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As part of the accreditation process for echocardiography laboratories, the ICAEL sets forth basic standards for the performance of a pediatric transthoracic echocardiographic examination. As is stated in Section 3.2.1: Components of the Examination, a protocol must be in place that defines the components of the standard examination. Indication for performance of a complete and/or limited examination should be included. While the ICAEL Standards list the basic views, measurements and Doppler evaluations that, at a minimum, must be obtained, laboratory protocols vary. A protocol copied directly from a textbook or from the ICAEL Standards is not acceptable. The basic elements of a standard 2-D and Doppler examination must be included in every complete transthoracic examination. Laboratory staff members often seek guidance to ensure that their protocols meet the ICAEL requirements.

A laboratory's protocol must list the views to be obtained, the measurements obtained in those views and where color Doppler and/or spectral Doppler is obtained. When writing a protocol, it is important to specify in detailed steps the structure to be measured, the anatomic landmarks to be used and the part of the cardiac cycle in which the measurements should be taken. A list of the structures to be examined with each view is helpful and the required versus optional measurements should be clearly defined. There may be many "optional" views in a pediatric exam that are customized to the particular congenital lesion being addressed. While all of the ICAEL required components must be included within a protocol, it is crucial that the protocol be "laboratory specific." For example, many labs now routinely incorporate Doppler imaging of tissue velocities, including strain and strain rate imaging, color M-mode assessment of atrioventricular valve inflows and live 3-D images.

The pediatric echocardiogram differs from an adult echo exam in that there is a wide spectrum of anomalies that are encountered in patients with congenital heart disease. Certain views are of added importance for pediatric examinations, such as the subxiphoid and suprasternal notch views. The preferred method of display for the apical and subxiphoid views is with image apex "inverted" displaying the image apex at the bottom of the video screen (differing from an adult exam where the image apex is at the top of the screen). It is important to note this in the protocol because of the wide range of anatomic variations frequently seen in patients with congenital heart disease.

Part II, Section 3 of the ICAEL Standards details the components of a Pediatric Transthoracic Echocardiogram. When writing a protocol, laboratory staff are advised to review these standards to ensure that their protocols contain each component required. Since the ICAEL Standards are written for a pediatric "normal" study, complete sweeps of the heart should be made during the examination to rule out abnormalities. Therefore, the "normal" exam can be adapted for the abnormal congenital evaluation following orderly steps in the examination. It is with this standardized approach to following a written protocol that thorough evaluations are completed.

The protocol must also be written to be followed by a trained pediatric sonographer. A qualified sonographer who is new to a particular laboratory should be able to utilize the protocol to perform an echocardiogram in a consistent manner with each of the other sonographers in the laboratory. New sonographers or interns should use the protocol as their "teaching manual" to guide them through the proper steps for a complete exam. The protocol should not be a "how to" manual in instrument settings, knobology, or hardware or software issues. Rather, the protocol should be written to address the various unique qualities that a pediatric exam may entail, such as sedation of young patients and additional study time required for complicated anatomical studies. For example, in a child diagnosed with possible Kawasaki disease, very detailed views of the coronary arteries, which require additional scanning time, are employed.

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