Phil Arnold, MD
On the use of Sonosite ultrasound for paediatric cardiac anaesthesia in developing nations
Congenital heart disease is one of the most common forms of birth defect, affecting about one in 145 births in the UK or 4,600 babies every year1. About a third of these patients will require surgery, often early in life. Once performed, surgery can be effectively curative in many cases, the majority of these children will not require further surgery and be off all medications within a short period. Some children with more complex conditions will require medical treatment and follow up for much of their lives and may need further surgeries. In the UK around 5,000 heart operations are conducted for congenital heart disease each year and a further 4000 interventions are performed in children in catheter rooms (about 800,000 babies are born each year in the UK)2.
In countries with less developed health systems, access to diagnosis or treatment of such conditions can be extremely restricted. When resources are extremely stretched, other health issues will inevitably take priority, however as countries become better off and more funding is directed to health care, then a desire to provide vital surgery for children becomes an achievable aspiration. An issue then arises how such services can be developed safely and in a way which produces the best possible results. Cardiac surgery is complex and demanding: it demands high levels of skill and knowledge from the clinicians involved (surgeons, cardiologists, anaesthetists, perfusionists, intensivists and nurses), it requires infrastructure and it specialist equipment. This can be a challenge for parts of the world with no history of conducting these surgeries. To fill this gap a number of charities have been established which allow clinicians from richer countries to visit hospitals attempting to establish such services. Operations are performed on children who would have had no access to surgery, whilst local teams are built up to a level were they can sustain the service themselves. Clinicians at Alder Hey Hospital (Liverpool, UK) have worked with two such charities: the International Children’s Heart Foundation and Healing Little Hearts.
It is the author’s opinion that the development of portable high quality ultrasound machines has had a major impact on the practice of paediatric anaesthesia and in particular paediatric cardiac anaesthesia. In the UK we use these machines every day for placing lines (often in very small babies)3, for regional anaesthesia4 and for rapidly identifying important conditions such as pleural effusions. Because these machines are so portable, robust, and reliable we can take them to anywhere in the world and have confidence in them. In addition the versatility of these machines allows us to use them for other applications. In the first picture we are using a Sonosite MicroMaxx with a P10 probe to perform a precordial echocardiogram during surgery (placing the probe directly onto the heart inside a sterile cover). The child has a VSD, which is a hole between the two sides of the heart. Once the hole is closed the child would be expected to have a normal expectancy of life and should be symptom free. Ensuring the hole is properly closed whilst the child is still on the table ensures the best possible result. In the second picture we are using a Sonosite TITAN demonstrating to a paediatric anaesthetist in Morocco, the use ultrasound to place a central line in a small infant.
Because of the generosity of Sonosite in loaning machines for our use during these trips, we have been able to take them to many parts of the world (including India, Pakistan, China, Morocco, Ukraine). This has brought tangible benefits to patients and has always been met with interest by local clinicians. We have been able to demonstrate important anatomy and the benefits of ultrasound guided techniques for vascular access, nerve blocks, and diagnosis.
Dr. Phil Arnold is Consultant Paediatric Cardiac Anaesthetist and a Honorary Lecturer at the University of Liverpool. He practices at Alder Hey Children’s Hospital, Liverpool, UK.
References
1 BHF Congenital Heart Disease Statistics (2001-2003), www.heartstats.org, Table 1.1
2 Central Cardiac Audit Database UK 2008-2009 http://www.ccad.org.uk/congenital
3 Peter C. Murphy and Philip Arnold ‘Ultrasound-assisted vascular access in children’ BJA: Contin Educ Anaesth Crit Care Pain (2011) 11(2)
4 Rathi S, Raj N ‘Bilateral Paravertebral Blocks for Peadiatric Heart Surgey’ presented at APAGBI Annual Meeting 2011
On the use of Sonosite ultrasound for paediatric cardiac anaesthesia in developing nations
Congenital heart disease is one of the most common forms of birth defect, affecting about one in 145 births in the UK or 4,600 babies every year1. About a third of these patients will require surgery, often early in life. Once performed, surgery can be effectively curative in many cases, the majority of these children will not require further surgery and be off all medications within a short period. Some children with more complex conditions will require medical treatment and follow up for much of their lives and may need further surgeries. In the UK around 5,000 heart operations are conducted for congenital heart disease each year and a further 4000 interventions are performed in children in catheter rooms (about 800,000 babies are born each year in the UK)2.
In countries with less developed health systems, access to diagnosis or treatment of such conditions can be extremely restricted. When resources are extremely stretched, other health issues will inevitably take priority, however as countries become better off and more funding is directed to health care, then a desire to provide vital surgery for children becomes an achievable aspiration. An issue then arises how such services can be developed safely and in a way which produces the best possible results. Cardiac surgery is complex and demanding: it demands high levels of skill and knowledge from the clinicians involved (surgeons, cardiologists, anaesthetists, perfusionists, intensivists and nurses), it requires infrastructure and it specialist equipment. This can be a challenge for parts of the world with no history of conducting these surgeries. To fill this gap a number of charities have been established which allow clinicians from richer countries to visit hospitals attempting to establish such services. Operations are performed on children who would have had no access to surgery, whilst local teams are built up to a level were they can sustain the service themselves. Clinicians at Alder Hey Hospital (Liverpool, UK) have worked with two such charities: the International Children’s Heart Foundation and Healing Little Hearts.
It is the author’s opinion that the development of portable high quality ultrasound machines has had a major impact on the practice of paediatric anaesthesia and in particular paediatric cardiac anaesthesia. In the UK we use these machines every day for placing lines (often in very small babies)3, for regional anaesthesia4 and for rapidly identifying important conditions such as pleural effusions. Because these machines are so portable, robust, and reliable we can take them to anywhere in the world and have confidence in them. In addition the versatility of these machines allows us to use them for other applications. In the first picture we are using a Sonosite MicroMaxx with a P10 probe to perform a precordial echocardiogram during surgery (placing the probe directly onto the heart inside a sterile cover). The child has a VSD, which is a hole between the two sides of the heart. Once the hole is closed the child would be expected to have a normal expectancy of life and should be symptom free. Ensuring the hole is properly closed whilst the child is still on the table ensures the best possible result. In the second picture we are using a Sonosite TITAN demonstrating to a paediatric anaesthetist in Morocco, the use ultrasound to place a central line in a small infant.
Because of the generosity of Sonosite in loaning machines for our use during these trips, we have been able to take them to many parts of the world (including India, Pakistan, China, Morocco, Ukraine). This has brought tangible benefits to patients and has always been met with interest by local clinicians. We have been able to demonstrate important anatomy and the benefits of ultrasound guided techniques for vascular access, nerve blocks, and diagnosis.
Dr. Phil Arnold is Consultant Paediatric Cardiac Anaesthetist and a Honorary Lecturer at the University of Liverpool. He practices at Alder Hey Children’s Hospital, Liverpool, UK.
References
1 BHF Congenital Heart Disease Statistics (2001-2003), www.heartstats.org, Table 1.1
2 Central Cardiac Audit Database UK 2008-2009 http://www.ccad.org.uk/congenital
3 Peter C. Murphy and Philip Arnold ‘Ultrasound-assisted vascular access in children’ BJA: Contin Educ Anaesth Crit Care Pain (2011) 11(2)
4 Rathi S, Raj N ‘Bilateral Paravertebral Blocks for Peadiatric Heart Surgey’ presented at APAGBI Annual Meeting 2011