Overview of point-of-care ultrasound and functional echocardiography training programs in India

INTRODUCTION

Point-of-care ultrasound (POCUS) and functional echocardiography (fECHO) are increasingly being used in neonatal intensive care units (NICUs) and pediatric intensive care unit across the world, including in India.^[1,2] As per a recent survey of clinicians, there is a lack of structured training and guidelines for its use across India. Moreover, there is a limited availability of trained personnel conducting supervised training and strict legislation related to ultrasound (US) use which are major barriers to its implementation.^[3] There was a recommendation for accredited training programs and standardized guidelines which need to be established for the safer use of POCUS/fECHO in India. POCUS can potentially improve patient care and outcomes, reduce unnecessary testing and procedures, and enhance the efficiency of care delivery. In this review article, we will explore the current use of POCUS/fECHO in NICUs in India, its benefits and limitations, and the challenges associated with its implementation.

BENEFITS OF POCUS IN NICUS

The use of POCUS in NICUs in India has several benefits. First, it provides real-time imaging, which can be used to guide clinical decision-making and reduce the need for additional diagnostic tests. Second, POCUS is non-invasive and does not expose the neonate to ionizing radiation, which is a concern with traditional imaging modalities such as X-rays and CT scans. Third, POCUS can be used at the bedside, reducing the need to transport critically ill neonates and improving care delivery efficiency.

With the increasing interest in POCUS, a need for formal training of neonatologists and pediatric intensivists has arisen. Internationally, Certificate of clinicians performed Ultrasound (CCPU)^[4] by Australian society of ultrasound medicine (ASUM) was one of the early structured training programs followed by targeted neonatal echocardiography^[5] training in Canada. Surveys in UK and Europe evaluated and confirmed the need for neonatologist performed echocardiography (NPE) training.^[6] Formal guidelines were laid down and consensus statements were published by various groups such as NPE/NoPE for structured training in UK and Europe and a more unified approach to performing hemodynamic assessment of newborns.^[7,8] In India, national bodies like national neonatology forum and Indian academy of pediatrics are promoting regular POCUS workshops in annual conferences and many institutes are now conducting individual workshops/courses at a local level or in collaboration with international groups. There are a few programs in India developed by leaders in the field for online training for POCUS, some of which offer limited hands-on training. Thus overall training opportunities are increasing but there is a lack of unified structure for training, guidelines for its use, competency requirements, and national certification for training which will cover legal requirements.

NEONATAL fECHO

fECHO training is a specialized training program designed to teach healthcare professionals how to perform and interpret fECHO exams. fECHO is a non-invasive technique that uses US imaging to evaluate the function of the heart and its blood flow. It is commonly used in critical care settings to assess the hemodynamic status of patients, particularly those with shock, cardiac arrest, or other critical illnesses. The training program for fECHO typically includes both theoretical and practical components. The theoretical component covers the principles of US physics, cardiac anatomy and physiology, hemodynamic monitoring, and interpretation of fECHO findings. The practical component involves hands-on training on how to acquire and interpret fECHO images, as well as how to integrate fECHO findings into clinical decision-making.

Following are the general steps one could take to get formally trained for fECHO:

OTHER ORGAN ULTRASOUND

Beyond the heart, POCUS extends to:

1. Acute head US to exclude cerebral/intraventricular hemorrhage and ischemic injury to brain

2. Abdominal and thoracic US to diagnose perforation, abnormal fluid, and early changes of necrotizing enterocolitis (NEC)

3. Bladder Ultrasound to confirm urine before supra-pubic aspiration

4. Screening of the entry points of the inferior vena cava and superior vena cava into the heart can exclude an intra-cardiac line tip position. US allows real time localization of UVC tip position during insertion.^[30]

5. Confirmation of ECMO cannula

6. There is an evolving use of lung US to diagnose a range of pulmonary conditions for early diagnosis and decision for surfactant administration for respiratory distress syndrome^[31] and transient tachypnea of newborn.^[32] Moreover, Lung US is also useful for bedside diagnosis of pneumothorax, pleural effusions, pneumonia/ consolidation, and changes in chronic lung disease (Bronchopulmonary dysplasia)

7. Newer techniques like US-guided endotracheal tube placement and assessing thickness of optic nerve are also practiced more in the NICUs.

CHALLENGES IN IMPLEMENTING POCUS IN INDIA

The implementation of POCUS in NICUs in India is not without challenges. First, there is a shortage of trained personnel who can perform POCUS. Second, there is a lack of standardized protocols and guidelines for the use of POCUS in NICUs. Third, there is a need for adequate infrastructure, such as appropriate equipment and facilities, to support the use of POCUS.

At Bai Jerbai Wadia Hospital for Children, we have designed and developed a structured program for formal training and certification of fECHO and POCUS. The program has a set curriculum offering a series of online and classroom lectures, observed and supervised hands-on ECHOs in the NICU, and Echo Lab-Pediatric cardiology outpatient department.

Trainees need to gain an understanding of the skills required to obtain echo images using standard views in the newborn, segmental sequential scanning, and also identifying normal anatomy (pattern recognition). Bedside discussion on interpretations of images and translation of information to clinical decision-making is an important part of program. To experience a variety of clinical scenarios and to achieve the learning objectives within the curriculum, trainees will be expected to perform a minimum of 100–150 fECHOs/ POCUSs and maintain a logbook.

CONCLUSION

POCUS and fECHO are an emerging technology that has the potential to improve patient care and outcomes in NICUs in India. Its use is increasing, particularly in tertiary care hospitals, but there are still challenges that need to be addressed. The development of standardized protocols and guidelines, increased availability of trained personnel, and adequate infrastructure are necessary for the effective implementation of training of POCUS in NICUs in India.