Guidelines and Standards
Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography

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Cardiac point-of-care ultrasound has the potential to improve patient care, but its application to children requires consideration of anatomic and physiologic differences from adult populations, and corresponding technical aspects of performance. This document is the product of an American Society of Echocardiography task force composed of representatives from pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric anesthesiology, and others, assembled to provide expert guidance. This diverse group aimed to identify common considerations across disciplines to guide evolution of indications, and to identify common requirements and infrastructure necessary for optimal performance, training, and quality assurance in the practice of cardiac point-of-care ultrasound in children. The recommendations presented are intended to facilitate collaboration among subspecialties and with pediatric echocardiography laboratories by identifying key considerations regarding (1) indications, (2) imaging recommendations, (3) training and competency assessment, and (4) quality assurance.

Section snippets

Table of Contents

Purpose of This Document 265

Definitions 266

  • I.

    Indications 266

    • A.

      Framework for cardiac POCUS indications 267

    • B.

      Proposed Indications for Cardiac POCUS 267

  • II.

    Imaging Recommendations 269

    • A.

      Equipment and Technical Considerations 269

    • B.

      Imaging Overview 269

    • C.

      Recommended Imaging Views 269

    • D.

      Storage and Reporting 272

  • III.

    Training and Competency Assessment 273

    • A.

      Defining Cardiac POCUS Competency 273

    • B.

      Competency Assessment 274

  • IV.

    Quality Assurance 275

Conclusion 275

Purpose of This Document

Ultrasound is a powerful tool for evaluating cardiac structures and function. Technological advances and education have led to widespread bedside use of point-of-care ultrasound (POCUS) by practitioners from a variety of disciplines and subspecialties. One of the goals of the American Society of Echocardiography (ASE) is to provide education and guidance in cardiac imaging to practitioners across a range of diverse clinical and experiential backgrounds.

Two prior ASE task forces addressed the

Definitions

In this document, the term cardiac POCUS is used to describe ultrasound image acquisition and interpretation of cardiac structures by pediatric noncardiology clinicians to evaluate size, systolic function, and/or physiology. The expectation is that cardiac POCUS involves a focused evaluation of the heart, performed at the bedside, to assist in rapid clinical decision-making and management. Cardiac POCUS does not include anatomic evaluation of CHD, which requires TTE interpreted by a pediatric

I. Indications

Translating cardiac POCUS to clinical care requires integrating the needs of local patient populations, the demands of highly variable clinical practice contexts, and the clinician's skill set. Potential applications for cardiac POCUS will continue to evolve, and an exhaustive list of indications among various noncardiology specialties cannot be provided here. However, by harmonizing previously published cardiac POCUS applications across noncardiology specialties, this task force proposes a

A. Equipment and Technical Considerations

Cardiac POCUS is not defined by the type of machine used but is most often performed with ultrasound devices with fewer image optimization tools and, important to pediatrics, fewer transducer options compared with standard echocardiography machines.58,59 Ultrasound machines designated for cardiac POCUS in children should ideally have both low-frequency (∼2-2.5 MHz) and higher frequency (≥∼7.5 MHz) sector probes available, because of the wide range of imaging depths encountered in the pediatric

III. Training and Competency Assessment

Multiple pathways currently exist for training and certification in adult cardiac POCUS. A prior ASE guideline discussed the role of echocardiography laboratories in adult cardiac POCUS training.2 Similar approaches and considerations apply in the pediatric population, with the addition of local decisions on scope of practice and criteria for referral to cardiology, as noted above. Training in adult cardiac POCUS may be helpful, but not sufficient for practice in pediatrics, given differences

IV. Quality Assurance

For all diagnostic tools in the medical setting, there must be a built-in process for continued evaluation of examination quality in addition to infrastructure that allows the examination of the root cause of errors, the promotion of ongoing quality improvement, and the integration of new technology and evolving applications. As noted above, this includes a robust imaging archive system. In addition, the program should have well-delineated plans for review of archived studies, which involves at

Conclusion

Cardiac POCUS is a rapidly growing imaging modality with current and evolving applications in the pediatric population. Specific indications, training pathways, and competencies need to be defined by individual subspecialties and cannot be globally prescribed by any one society or organization. However, certain common principles are shared regardless of area or field of clinical practice. Evolving indications are limited by the equipment and focused nature of this modality, and thus cardiac

Acknowledgments

This task force would like to acknowledge Dr Amer Johri for his mentorship and guidance, Lisé Blandino and Marissa Moran for their administrative support throughout the formulation of this document, and Jayur Patel for creating the illustrations for Table 1. Images for Table 1 are courtesy of pediatric critical care physicians from the Children's Hospital of Philadelphia. Videos 1 to 6 are courtesy of pediatric emergency medicine physicians from Texas Children's Hospital.

This document was

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    The following authors reported no actual or potential conflicts of interest in relation to this document: Jimmy C. Lu, MD, FASE, Alan Riley, MD, FASE, Thomas Conlon, MD, Jami C. Levine, MD, Charisse Kwan, MD, Wanda C. Miller-Hance, MD, FASE, Neha Soni-Patel, MEd, RCCS, RDCS, FASE, and Timothy Slesnick, MD, FASE.

    No authors reported relationships with one or more commercial interests.

    Endorsed by the Society of Critical Care Medicine

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