Executive Summary: Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024

Critical care ultrasonography (CCUS) is point-of-care ultrasonography performed and interpreted by the treating clinician of critically ill patients, regardless of the hospital setting, to augment diagnosis, manage care, and guide invasive procedures (1). The role of CCUS as a diagnostic tool is well established, resulting in its rapid uptake throughout critical care medicine, where it is now commonly used at bedside. Despite the use of CCUS in everyday practice, we are uncertain of its effect on patient-important outcomes. This executive summary updates the previous guidelines on CCUS (2,3) by comparing clinical outcomes when using CCUS to those of usual care without CCUS in patients with cardiac arrest, septic shock, acute respiratory failure, volume management, and cardiogenic shock. The recommendations from these guidelines are the result of a diverse panel of experts systematically evaluating all available evidence to date (4–6). These recommendations assume that practitioners performing CCUS have appropriate equipment, training, and competency. These recommendations are meant to guide clinicians, although individual patient and practitioner characteristics must be factored into guideline implementation and should not solely replace a clinician’s judgment. For this focused update and systematic reviews, we developed five questions using the Population, Intervention, Control (Comparison), and Outcomes (PICO) framework. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is used to evaluate the certainty of evidence, and recommendations are made using the evidence-to-decision framework (7). The strength of each recommendation is designated as strong (signified by “we recommend”) or conditional (signified by “we suggest”). A summary of all recommendations is provided in Figure 1. In the executive summary below, we will highlight key recommendations from the PICO questions. A full description of the recommendations is provided in the complete guidelines document Additionally, Supplemental Contents 1-9 (http://links/lww.com/CCM/H630) can be accessed digitally for further clarificaiton.Figure 1.: Infographic summary of recommendations. CCUS = critical care ultrasonography, SCCM = Society of Critical Care Medicine.CCUS IN PATIENTS WITH SEPTIC SHOCK Recommendation We suggest using CCUS in the management of adults with septic shock to improve clinical outcomes (Conditional Recommendation, For; Low Quality of Evidence). Remark Although we observed a small benefit of mortality in patients with septic shock, it is possible that CCUS may offer more benefit in some patients compared with others. In septic patients where volume responsiveness is in question, there may be greater value in CCUS. Rationale Compared with usual care, CCUS may reduce mortality (low certainty), but there is little to no difference in the receipt of renal replacement therapy and ICU length of stay (both low certainty). Given the small reduction in mortality, the panel believes that the benefits of using CCUS likely outweigh the adverse effects. This is a weak recommendation, recognizing involvement of other factors such as resourcefulness to obtain ultrasound machines and proper training. Special Considerations The role of CCUS for guiding vasopressors and inotropes is not as clear, although CCUS can be useful in patients with underlying septic cardiomyopathy or those without a definitive characterization of shock. At present, there is no consensus on thresholds for initiating or titrating inotropes, vasopressors, or other adjunctive therapies in sepsis based on echocardiographic or ultrasound findings (8,9). The evidence indicates that the implementation of various CCUS modalities can effectively guide volume management in septic patients. CCUS IN PATIENTS WITH ACUTE DYSPNEA OR RESPIRATORY FAILURE Recommendation We suggest using CCUS to aid with diagnoses and to guide the management of adults with acute dyspnea or acute respiratory failure to improve clinical outcomes (Conditional Recommendation, For; Low Quality of Evidence). Remark The role of CCUS for diagnosis in patients with acute dyspnea or acute respiratory failure is viewed as a patient-relevant outcome because of the potential variations in etiology and the necessity for tailored therapies in such cases. In situations where the diagnosis is unequivocal, CCUS may not be as beneficial, although it still may offer other utility in ventilator management. Rationale The reduction in duration of mechanical ventilation, time to reach correct diagnosis and treatment, and the absence of increased adverse outcomes supports our suggestion to use CCUS in these patients, albeit with low certainty. CCUS may be more valuable in settings with limited access to conventional radiographic tests, such as during the COVID-19 pandemic or in resource-limited settings (10,11). In addition to diagnosis, CCUS can guide management of patients with acute dyspnea or respiratory failure, both with respect to diuresis and ventilator management (12,13). Special Considerations At present, it is unclear whether any specific CCUS protocol should be used. For example, CCUS was associated with shorter duration of mechanical ventilation when Salem et al (12) used lung ultrasound to titrate positive end-expiratory pressure compared with the Acute Respiratory Distress Syndrome Network standard protocol and demonstrated improved mortality and reduced duration of mechanical ventilation. Xia et al (14) assessed lung and diaphragm to gauge appropriateness for liberation from mechanical ventilation, while Pradhan et al (15) monitored patients with CCUS to evaluate for ventilator associated pneumonia. Studies in this area could help clarify and standardize approaches. CCUS FOR TARGETED VOLUME MANAGEMENT Recommendation We suggest the use of CCUS for targeted volume management compared with usual care without CCUS in acutely ill adult patients to improve clinical outcomes (Conditional Recommendation, For; Low Quality of Evidence). Rationale CCUS for targeted volume management may offer desirable effects with an observed decrease in mortality. This evidence is limited by indirectness, given both the varied designs and use of ultrasound by the individual studies. Although our systematic review finds that CCUS may reduce fluid balance, this should be interpreted contextually. With the publication of the CLASSIC and CLOVERS trials (16,17), it is evident that an isolated measure of fluid balance is not sufficient to make overarching conclusions. Some patients may benefit from more fluids and some from less (12,13). These findings, the lack of data to suggest that CCUS has undesirable effects, and the indirect evidence that a personalized approach to fluid management may be beneficial, informs our recommendation. Special Considerations CCUS is only one component of a multifaceted approach to determination of volume status. Much like clinical decision-making, CCUS is also prone to error, particularly in unskilled hands. The evidence shows that a variety of CCUS modalities can help target volume management. CCUS IN PATIENTS WITH CARDIOGENIC SHOCK Recommendation We suggest the use of CCUS compared with usual care without CCUS in adults with cardiogenic shock to improve clinical outcomes (Conditional Recommendation, For; Very Low Quality of Evidence). Remark Usual care in cardiogenic shock patients may include the use of a pulmonary artery catheter (PAC). CCUS can provide comparable information to that of a PAC, with the added advantages of portability, and superior safety profile. CCUS may provide further usefulness for certain patients who already have a PAC. Rationale Despite the lack of evidence showing a clear benefit of CCUS use for patients with cardiogenic shock, the panel made a conditional recommendation for its use due to the minimal adverse events with the use of CCUS and the undesirable effects of its alternatives (i.e., PAC). CCUS including transthoracic echocardiography (TTE) is noninvasive and more cost-effective when compared with PAC (18). CCUS involving transesophageal echocardiography (TEE) while invasive has overall low complication rates (19–23). In contrast, PACs can be associated with adverse events and data misinterpretation (24–26) but can be useful for cardiogenic shock patients receiving mechanical circulatory support or following heart transplantation (27–29). Considering these points, we suggest the use of CCUS over no use in patients with cardiogenic shock, including those who already have a PAC (30). Special Considerations CCUS is often used to diagnose cardiogenic shock and is routinely used in the management of these patients, despite lack of strong evidence supporting its use. It remains unclear whether patients receiving standard care were referred for consultative echocardiography (TTE or TEE performed by the echo laboratory team) during their treatment. These studies did not specifically compare CCUS and consultative echocardiography. Future studies comparing CCUS to PACs for the management of cardiogenic shock patients will be informative. CONCLUSIONS This focused guideline reviews the effect of CCUS vs. usual care without CCUS on patient-important outcomes. A few important areas where new CCUS data can guide best practices include: 1) randomized trials in septic shock using protocolized CCUS care for targeted volume management, 2) randomized trials comparing CCUS management and PAC management of cardiogenic shock, especially with practitioners appropriately trained in both modalities, and 3) the use of artificial intelligence to improve image acquisition, accuracy, and reproducibility of CCUS between users to improve clinical outcomes. An intentional research agenda for CCUS is paramount. ACKNOWLEDGMENTS The guidelines leadership would like to acknowledge Society of Critical Care Medicine staff, Hariyali Patel, and American College of Critical Care Medicine Board of Regents Dr. Lori Shutter, Dr. Karin Reuter-Rice, and Dr. Ana Lia Graciano for project management support throughout the guidelines-development process. Furthermore, we thank Kaitryn Campbell for developing the electronic search strategies, Karin Dearness for peer-review of search strategies, and Payal Jain, João Lima, Ali Moinuddin, Joshua Piticaru, Monica Sabbineni, Natasha Ovtcharenko, Irene Armanious, Jose Estrada-Codecido, Laiya Carayannopoulos, Holden Flindall, and Brian Tang for assisting with the systematic review.

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