I am disastrously late this week… Mea culpa :-( Quite ambitious though – to tickle those amazing neonatal and pediatric critical care SonoSenses! While rather advanced, the idea is to stimulate the reflection and interest – cranial sonography and transcranial Dopplers.
Furthermore, I decided to share the weekly journal club articles chosen by the SickKids SonoTeam from Toronto! They have one of the most amazing pediatric ultrasound programs in the world! Check out the last two papers and stay tuned for future info on online journal clubs offered by this brilliant group led by Jason Fischer, Charisse Kwan and Mark Tessaro!
Pediatr Crit Care Med. 2014 Jul 28. [Epub ahead of print]
Transcranial Doppler-Based Assessment of Cerebral Autoregulation in Critically Ill Children During Diabetic Ketoacidosis Treatment.
Ma L1, Roberts JS, Pihoker C, Richards TL, Shaw DW, Marro KI, Vavilala MS.
Impaired cerebral autoregulation may be associated with poor outcome in diabetic ketoacidosis. We examined change in cerebral autoregulation during diabetic ketoacidosis treatment.
Prospective observational cohort study.
Tertiary care children’s hospital.
Children admitted to the ICU with diabetic ketoacidosis (venous pH < 7.3, glucose > 300 mg/dL, HCO3 < 15 mEq/L, and ketonuria) constituted cases, and children with type I diabetes without diabetic ketoacidosis constituted controls.
MEASUREMENTS AND MAIN RESULTS:
Between 2005 and 2009, 32 cases and 50 controls were enrolled. Transcranial Doppler ultrasonography was used to measure middle cerebral artery flow velocities, and cerebral autoregulation testing was achieved via tilt-table testing. Cases underwent two and controls underwent one cerebral autoregulation test. Cerebral autoregulation was quantified by the autoregulatory index (autoregulatory index < 0.4 = impaired and autoregulatory index 0.4-1.0 = intact autoregulation). The first autoregulation test was obtained early (time 1, 12-24 hr; median [interquartile range], 8 hr [5-18 hr]) during diabetic ketoacidosis treatment, and a second autoregulation test was obtained during recovery (time 2, 36-72 hr; median [interquartile range], 46 hr [40-59 hr]) from time 0 (defined as time of insulin start). Cases had lower autoregulatory index at time 1 than time 2 (p < 0.001) as well lower autoregulatory index than control subjects (p < 0.001). Cerebral autoregulation was impaired in 40% (n = 13) of cases at time 1 and in 6% (n = 2) of cases at time 2. Five cases (17%) showed persistent impairment of cerebral autoregulation between times 1 and 2 of treatment. All control subjects had intact cerebral autoregulation.
Impaired cerebral autoregulation was common early during diabetic ketoacidosis treatment. Although the majority improved during diabetic ketoacidosis treatment, 17% of subjects had impairment between 36 and 72 hours after start of insulin therapy. The observed impaired cerebral autoregulation appears specific to the diabetic ketoacidosis process in patients with type I diabetes.
PMID: 25072475 [PubMed - as supplied by publisher]
Curr Pediatr Rev. 2014;10(1):16-27.
Cranial Ultrasound – Optimizing Utility in the NICU.
Wezel-Meijler Gv, de Vries LS1.
Cranial ultrasonography (cUS) is a reliable tool to detect the most frequently occurring congenital and acquired brain abnormalities in full-term and preterm neonates. Appropriate equipment, including a dedicated ultrasound machine and appropriately sized transducers with special settings for cUS of the newborn brain, and ample experience of the ultrasonographist are required to obtain optimal image quality. When, in addition, supplemental acoustic windows are used whenever indicated and cUS imaging is performed from admission throughout the neonatal period, the majority of the lesions will be diagnosed with information on timing and evolution of brain injury and on ongoing brain maturation. For exact determination of site and extent of lesions, for detection of lesions that (largely or partially) remain beyond the scope of cUS and for depiction of myelination, a single, well timed MRI examination is invaluable in many high risk neonates. However, as cUS enables bedside, serial imaging it should be used as the primary brain imaging modality in high risk neonates.
PMID: 25055860 [PubMed - in process]
Eur J Radiol. 2014 May 10. pii: S0720-048X(14)00235-6. doi: 10.1016/j.ejrad.2014.04.033. [Epub ahead of print]
Paediatric and particularly neonatal neurosonography still remains a mainstay of imaging the neonatal brain. It can be performed at the bedside without any need for sedation or specific monitoring. There are a number of neurologic conditions that significantly influence morbidity and mortality in neonates and infants related to the brain and the spinal cord; most of them can be addressed by ultrasonography (US). However, with the introduction of first CT and then MRI, neonatal neurosonography is increasingly considered just a basic first line technique that offers only orienting information and does not deliver much relevant information. This is partially caused by inferior US performance – either by restricted availability of modern equipment or by lack of specialized expertise in performing and reading neurosonographic scans. This essay tries to highlight the value and potential of US in the neonatal brain and briefly touching also on the spinal cord imaging. The common pathologies and their US appearance as well as typical indication and applications of neurosonography are listed. The review aims at encouraging paediatric radiologists to reorient there imaging algorithms and skills towards the potential of modern neurosonography, particularly in the view of efficacy, considering growing economic pressure, and the low invasiveness as well as the good availability of US that can easily be repeated any time at the bedside.
Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
PMID: 24890085 [PubMed - as supplied by publisher]
Am J Emerg Med. 2014 Apr 18. pii: S0735-6757(14)00267-8. doi: 10.1016/j.ajem.2014.04.023. [Epub ahead of print]
Acute pediatric stroke-what’s the hurry? A case for emergency physician-performed echocardiography.
Thom CD1, Sparks SE2.
No abstract available – though a great case report – try to look it up!
PMID: 24856752 [PubMed - as supplied by publisher]
J Pediatr. 2014 Jul;165(1):78-84.e2. doi: 10.1016/j.jpeds.2014.02.055. Epub 2014 Apr 13.
Ultrasonography of the colon in pediatric ulcerative colitis: a prospective, blind, comparative study with colonoscopy.
Civitelli F1, Di Nardo G1, Oliva S1, Nuti F1, Ferrari F1, Dilillo A1, Viola F1, Pallotta N2, Cucchiara S1, Aloi M3.
To evaluate the usefulness of colonic ultrasonography (US) in assessing the extent and activity of disease in pediatric ulcerative colitis (UC) and to compare US findings with clinical and endoscopic features.
Consecutive pediatric patients (n = 60) with a diagnosis of UC and suspected disease flare-up were prospectively enrolled; of these, 50 patients were eligible for the study. All underwent clinical evaluation, bowel US with color Doppler examination and colonoscopy. Blind US was performed the day before endoscopy in all patients. The US assessed variables were bowel wall thickness >3 mm, bowel wall stratification, vascularity, presence of haustra coli, and enlarged mesenteric lymph nodes.
The endoscopic extent of disease was independently confirmed in 47 patients by US that yielded a 90% concordance with endoscopy (95% CI 0.82-0.96). Multiple regression analysis showed that US measurements with an independent predictive value of severity at endoscopy were increased bowel wall thickness (P < .0008), increased vascularity (P < .002), loss of haustra (P = .031), and loss of stratification of the bowel wall (P = .021). Each variable was assigned a value of 1 if present. The US score strongly correlated with clinical (r = 0.94) and endoscopic activity (r = 0.90) of disease (P < .0001).
Colonic US is a useful first line noninvasive tool to assess the extent and activity of disease in children with UC and to estimate the severity of a flare-up, prior to further invasive tests.
PMID: 24725581 [PubMed - in process]