Yasser Elsayed1, Muzafar Gani Abdul Wahab2, Adel Mohamed3, Nadya Ben Fadel4, Shazia Bhombal5, Nadya Yousef6, María V Fraga7, Jehier Afifi8, Pradeep Suryawanshi9, Abbas Hyderi10, Anup Katheria11, Martin Kluckow12, Daniele De Luca2,13, Yogen Singh14,15. 1. Section of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada. 2. Section of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada. 3. Department of Pediatrics, University of Toronto, Toronto, Canada. 4. Department of Pediatrics, University of Ottawa, Ottawa, Canada. 5. Department of Pediatrics, Division of Neonatal and Behavioral Medicine, Stanford University School of Medicine, Palo Alto, CA, USA. 6. Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Centre, APHP - Paris Saclay University Hospitals, Paris, France. 7. Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA. 8. Department of Pediatrics, Division of Neonatal Perinatal Medicine, Dalhousie University, Halifax, NS, Canada. 9. Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, Maharashtra, India. 10. Department of Pediatrics, Division of Neonatology, University of Alberta, Edmonton, Canada. 11. Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA. 12. Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, Australia. 13. Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France. 14. Department of Pediatrics, Division of Neonatology, School of Clinical Medicine, Loma Linda University, Loma Linda University Children's Hospital, Campus Street Coleman Pavillion, Loma Linda, CA, 11175, USA. drsinghy@gmail.com. 15. Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. drsinghy@gmail.com.
Abstract
Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a "crashing" neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention. Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained "crashing" neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.
Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a "crashing" neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention. Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained "crashing" neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.
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Authors: Anthony Y B Teoh; Vinay Dhir; Mitsuhiro Kida; Ichiro Yasuda; Zhen Dong Jin; Dong Wan Seo; Majid Almadi; Tiing Leong Ang; Kazuo Hara; Ida Hilmi; Takao Itoi; Sundeep Lakhtakia; Koji Matsuda; Nonthalee Pausawasdi; Rajesh Puri; Raymond S Tang; Hsiu-Po Wang; Ai Ming Yang; Robert Hawes; Shyam Varadarajulu; Kenjiro Yasuda; Lawrence Khek Yu Ho Journal: Gut Date: 2018-02-20 Impact factor: 23.059