🧭 REBEL Rundown
🗝️ Key Points
- 📚Evidence suggests POCUS influences physician decision-making around use of IV fluids and vasoactive drugs
- 💪🏽Evidence supports its role in improving lactate clearance, one of many surrogates for shock resolution
- 🖥️POCUS may reduce 28-day mortality, duration of vasoactive medications, and the need for renal replacement therapy
- 🙅🏽♂️There was little to no effect on mechanical ventilation requirements, ICU/hospital admissions, or length of stay
📝 Introduction
Shock is a life threatening condition that requires rapid resuscitation, and targeted treatment. Due to its complex nature, shock management poses many challenges for physicians in the acute care setting, more specifically, in the emergency department (ED). Point-of-care-ultrasound (POCUS) has emerged as a promising diagnostic and therapeutic clinical tool in this context, allowing ED physicians to assess hemodynamics and guide treatment interventions in real-time at the bedside.
As POCUS becomes increasingly integrated in critical care and emergent care settings, understanding its impact on real-time guidance and management of treatment and on patient outcomes is of growing importance. POCUS as a clinical tool is already widely used for procedural guidance and focused assessments (i.e using FAST exams for identification of pericardial effusions, pneumothoraces or hypovolemia in trauma).
The appeal of POCUS lies in its non-invasive nature and immediate availability at the bedside to allow physicians to make critical decisions without the need for radiation exposure. This study is a systematic review and meta-analysis that evaluates the impact of POCUS-guided resuscitation on both patient-centered outcomes which include mortality, lactate clearance and organ support, as well as hospital-centered outcomes, including ICU utilization and diagnostic resource use.
🧾 Paper
Basmaji J, Arntfield R, Desai K, et al. The impact of point-of-care ultrasound-guided resuscitation on clinical outcomes in patients with shock: A systematic review and meta-analysis*. Critical Care Medicine. 2024;52(11):1661-1673. PMID: 39298556
🔙Previously Covered and Related Content:
⚙️ What They Did
📈 Results
💥 Critical Results
💪🏽 Strengths
- First of its kind: First comprehensive systematic review of evaluating POCUS-guided resuscitation involving clinical decisions, therapies, and patient outcomes
- Minimized risk of bias: Included only randomized controlled trials (RCTs)
- Other factors considered: Considered both patient-centered outcomes (i.e. mortality) and healthcare utilization metrics.
- Specific enrollment: focused on ICU patients with shock of any etiology, allowing for broad generalizability and strong external validity to real-world critical care settings.
- Accounted for bias through a formal Risk of Bias Assessment using Cochrane methodology, with most outcomes deemed at low risk of publication bias.
- Posed the right clinical question: Examined how rapidly expanding technology like POCUS can directly influence patient outcomes in shock resuscitation, a topic of clear clinical relevance for emergency and critical care providers.
- Operationally minded study: Determined whether a lower-cost, faster, noninvasive imaging modality could improve efficiency, reduce resource utilization, and potentially lower healthcare costs.
- Actively searched for missing data: Authors contacted six original study authors, four of whom provided additional information or clarifications that strengthened the dataset.
- Bias reduction: Incorporated a system where two independent authors performed study screening and data extraction, minimizing the potential for reviewer bias and improving methodological rigor.
⚠️ Limitations
- Missing details: Some studies did not report operator competency, training or experience which may influence the results
- Introducing bias: Certain evidence was low or very low for several outcomes which include (i.e. AKI, RRT duration, ICU admissions) which may reflect risk of bias
- Small ARR: The absolute risk reduction in some outcomes mentioned (i.e. mortality) were relatively small and may not be clinically relevant in all settings
- Cherry-picked trials: The study did not include data from non-randomized controlled trials which could influence data.
- Patients left out: The analysis was unable to investigate specific subgroup effects, such as outcomes in patients with significant comorbidities like heart failure or chronic kidney disease, limiting insights into how POCUS-guided resuscitation performs across diverse patient populations.
- Lacked precision: Some pooled estimates were constrained by small sample sizes, wide confidence intervals, and low certainty of evidence, reducing the precision and strength of certain conclusions.
- Lack of multicenter studies: With the exception of a single multicenter trial, all included studies were conducted at single centers, which may limit the generalizability of findings to different healthcare settings or practice environments.
- All eggs in one basket: The meta-analysis assumes POCUS as the primary driver of improved outcomes, though in clinical reality, multiple concurrent variables—such as clinician expertise, resuscitation protocols, and system-level factors—also influence patient outcomes.
🗣️ Discussion
Clinical Effectiveness and Impact
- POCUS-guided resuscitation demonstrates clear clinical benefits, including reduced 28-day mortality, shorter vasoactive medication duration, and improved lactate clearance.
- These outcomes reflect more precise, physiology-driven resuscitation, allowing clinicians to tailor therapy in real time rather than relying on delayed or indirect data.
- POCUS acts as a bedside extension of the physical exam, transforming how shock is diagnosed and managed in fast-paced settings like the emergency department and ICU.
Operator Competency and Standardization
- The operator-dependent nature of POCUS is a critical limitation. Variability in training, image acquisition, and interpretation likely contributed to the heterogeneity of results across studies.
- Inexperienced users risk misdiagnosis or inappropriate management for example, over-resuscitating a patient with cardiogenic shock due to misinterpretation of ventricular function or IVC dynamics.
- The solution is not simply to “take a course” or assume competency after limited exposure; rather, institutions should establish structured, longitudinal training pathways that emphasize hands-on experience, supervised image acquisition, and iterative feedback.
- True proficiency in POCUS develops over time through deliberate practice, mentorship, and exposure to a broad spectrum of pathologies—not from a single workshop or certification.
- Standardized competency and quality assurance programs are essential to safely expand POCUS use and ensure consistent benefit across institutions.
- A robust QA/QI program should include routine image review (for example, weekly “tape review” sessions led by credentialed faculty), correlation of ultrasound findings with patient outcomes or advanced imaging, and ongoing peer feedback.
- These programs provide both accountability and continued education, helping maintain high interpretive accuracy and reinforcing the culture of continuous improvement that underpins safe, effective ultrasound practice.
Precision and Generalizability
- The precision and scale of existing data limit how confidently we can apply these findings to every setting.
- Most included studies were small and single-center, meaning the results may not fully capture the diversity of real-world shock patients.
- A patient population with higher rates of comorbidities, complex social factors, and delayed presentations—may respond differently than those in smaller, controlled trials.
- Highlights the challenge of implementing POCUS without the same access to specialists or robust QA infrastructure.
- While the signal for benefit is strong, local context—resources, patient mix, and training—still matters when translating this evidence into daily practice.
- Future multicenter studies are crucial not just for validation, but for equity
- Broader enrollment across academic, community, and resource-limited settings will tell us whether POCUS-guided resuscitation improves outcomes universally or if benefits depend on environment and experience.
- Institutions should interpret the findings as an invitation to adapt, building local protocols, training, and QA systems that make POCUS effective for their unique patient populations rather than waiting for a perfect, one-size-fits-all dataset.
Cost, Value, and Implementation
- Although often described as “low-cost,” the initial investment for ultrasound devices and training can be significant, particularly for smaller or community hospitals.
- POCUS may deliver substantial return on investment (ROI) by reducing unnecessary imaging, improving resource allocation, and potentially shortening ICU stays.
- Even without direct cost-effectiveness data in this meta-analysis, the operational efficiency and diagnostic precision that POCUS provides make it a strong candidate for institutional investment.
Moving Toward Standard of Care
- POCUS should no longer be viewed as an optional or niche skill—it has evolved into a core component of shock resuscitation.
- Hospitals and departments should ensure 24/7 access to ultrasound equipment and formally trained providers capable of integrating POCUS findings into patient care.
- The absence of POCUS capability now represents a potential gap in quality and safety, particularly in the ED and ICU where time-sensitive decisions are critical.
- Future research should focus on standardizing POCUS protocols for undifferentiated shock, defining benchmarked training pathways and competency assessments, and rigorously exploring cost-effectiveness and resource-utilization outcomes to guide widespread implementation.
- For example, the international multicenter randomized trial titled SHoC‑ED Series, was a study that enrolled patients with undifferentiated hypotension across six EDs (Canada and South Africa). It highlights the move toward more robust, generalizable data3 which provides clinicians a clearer roadmap for integrating POCUS into everyday practice, enabling smarter deployment of equipment, training, and quality systems.
📘 Author's Conclusion
“POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.”
💬 Our Conclusion
This systematic review and meta-analysis provides evidence that POCUS-guided resuscitation in adult patients with shock offers both meaningful clinical and health system benefits to improve patient outcomes. POCUS appears to be a tool to improve markers of shock resolution such as lactate clearance, and likely reduces 28-day mortality, duration of vasoactive medication, need for renal replacement therapy, and without use of invasive therapies or prolonging ICU/hospital stays.
We believe that the findings support incorporating POCUS into shock resuscitation protocols as a non-invasive bedside tool to guide clinical-decision making.
🚨 Clinical Bottom Line
POCUS should be considered an essential tool in the resuscitation of undifferentiated shock, providing real-time physiologic data that directly guides clinical decision-making in time-sensitive environments like the ED and ICU. Its non-invasive, radiation-free, and efficient nature improves patient outcomes through faster, more targeted interventions.
📚 References
- Volpicelli G,et al.
Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med.
PMID: 23584471 - Bagheri-Hariri S, et al.
The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emerg Radiol.
PMID: 25794785 - Atkinson P, Taylor L, et al.
Does Point of Care Ultrasound Improve Resuscitation Markers in Undifferentiated Hypotension? An International Randomized Controlled Trial From The Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Series. Cureus.
PMID: 32968565
Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)
👤 Guest Authors
Christopher Karnicki, MD, MS
