Guidelines Procedures Quality and Patient Safety

Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024

José L. Díaz-Gómez, MD, MAS, NCC (UCNS), FASE, FCCM Sara Nikravan, MD, FASE, FCCM

PUBLISHED: 02/21/2025

Guidelines on Adult Critical Care Ultrasonography: Focused Update 2024

Citation: Diaz-Gomez JL, Sharif S, Ablordeppey E, et al. Society of Critical Care Medicine guidelines on adult critical care ultrasonography: focused update 2024. Crit Care Med. 2025;53(2):e447-e458.

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Critical care ultrasonography (CCUS) is rapidly evolving with new evidence since the publication of the 2016 guidelines. This focused update provides current evidence to assist clinicians in performing CCUS in five essential clinical scenarios: cardiac arrest, sepsis, acute dyspnea/respiratory failure, volume management, and cardiogenic shock.

In adult patients with septic shock, acute dyspnea/respiratory failure, or cardiogenic shock, the guidelines panel suggests using CCUS to guide management. Given evidence supporting an improvement in mortality, the guideline panel suggests the use of CCUS for targeted volume management as opposed to usual care without CCUS. There were insufficient data to determine whether CCUS should be used over standard care without CCUS in the management of patients with cardiac arrest.

Guideline Type: Clinical

Visual Abstract: Guidelines on Adult Critical Care Ultrasonography

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We suggest either using CCUS or usual care without CCUS to guide management of adult patients in cardiac arrest.
Quality of evidence: Very low

Conditional For or Against Cardiac arrest

We suggest using CCUS in the management of adults with septic shock to improve clinical outcomes.
Quality of evidence: Low

Remarks

Although we observed a small benefit of mortality in these patients, it is possible that CCUS may offer more benefit in some patients compared with others. These studies used different CCUS protocols at different points in the patients’ resuscitation. For example, patients in the most favorable study had received around 3 L less crystalloid than patients in the least favorable study. CCUS can rapidly inform on alternative diagnoses and guidance of fluid administration. Although fluid administration remains a cornerstone of sepsis management, CCUS might offer less benefit in patients who are already hemodynamically optimized at the time of imaging. In septic patients where volume responsiveness is in question, there may be greater value in CCUS (see Recommendation 4).

Conditional For Septic shock

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.
Quality of evidence: Low

Conditional For Acute dyspnea Acute respiratory failure

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.
Quality of evidence: Low

Conditional For Acutely ill adults

We suggest the use of CCUS compared with usual care without CCUS in adults with cardiogenic shock to improve clinical outcomes.
Quality of evidence: Very low

Remarks

Usual care in cardiogenic shock patients often involves the use of a pulmonary artery catheter (PAC). Although PAC and CCUS require proficiency in their utilization, CCUS provides comparable information to a PAC, which is portable and has a better safety profile. However, some patients may benefit from both a PAC and CCUS for management, particularly for volume management and titration of inotropic support (D/E cardiogenic shock defined as patients in a critically deteriorating state with cardiogenic shock by the Society for Cardiovascular Angiography & Intervention, post-cardiotomy shock, and those requiring mechanical circulatory support.

Conditional For Cardiogenic shock

CCUS = critical care ultrasonography.

Author

José L. Díaz-Gómez, MD, MAS, NCC (UCNS), FASE, FCCM

José L. Díaz-Gómez, MD, MAS, NCC (UCNS), FASE, FCCM, is the institute chair, critical care at Cleveland Clinic Abu Dhabi. His immediate previous position was chief of cardiothoracic, mechanical circulatory support, and transplant critical care at the Texas Heart Institute at Baylor St. Luke's Medical Center in Houston, Texas, USA.

Author

Sara Nikravan, MD, FASE, FCCM

Sara Nikravan, MD, FASE, FCCM, is the vice-chair of education and former director of point-of-care ultrasound at the University of Washington in Seattle, Washington, USA. She is a past chair of SCCM’s Adult Ultrasound Committee, Critical Care Ultrasound Course, and Critical Care Echocardiography Review course. She is coeditor of the Comprehensive Critical Care Ultrasound, 2nd edition, textbook.

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