Thank you to Dr El-Sayed for providing slides and a great deal of guidance in developing this post!
I am too young a Neonatologist to recall some of the changes in practice that would be considered giant leaps in my field. Provision of antenatal steroids to accelerate lung maturity, development of ventilators and provision of surfactant to premature infants have saved millions of lives the world over and reduced morbidities from the conditions they were designed to treat.
I believe we are embarking on another such tidal wave of change that is beginning to take shape and will come crashing into the shores of our practices globally before long. What makes it all the more exciting is that I have a front row seat to view the birth of this development. The story begins over a decade ago with the understanding that traditional echocardiograms as performed by a Cardiologist in some instances could not provide us as Neonatologists with enough information to guide clinical decision making. Let me state up front that the program I will be discussing would not be possible without the participation of our colleagues in Cardiology and moreover the information that they provide for many infants with congenital heart disease is critical to our practice. What I am referring to though are those instances where we are more interested in the flow of blood or the function of the heart in the presence of a structurally normal heart.
In Canada there is no doubt that Dr. Patrick McNamara has been a pioneer in the field of Targeted Neonatal Echocardiography (TNE) and has published extensively in the field. One such paper from 2009 highlights how TNE can be of use in the treatment of a PDA. TNE though has expanded in use to guide treatment of such conditions as PPHN with or without BPD, heart failure, shock and also point of care functions such as determination of line placements or intravascular clots. Additional work has been done by pioneers in Australia such as Nick Evans. We were very fortunate to have Dr. Yasser El-Sayed train under Dr. McNamara and then return to Winnipeg to develop our own clinical program for TNE in consultation with our colleagues in Pediatric Cardiology.
Since it’s inception here the program has been utilized extensively with clinical management in many cases influenced by the findings. We believe though that our program may be unique in the sense that the philosophy of using this technology is only as part of a larger framework as outlined in this figure. The program is known as Integrated Evaluation of Neonatal Hemodynamics (INEH). The concept is that we cannot rely on only one measure of cardiac performance or blood flow patterns. Rather it is through consideration of six separate streams of data that we can come to an accurate conclusion. For example a patient who is hypotensive as defined by a mean blood pressure lower than their gestational age but who has adequate cerebral blood flow as measured by Near Infrared Spectroscopy, normal SVC flow and contractility, as a measure of cardiac performance with a normal lactate and urine output, may need simple observation. Why treat with an inotrope if the end organs are not impaired in the least?
How do we accomplish this is practice? The integration is done by using data as shown in the next figure. Markers such as NIRS, lactate, BNP, indwelling arterial access, urine output all provide useful markers which are integrated to determine the best course of action.
I would like to provide an illustrative case. The patient in this presentation is one who developed hypoxic ischemic encephalopathy. If you read through the slides you will clearly see how the use of INEH brought about a significant change in the approach to the care of the infant. Without this information we would have continued to go down a treatment path which was not addressing the issues at hand appropriately. Please click on the link to view this presentation.
An infant with HIE and hypotension
I am proud to say that Dr. El-Sayed is spreading this message and approach globally having recently given workshops in Turkey and Egypt. We are also very excited that in the Fall from October 29th – 31st we will be hosting the 10th Annual Bowman Symposium featuring Neonatal Hemodynamics. For more information please click here.
The importance of this approach to Neonatal Care can not be emphasized enough. With so many needs in our Health Region it is difficult to always obtain enough funds to purchase all the equipment that one needs for a service. As such I was grateful to Dr. El-Sayed for presenting such need at a recent charitable event as shown below!
If you or someone you know is interested in this emerging field we would love to hear from you. If you would like to attend the Bowman Symposium please contact us at:
or email to:
Iam thankful to Dr. Yasser wonderful course in Egypt, he left us all waiting for his next visit, trying to apply his fantastic simple hemodynamic principles in managing ill neonate
Thank you so much Dr El-Sayed for being a pioneer in our city for initiating neonatal targeted echo programme. The course and things we have learned from you were excellent and also quality was very high. Looking on your next visit to Turkey.
All the best
Dr. Hanifi Soylu, MD, MSc