Focused Cardiac Ultrasound in the Pediatric Perioperative Setting

Karen R. Boretsky, MD; David B. Kantor, MD, PhD; James A. DiNardo, MD; Achikam Oren-Grinberg, MD


Anesth Analg. 2019;129(4):925-932. 

In This Article

Abstract and Introduction


Focused cardiac ultrasonography (FoCUS) has become an important diagnostic tool for acute care physicians. FoCUS allows real-time visualization of the heart and, in combination with the physical examination, acts as a hemodynamic monitor to manage patient care in acute situations. Most of the available perioperative literature has focused on adult patients. Little has been published on the perioperative application of FoCUS for pediatric patients. This article provides an overview of FoCUS used at the bedside by pediatric anesthesiologists. Variations in clinical applications, technical aspects, and interpretation of FoCUS findings in children are described. Discussion of training and competency is included. Barriers to implementation by pediatric intensivists and emergency medicine physicians include a lack of understanding of indications and training opportunities in pediatric FoCUS. It is likely that similar barriers exist in pediatric anesthesiology resulting in underutilization of FoCUS. The use of FoCUS in the pediatric operating room, however, may positively impact care of infants and children and should be encouraged.


Bedside transthoracic focused cardiac ultrasonography (FoCUS) has become an important diagnostic tool for acute care physicians including anesthesiologists.[1–7] FoCUS allows real-time visualization of cardiac structures, and information is utilized to guide patient care. In adult patients, FoCUS is used in the emergency department, critical care units, and in perioperative setting to aid in diagnosis and treatment of cardiovascular and respiratory critical states.[6–13] However, published descriptions of use of FoCUS in pediatric patients are scarce.[14] While standardized FoCUS windows and views, as described for adult patients, are utilized for infants and children, the unique aspects of FoCUS related to pediatric patients warrant discussion.

FoCUS is not a replacement for echocardiography performed and interpreted by a cardiologist. It provides limited and simple cardiac ultrasound views,[2,6,13,15,16] and the examination is immediate, noninvasive, and problem oriented. It is repeatable, performed at the bedside, and, unlike chest x-rays, does not expose patients to ionizing radiation. For the acute care provider, the FoCUS examination provides quick, qualitative answers to straightforward questions with yes/no answers to acute hemodynamic conditions. The FoCUS examination provides visual assessment of the beating heart and provides the ability to qualitatively evaluate the size of the cardiac chambers, thickness of the walls, ventricular function, intracardiac volume status, and the presence of pericardial effusion or air emboli.[6,11,13,17] The information is basic, as compared to the detailed anatomical and physiologic assessments performed by pediatric cardiologists and cardiac anesthesiologists, and the information provides key insights immediately relevant to patient management. Importantly, FoCUS favors specificity over sensitivity, such that unambiguous findings provide information useful for patient care, while any uncertainty should prompt consultation. Currently, the most common indication for FoCUS in pediatric patients is undifferentiated hypotension or tachycardia unresponsive to routine interventions and cardiac arrest.[13,18] FoCUS is currently widely used in adult and pediatric emergency medicine and intensive care departments with documented reductions in diagnostic delays, improved guidance of clinical decisions, and improvement of patient care.[4,19–25] The American Society of Echocardiography supports the use of FoCUS for acute care providers and has provided guidelines.[2,26]

Given the number of congenital heart anomalies in this population, it is important to understand that FoCUS has very limited applications in patients with congenital heart disease (CHD).[15] The FoCUS examination in CHD patients is limited to identification of acute conditions (pericardial effusion, air embolus) and assessment of global myocardial function rather than further delineation of existing structural anomalies. Any interpretation of FoCUS images involving children with CHD should be undertaken cautiously and a formal cardiology consult obtained as soon as possible. This narrative review of pediatric FoCUS excludes discussion and consideration of patients with CHD.

Barriers to general adoption of pediatric FoCUS in the perioperative environment are likely similar to those barriers identified in pediatric emergency medicine and include lack of clear indications, performance expectations, and availability of high-quality, organized, and readily accessible training.[18,27]