical abdominal pathologic conditions that might occur in neonates warrant real-time radiologic assessment. Abdominal radiographs have limited value with low sensitivity and specificity in many of these cases.⁵⁸  The advantages of abdominal US include that it is noninvasive, easily available, can provide information in real time, and can aid in therapeutic intervention (such as paracentesis), making it an excellent tool for use in neonatal emergencies. In fact, US is by large the first imaging modality of choice for most abdominal conditions in neonates. However, US is considered as an adjunct to additional imaging studies because of its limitations and operator constraints.^59,60 

1. Assessment of abdominal bleeding or ascites.

   US has high sensitivity in assessing and localizing intraabdominal fluid. Although US cannot differentiate the nature of the fluid, bleeding is often suspected with unexplained anemia and abdominal trauma. Furthermore, it has been a useful modality to follow the degree and severity of ascites and, most importantly, to guide paracentesis, identifying the largest fluid pocket and avoiding the accidental puncture of epigastric vessels.^6,61 

2. Assessment of bowel ischemia.

   US has been proven to be an excellent imaging modality with high sensitivity in assessing intestinal emergencies such as necrotizing enterocolitis (NEC) and its related complications. NEC is the most common and severe intestinal disease in preterm infants, carrying a mortality rate of 40%.^62–67  Bowel US offers a dynamic evaluation that provides more specific information and markers of inflammation by 2-dimensional and color Doppler for NEC compared with traditional abdominal radiography. Intestinal ischemic injury can be also secondary to CHD, compromised blood flow attributable to twisted blood vessels in volvulus and intussusception, or circulatory shock or cardiovascular arrest.⁶⁸  Abdominal radiography and routine clinical assessment are limited for the evaluation of intestinal ischemia in all these etiologies. Bowel US is interpreted in the clinical context and needs to be integrated with other clinical and biochemical markers like all other US applications. There is no defined difference between radiology-led and POCUS bowel assessment for injury and/or ischemia, and as such, procedures ought to be adopted according to local availability, coverage, and expertise. The technique of abdominal POCUS for bowel injury needs to include liver assessment for portal venous gas and the evaluation of 4 abdominal quadrants for the presence of all the pathologic signs described in Table 2. The presence of ≥3 markers in all 4 quadrants is a sign of significant bowel injury. Table 2 shows the diagnostic values and technical consideration for different intestinal US markers.

Cranial US is the most common neuroimaging modality used in the NICU. In sick infants, cranial US enables the diagnosis of various hemorrhagic or ischemic brain lesions and noninvasive monitoring of intracranial pressure, mainly through the anterior fontanelle. Cranial POCUS can help in rapidly detecting severe intraventricular hemorrhage as a cause of acute decompensation and can help redirect clinical management (see next section).⁶⁹ 

The acutely decompensating infant algorithm introduces a systematic approach using POCUS with preidentified steps focusing on the assessment of mechanisms of unresponsiveness to resuscitation, unexplained acute decompensation, or acute unexplained anemia or blood loss.⁷⁰  Focused US views that are relatively easy to practice and are reproducible are recommended to detect specific pathologies. Use of a POCUS-guided acutely decompensating infant algorithm provides an important opportunity for neonatal intensive care practitioners to identify the pathophysiology of an acutely decompensating infant in real time, replacing the empirical approach.²⁴  This stepwise systematic assessment of the acutely decompensating infant can be applied in any setting, such as the resuscitation room, the emergency department, or for any infant who has become acutely ill at any time after birth. If there is no response to resuscitation, as per the Neonatal Resuscitation Program guidelines, identifying the mechanism of unresponsiveness is recommended utilizing the algorithm presented as a flow diagram in Fig 4. A stepwise approach should be used, moving from organ to organ considering the organ priorities as per the Neonatal Resuscitation Program. First, lung assessment is performed including lung inflation with optimum ventilation followed by the assessment of underlying pathologies, including lung collapse, pneumothorax, effusions, and undiagnosed congenital diaphragmatic hernia. Second, cardiac assessment is performed, including volume status evaluation and cardiac filling, cardiac contractility, pulmonary hypertension, and pericardial effusion. If there is associated anemia or severe pallor, or effusion attributable to line migration, then cranial and abdominal POCUS needs to be performed.

The implementation of procedural US has undoubtedly grown and widened across many pediatric specialties; however, neonatology has slowly been adopting and introducing this technology into clinical practice. Exponential growth of supportive evidence makes a strong case for using POCUS for any pediatric intervention. POCUS guidance has become a powerful tool for improving procedural success and, most importantly, patient safety.⁷¹  Although we continue to anticipate a growing body of supportive literature, common sense tells us that we may move beyond equipoise and focus our efforts toward formal implementation of procedural ultrasonography. POCUS training in neonatology has long ago been addressed, and the benefits to both patient and provider can no longer be disputed.

Vascular access is the most common lifesaving procedure in medicine. Although usually considered a “basic” technical skill, in neonates, inserting a needle in small targets requires a high degree of skill.

1. ECCs and PICCs.

ECCs and PICCs are the preferred central lines in neonates to provide long-term parenteral nutrition and intravenous medications. The use of POCUS for ECC or PICC insertion has been limited because of the high degree of skills required to access these small veins compared with older children. Typically, this procedure was performed blind with subsequent catheter tip localization by radiography. US has been described as more accurate in identifying malpositioned catheters than radiography, particularly in low birth weight infants.⁷²  High-frequency linear probes are the transducer of choice for vascular access, because they offer optimal resolution when dealing with small vessels. Line insertion can be performed using a short axis or “out of plane,” or long axis or “in plane” approach, as illustrated in Table 3A and B. POCUS is used for dynamic needle guidance during placement and following line insertion to evaluate and adjust tip position in real time (Table 3C and 3-dimensional), thereby reducing the need for confirmatory radiography.^73,74  Data on catheter diameter, vessel size, and risk of thrombosis suggest that limiting the external catheter diameter to one third of the vessel internal diameter may reduce the incidence of thrombosis.^75–77  US can be used to measure the vessel diameter to decide on the adequate catheter size before central line insertion. To date, 1 randomized controlled trial has evaluated the use of US for confirmation of tip position compared with standard verification using radiography and have shown a reduced number of manipulations after placement and less radiographs needed.⁷⁸  In the near future, it is not unreasonable to think that POCUS is likely to become a useful tool for central line tip evaluation after placement.⁷⁹ 

2. Umbilical venous catheters.

The placement of umbilical venous catheters (UVCs) is an essential technique for the treatment of many unstable newborn infants. Although this procedure is usually performed quickly and easily, there are sometimes difficulties. The UVC ought to follow the intended path through the umbilical vein into the portal recess and through the ductus venous, terminating at its junction with the right atrium and the inferior vena cava. The UVC is inserted to a calculated depth, then evaluated by radiography. A commonly encountered challenge with UVC placement is the misdirection of the catheter into the left or the right portal veins rather than the ductus venous. Recently, a UVC dynamic US-guided approach was published, suggesting a possible technique to troubleshoot UVC placement.⁵⁶  The optimal UVC position is most frequently assessed by radiography. However, the use of POCUS is deemed to be superior to radiography and may be considered as the gold standard for easily revealing UVC tip position and catheter migration, especially in situations in which abnormal anatomy, such as in congenital diaphragmatic hernia, makes radiographic assessment extremely challenging.^{52,53,80–84}  Visualization of the catheter tip with a high-frequency linear probe or phased array probe allows for accurate measurement and retraction in “real time” under US guidance until it reaches the satisfactory and desired final position as shown in Table 3E and F.

3. Peripheral arterial lines.

Placement of peripheral arterial lines is a challenging procedure in newborn infants, especially preterm infants, given the small size of the peripheral arteries. Strong evidence in adults has revealed that the use of US guidance improves first attempt rates and reduces the incidence of complications.^85–88  Subsequent studies in the pediatric population have confirmed these findings.^89–92 

4. Peripheral intravenous lines.

POCUS adds significant value to the insertion of peripheral venous catheters. POCUS has been shown to decrease insertion attempts and time to cannulation.^93,94  Patients in whom peripheral veins may not be identified with palpation or visualization may have additional points of access identified by POCUS.

Lumbar puncture (LP) is a common procedure performed by neonatologists to rule out infection and for diagnostic purposes.⁹⁵  Spine US is performed using a linear transducer and obtaining images in both planes, long and short axis. It is helpful in identifying landmarks either before the procedure, such as identification of the conus medullaris, depth required to reach cerebrospinal fluid, as well as the level where the spinal canal begins to narrow, or as the needle is introduced and advanced into the spinal canal (Table 3G). Studies have shown that in many cases of failed LP using the landmark technique, a successful LP was subsequently performed using US.^96,97  A systematic review and meta-analysis compared US-assisted LP with the landmark technique in adult and pediatric patients.⁹⁸  US-assisted LPs were associated with higher success rates, fewer traumatic LPs, shorter time to a successful LP, and lower patient pain scores. A recent systematic review and meta-analysis of 4 randomized controlled trials in infants and neonates found no statistically significant difference in the rate of LP failure; however, significantly fewer traumatic taps occurred with US assistance.⁹⁹ 

Other neonatal procedures for which US guidance provides benefits, improves accuracy, and increases patient safety include paracentesis, pericardiocentesis, thoracentesis, and suprapubic aspiration.

1. Paracentesis.

Abdominal US enables confirmation of ascites, identification of the largest ascitic pocket, and localization of epigastric vessels to safely avoid catastrophic complications, such as undesired punctures of adjacent structures and bleeding.^100–102 Table 3H and I demonstrate the epigastric vessels using color Doppler and the needle insertion, respectively.

2. Pericardiocentesis.

This US-guided technique was first described in 1979,^50,103  and since then, it has been the preferred method, not only for diagnosis but also for management of cardiac tamponade.^103,104 

3. Thoracentesis.

A multicenter collaborative study (Lung Ultrasound in Crashing Infants) demonstrated that lung US is safe and accurate and enables chest tube placement guidance or needle aspiration in neonates with pleural effusion and pneumothorax.⁸⁰  Lung US is a well-recognized use of POCUS that allows for identification of the lowest intercostal space above the diaphragm where thoracentesis can be safely performed.

4. Suprapubic aspiration.

US of the bladder provides direct visualization of and determines the size and location of the bladder as well as the volume of urine before either aspiration or catheterization.¹⁰⁵  Kiernan et al have shown that dynamic US guidance of suprapubic aspiration compared with the traditional landmark technique significantly increased the volume of urine obtained and first attempt success while decreasing procedure time.^106,107 

The current methods used to confirm the placement of the endotracheal tube (ETT) are the presence of end-tidal carbon dioxide, auscultation, and chest radiography. However, the presence of an ETT into the trachea or esophagus can be easily distinguished by using an US probe in a transverse position over the airway.^108–111  Furthermore, POCUS can be used to assess ETT tip position in preterm and term infants.¹¹²  Bedside US may be a better diagnostic modality for confirming ETT position in neonates, especially in situations in which radiographs are not obtained, such as in the delivery room before surfactant administration or when time is critical and waiting for radiography to arrive to the bedside may not be appropriate. The ETT tip can be assessed in the suprasternal view, with the tip being above the aortic arch by 1 to 2 cm¹¹³  (Fig 5).

The accompanying clinical report²¹  provides general guidance for POCUS program development in the NICU. In this technical report, the basic technical aspects of neonatal POCUS are described. Clinicians must be aware that these guidelines were written by North American experts, and thus, application in other countries may not be appropriate. Nonetheless, they have been approved by the American Academy of Pediatrics, Canadian Pediatric Society, and American Institute of Ultrasound in Medicine, and they are now available as an important cornerstone and reference for appropriate institutions to adopt POCUS guidelines and define limitations of practice, training programs, and quality assurance processes. POCUS has been frequently used in adult critical care and emergency medicine for the past 2 decades. Neonatology has slowly been incorporating and accepting this technology as part of clinical practice. Compelling evidence exists that validates neonatal POCUS as an important extension to clinical examinations.²⁶  However, the clinician must be aware that practice models in other countries may be very different, which limits any inference as to the utility and effectiveness of POCUS in the United States.

The diagnostic and procedural applications described in this report are frequently used in all aspects of daily practice, including delivery rooms and resuscitation rooms, NICUs, and on neonatal transports. For simplification purposes, the diagnostic applications in this report are described based on organ systems and not per clinical scenarios. However, case presentations could be complex, involve different organs, and require a multiorgan evaluation. For this reason, a systemic multiorgan assessment approach for the decompensating infant to evaluate the etiology of the acute decompensation or unresponsiveness to resuscitation and the impact of shock or hypoxemia on other organs is proposed. Unfortunately, clinical examinations are often inconclusive, monitoring devices can be inaccurate, and laboratory values can be imprecise. Understanding the underlying pathophysiology leads to early and targeted support and management, which ultimately protects and limits ongoing end-organ injury.⁶⁷  The evidence shows that integrating POCUS with clinical management helps in providing a pathophysiologic-based medical recommendation and avoids empirical therapy based on insufficient or nonspecific clinical examination.^14,46  POCUS presents accurate and relevant information and often changes clinical management. Early recognition of pathophysiologic processes often proves to be the most important determinant of outcomes. Previous published data showed that applying different POCUS techniques shortened the time to clinical recovery when compared with routine or standard clinical practice.²⁴  The most important value and main feature of POCUS is being clinically focused to answer a specific question at a particular time, requiring immediate changes to treatment. However, POCUS findings need to be integrated with the clinical, biochemical, and other monitoring parameters.²⁹ 

POCUS guidance has improved procedural success, provider performance, and patient safety across all pediatric procedures.⁷¹ 

US is operator dependent, and the quality of the images depend on the training and competency of the operator, which can also be limited by equipment choices and quality. Institutional protocols for training and guidelines for practice needs to be well established and based on the general recommendations outlined in this technical report and accompanying clinical report.²¹ 

The information gained by POCUS is used as an adjunct to the clinical examination by gaining insight into the underlying pathophysiology in critically ill infants with unexplained clinical deterioration. Diagnostic and procedural POCUS presents an opportunity by which we can demonstrate that improved processes translate to improved outcomes.

Dan L. Stewart, MD, FAAP Yasser Elsayed, MD, FRCPC María V. Fraga MD Brian D. Coley, MD, FAAP, FACR Aparna Annam, DO, FAAP Sarah Sarvis Milla, MD, FAAP

Eric Eichenwald, MD, Chairperson Charleta Guillory, MD Ivan Hand, MD Mark Hudak, MD David Kaufman, MD Camilia Martin, MD Ashley Lucke, MD Margaret Parker, MD Arun Pramanik, MD Kelly Wade, MD

James Cummings, MD Daniel Stewart, MD Karen Puopolo, MD

Timothy Jancelewicz, MD – AAP Section on Surgery Michael Narvey, MD – Canadian Paediatric Society Russell Miller, MD – American College of Obstetricians and Gynecologists RADM Wanda Barfield, MD, MPH – Centers for Disease Control and Prevention Lisa Grisham, APRN, NNP-BC – National Association of Neonatal Nurses

Jim Couto, MA

Hansel J. Otero, MD, FAAP, Chairperson Patricia Trinidad Acharya, MD Adina Lynn Alazraki, MD, FAAP Ellen Benya, MD, FAAP Brandon P. Brown, MD MA, FAAP Reza James Daugherty, MD, FAAP Edward Richer, MD, FAAP

Laura Laskosz, MPH

CDH

congenital diaphragmatic hernia

CHD

congenital heart disease

ECC

epicutaneo-caval catheters

ETT

endotracheal tube

LP

lumbar puncture

MRI

magnetic resonance imaging

NEC

necrotizing enterocolitis

PH

pulmonary hypertension

PICC

peripherally inserted central catheter

POCUS

point-of-care ultrasonography

RDS

respiratory distress syndrome

RV

right ventricular

TTN

transient tachypnea of the newborn

US

ultrasonography

UVC

umbilical venous catheter