Critical Care Ultrasonography in the Management of Cardiogenic Shock

• In ICU
• Wed, 20 Aug 2025

Despite recent advances, mortality in cardiogenic shock (CS) remains very high. Early diagnosis and proper management are crucial, especially given shifts in CS causes, from fewer myocardial ischaemia cases to more acute decompensated heart failure. The establishment of a consensus CS definition has improved clinical and research communication. 

Critical care ultrasonography (CCUS) plays a key role in diagnosing and managing CS. In a recent review, the authors liken their CCUS-based approach to a strategic chess game, where each diagnostic and management step (chess piece) must be tactically coordinated by the team to protect the patient (the king). 

Critical care echocardiography (CCE) is essential for confirming CS, determining intervention timing, guiding therapy choices, and monitoring treatment responses. It is likened to the “queen” in chess, flexible and pivotal in managing CS, because early basic CCE can accurately identify cardiac causes of shock, while advanced techniques provide detailed haemodynamic assessment and diagnosis of underlying conditions. CCE provides urgent, aetiology-based treatments, such as decisions on revascularisation, surgery, or advanced care transfers, and helps assess candidacy for mechanical support by identifying contraindications. It also detects mechanical complications like ventricular ruptures, guiding early multidisciplinary interventions. Serial CCE exams assist ongoing haemodynamic management, including fluid responsiveness and drug dosing, even though fluids are rarely needed in CS. Beyond CCE, CCUS includes other modalities like lung ultrasound and venous congestion assessment, offering a comprehensive evaluation of shock severity, with CCE remaining the sovereign tool in this multi-modality approach.

In managing CS, lung ultrasound (LUS) acts like the bishop in chess, subtle but powerful, complementing CCE. LUS accurately differentiates cardiac from non-cardiac causes of dyspnoea and quantifies pulmonary congestion and pleural effusions quickly and reproducibly at the bedside. Despite some challenges like lack of standardised scoring and protocol variability, combining LUS findings with CCE measures of left ventricular filling pressure strengthens CS diagnosis and guides treatment with vasoactive drugs, ventilation, and diuretics. Studies show that early use of LUS alongside echocardiography can predict in-hospital mortality and CS development in myocardial infarction patients. Overall, LUS is used early, easy to perform, and enhances the haemodynamic assessment led by the “queen” (CCE) and later the “rook” in this strategic management approach.

In managing CS, the “rook” symbolises invasive continuous cardiac output (CO) monitoring, a key tool in later, complex patient management. While not used immediately like the “queen” (CCE), invasive monitoring, such as pulmonary artery catheterisation (PAC) or transpulmonary thermodilution, provides crucial data that can alter treatment strategy. Though PAC use has declined, it remains recommended for patients unresponsive to initial therapies or with diagnostic uncertainty, and may reduce mortality based on observational studies. If PAC isn’t available, other invasive methods serve as alternative “rooks,” each with pros and cons. For example, transpulmonary thermodilution helps quantify lung oedema but can be unreliable in common CS conditions like low flow, shunts, or valve issues. Thus, the “rook” brings strategic power when employed appropriately in CS care.

In CS, arterial hypoperfusion worsens shock and multiorgan failure with high mortality. The “knight” in this context represents the assessment of arterial resistive index combined with venous congestion evaluation via Venous Excess Ultrasound. Like a knight’s ability to jump and reveal hidden threats, these Doppler assessments uncover haemodynamic patterns missed by standard monitoring. They help differentiate causes of organ hypoperfusion while acute heart failure decompensation shows high resistive index with high venous pulsatility. Although promising, this Doppler approach remains mostly studied in cardiac surgery, with knowledge gaps and unclear integration into routine intensive care. Interpretation is complex and skill-demanding, but when used properly, it offers powerful guidance, just like the knight’s unique moves on the chessboard.

CCE and LUS enable ongoing evaluation of therapeutic effectiveness and tolerance in CS, considering ventilation and medications. Positive pressure ventilation reduces left ventricular afterload but increases right ventricular afterload, requiring careful balance; CCE is ideal for monitoring these heart–lung interactions. Noradrenaline is the first-line vasopressor to restore blood pressure in persistent hypoperfusion, with CCUS complementing CCE assessments. Short-term inotropes are used only if hypoperfusion persists despite adequate volume, and CCE monitors their effectiveness and potential harms like LV outflow obstruction. Serial CCE and pulmonary artery catheter (PAC) data guide drug choice, dosing, and weaning. While CCE evaluates stroke volume generation and cardiac mechanics, PAC provides direct LV filling pressures and distinguishes types of pulmonary hypertension. Venous Doppler ultrasound adds insight into organ perfusion beyond arterial assessment.

Integrating CCUS, including CCE, with other haemodynamic and clinical data can help identify important patient subtypes (endotypes) that may respond differently to treatments. CCE enables early detection of clinical deterioration, distinguishing patients needing urgent advanced interventions like extracorporeal support or surgery from those unlikely to benefit. However, disparities in access to CCUS and education contribute to uneven CS care worldwide. Networking and telemedicine could improve management in less-equipped centres. Additionally, artificial intelligence (AI) applied to large CCUS and haemodynamic datasets holds promise for predicting deterioration and personalising treatment. 

Though currently a “pawn” in the strategic chess game of CS care, telemedicine and AI may grow into more powerful tools, enhancing and supporting CCUS and CCE’s pivotal roles.

Source: Intensive Care Medicine
Image Credit: iStock 
 

References:

Sanfilippo F, Dugar S. Chew MS (2025) How we use critical care ultrasonography in the management of cardiogenic shock: a strategic game of chess in intensive care. Intensive Care Med.