Clinical Progress Note: Point-of-Care Ultrasound for the Pediatric Hospitalist

The recent designation of Pediatric Hospital Medicine (PHM) as a board-certified subspecialty has provided the opportunity to define which skills are core to hospitalist practice. One skill that is novel to the field and gaining traction is point-of-care ultrasonography (POCUS). POCUS differs from traditional ultrasonography in that it is performed at the bedside by the primary clinician and aims to answer a focused clinical question (eg, does this patient have a skin abscess?) rather than to provide a comprehensive evaluation of the anatomy and physiology. The proposed advantages of POCUS include real-time image interpretation, cost savings, procedural guidance to minimize complications, and reduction of ionizing radiation. Although specialties such as Critical Care (CC) and Emergency Medicine (EM) have integrated POCUS into their practice and training, best practices in PHM have not been defined. This Progress Note is a summary of recent evidence to update past reviews and set the stage for future PHM POCUS research and education.

We met with an academic librarian in March 2019 and performed a search of PubMed using Medical Subject Headings (MESH) terms associated with POCUS as well as Pediatrics. We limited our search to studies published within the past five years. The search was originally focused to the field of PHM before expanding to a broader search since very few studies were found that focused on Hospital Medicine or general pediatric ward populations. This initial search generated 274 publications. We then performed a supplemental literature search using references from studies found in our initial search, as well as further ad hoc searching in Embase and Google Scholar.

After our literature search, we reviewed the PHM core competencies and identified the common clinical diagnoses and core skills for which there is POCUS literature published in the past five years. These included acute abdominal pain, bronchiolitis, pneumonia, skin and soft tissue infection, newborn care/delivery room management, bladder catheterization, fluid management, intravenous access, and lumbar puncture (LP). We chose to focus on one skill and two diagnoses that were generalizable to pediatric hospitalists across different settings and for which there was compelling evidence for POCUS use, such as pneumonia, skin abscess, and LP. We found few studies that included general pediatric ward patients, but we considered EM and CC studies to be relevant as several pediatric hospitalists practice in these clinical settings and with these patient populations.

POCUS can be useful for diagnosing pneumonia by direct visualization of lung consolidation or by identification of various sonographic artifacts that suggest pathology. For example, “B-lines” are vertical artifacts that extend from the pleura and suggest interstitial fluid or pneumonia when they are present in abnormally high numbers or density. POCUS can also be used to diagnose parapneumonic effusions by scanning dependent areas of the lung (eg, the diaphragm in children sitting upright) and looking for anechoic or hypoechoic areas.