As team-based shock management continues to evolve to include pulmonary embolism response teams, shock teams, and the SUSPECT cardiogenic shock algorithm (Symptoms/Signs, Urine output, Sustained hypotension, Perfusion, ECG/Echocardiogram, Congestion, Triage), there is an increasing adoption of temporary mechanical circulatory support (MCS) over the recent years.^1,2 Intensivists are now tasked with providing real-time, accurate assessments to guide advanced care.

Point-of-care ultrasound (POCUS) has revolutionized clinical practice due to its rapid learning curve across diverse learners, immediate availability, ability to assess critical hemodynamic parameters, procedural guidance capabilities, and minimal radiation exposure. While invasive hemodynamic monitoring remains the gold standard form of diagnostic measurements, its inherent risks and variable operational feasibility in urgent bedside decision-making underscore the need for complementary modalities. 

POCUS effectively bridges this gap by delivering timely, efficient, and precise evaluations of patients requiring extracorporeal membrane oxygenation, microaxial circulatory support, or a combination of therapies for ongoing guidance of patient management.³ Its capacity to achieve multiorgan assessment, hemodynamic profiling, device visualization, and troubleshooting makes it an indispensable tool for the trained practitioner.

POCUS use in determining the need for mechanical support 

POCUS provides intensivists with crucial information for determining the need for intracorporeal or extracorporeal mechanical support, in part by leveraging spectral doppler, which can be used to estimate stroke volume, venous excess congestion, left atrial pressure, and biventricular function. Some key hemodynamic parameters include cardiac output/index derived from velocity time integral at the left ventricular (LV) outflow tract, estimated right ventricular (RV) systolic function using tissue doppler S’ and/or RV to pulmonary artery coupling using tricuspid annular plane systolic excursion, and RV systolic pressure estimation from tricuspid regurgitation doppler.⁴ Estimated left atrial pressure can be acquired by septal E/e’ ratios from mitral inflow velocity and tissue doppler or leveraging estimated volume.⁵ In addition, excessive venous congestion can be qualitatively assessed using doppler at the inferior vena cava, hepatic, portal, and renal veins. These parameters play an essential role in the primary identification of shock physiology and prevention of downstream multiorgan dysfunction in shock states, while also boosting the confidence of critical care teams in clinical decision-making. 

POCUS use in cannulation of a patient with shock

Aside from hemodynamic assessment, POCUS use is crucial in safe peripheral cannulation, ensuring accurate line placement and minimizing cannulation-related complications. Transthoracic or transesophageal ultrasound can confirm proper cannula positioning within the intended vessels, optimizing circuit function and reducing the risk of vascular injury. Routine ultrasonography should be considered to verify stability of the cannula and to monitor complications, such as cardiac thrombus, tamponade, or vessel thrombus following removal.

POCUS use in ongoing management of a patient with shock

Beyond the initial assessment, POCUS can be used for the ongoing management of patients on temporary MCS, as it allows intensivists to monitor cardiac function, evaluate recovery, and track organ perfusion trends in real time using the parameters mentioned above. Routine ultrasound assessments can confirm adequate LV unloading, detect pulmonary congestion, and guide medication or configuration transitions as indicated. 

POCUS use in weaning from MCS

POCUS is a well-studied tool to guide weaning trials prior to decannulation. Native cardiac function can be monitored while on minimal mechanical support to predict weaning success, minimizing the risk of decompensation.  

As POCUS use becomes an integral component of critical care practice, its significance in temporary intracorporeal and extracorporeal MCS management cannot be overstated. Empowering intensivists to make timely, data-driven decisions, POCUS not only refines diagnostic accuracy and therapeutic precision but also enhances procedural safety and, ultimately, optimizes outcomes for patients who are critically ill who are being evaluated for or require advanced circulatory support. 

1. Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO. 2025 concise clinical guidance: an ACC expert consensus statement on the evaluation and management of cardiogenic shock: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025. https://doi.org/10.1016/j.jacc.2025.02.018

2. Rao SV, O’Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2025. https://doi.org/10.1016/j.jacc.2024.11.009

3. Cha S, Kostibas MP. Echocardiographic and point-of-care ultrasonography (POCUS) guidance in the management of the ECMO patient. J Clin Med. 2024;13(9):2630. doi:10.3390/jcm13092630

4. He Q, Lin Y, Zhu Y, et al. Clinical usefulness of right ventricle-pulmonary artery coupling in cardiovascular disease. J Clin Med. 2023;12(7):2526. doi:10.3390/jcm12072526

5. Lashin H, Olusanya O, Smith A, Bhattacharyya S. Echocardiographic correlates with pulmonary capillary wedge pressure in ischemic cardiogenic shock: insights beyond E/e′. J Cardiothorac Vasc Anesth. 2025;39(4):1090-1092. doi:10.1053/j.jvca.2025.01.027