The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study

The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study Luke Flower, Alicia Waite, Adam Boulton, Marcus Peck, Waqas Akhtar, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4611404/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Aug, 2024 Read the published version in Intensive Care Medicine → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Echocardiography is an essential tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. We sought to evaluate the utilisation of echocardiography in patients presenting to critical care with undifferentiated shock and its impact on decision making. Methods We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom and Crown Dependencies. The study was led by the UK’s Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 hours to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making. Results 1015 patients with undifferentiated shock were included. An echocardiogram was performed on 545 (54%) patients within 72 hours and 463 (43%) within 24 hours of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive, cardiogenic, or mixed shock had their management altered numerically more often by echocardiography (n = 15 [71%], n = 100 [58%] and n = 67 [58%]). 24% of echocardiograms performed adhered to current national information governance and image storage guidance. Conclusion Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock. echocardiography shock ultrasound intensive care critical care Figures Figure 1 Figure 2 Figure 3 Take home message Echocardiography use in the assessment of critically ill patients with shock remains heterogeneous and adherence to image storage and documentation guidelines is low. When echocardiography is utilised in shock, it alters management or improves diagnostic certainty in the majority of patients, with the strongest association seen in those presenting with obstructive or cardiogenic shock. Introduction Echocardiography in critically ill patients with shock supports the identification of life-threatening pathology and guides patient management [ 1 – 6 ]. Its strength lies in its ability to provide a highly sensitive and rapid assessment of cardiac function and structure at the bedside. Accordingly, echocardiography is recommended as a first-line diagnostic tool in patients with undifferentiated shock [ 1 , 7 ]. Historically, echocardiography was a tool of the cardiologist or cardiac physiologist [ 2 ]. Over the last 15 years, an increasing cohort of current and emerging critical care practitioners have undertaken training in critical care echocardiography. This has been driven by increasing recognition of its clinical utility, alongside the publication of guidelines recommending that echocardiography should be readily accessible, and performed on admission to intensive care, for patients presenting with shock [ 1 , 7 – 9 ]. Numerous critical care echocardiography accreditations exist to support delivery, from basic focussed protocols, through to advanced comprehensive assessments [ 10 – 12 ]. Prior studies have demonstrated that both modalities offer diagnostic benefit, both in differentiation of shock phenotypes and guiding critical patient management [ 13 – 16 ]. Despite recommendations and a range of accreditation pathways, there exist limited data describing the contemporary provision of echocardiography in critical care units and specifically in the context of undifferentiated shock. The aims of this study were to describe the current provision and utilisation of echocardiography in patients presenting to critical care with shock, its impact on critical decision making and adherence to guidelines. Methods We conducted a multicentre, prospective, observational study in National Health Service (NHS) hospitals in England, Wales, Scotland, Northern Ireland and non-NHS hospitals in the Crown Dependencies of the Isle of Man and Jersey. The study met the criteria for a service evaluation according to the NHS Health Research Authority tool and ethical approval was therefore not required [ 17 , 18 ]. The study was prospectively approved by the Information Governance departments at all participating sites, and Caldicott approval from the lead site was obtained. Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed in the reporting of this study [ 19 ]. The study was led and delivered by the UK’s Trainee Research in Intensive Care Network (TRIC) Network and formally endorsed by the Intensive Care Society (ICS), the Faculty of Intensive Care Medicine (FICM), and the British Society of Echocardiography (BSE). Representatives of these organisations formed the study management group and contributed to the study design. All UK and Crown Dependency intensive care units (n = 255) were invited to participate. Invitation was via mailing lists, newsletters, bulletins and through the national FICM Regional Advisor network. The eligibility time-period was a consecutive 7-day period, identified by individual sites, starting at 00:00 on any day between March 4th and March 25th 2024. Patients included were adults (≥ 18 years of age), admitted to a critical care setting, with shock of any aetiology [ 20 ]. Critical care was defined by UK societal guidance, but broadly described an area where there were higher staffing ratios than on wards, where immediate access to staff trained in critical care and organ support were available [ 21 ]. Patients were eligible for inclusion in the study as soon as a decision was made to admit to critical care. Shock was defined as a systolic blood pressure < 90mmHg for ≥ 30 min, or the need for vasopressors/inotropes to maintain systolic blood pressure ≥ 90mmHg, with evidence of hypoperfusion of the peripheries and vital organs [ 22 , 23 ]. Example cases were provided to all sites in the study protocol and any individual site queries were discussed with the study management group. Patients were followed for 72-hours to ascertain whether an echocardiogram was performed following the decision to admit. Data collected included; time of admission (‘in-hours’ or ‘out-of-hours’ was selected as per the local intensive care unit definition); whether an urgent echocardiogram was indicated on index assessment; whether an echocardiogram was performed within 72-hours of the decision to admit; information regarding the nature of echocardiogram performed and associated documentation; and whether it aided diagnosis or altered patient management. Focussed echocardiography referred to a targeted scan that requires a basic or intermediate accreditation, whilst comprehensive echocardiography referred to a detailed scan that requires advanced accreditation [ 24 , 25 ]. The case report form is included in the Supplementary Material. Data were collected and uploaded by investigators at each site using an electronic data capture tool, hosted by Research Electronic Data Capture platform (REDCap) at the University of Liverpool [ 26 , 27 ]. Records with incomplete data were excluded. Data were summarised using counts and percentages. Differences between categorical variables were assessed using chi-squared tests. All analyses were performed using the R statistical software version 4.0.0 (The R Foundation for Statistical Computing, Vienna, Austria). Figures were produced using ggplot2 and the external package 'sf', with spatial data obtained from the ONS Open Geography Portal. A p value of < 0.05 was considered statistically significant. Results Admission summary 1042 patients were enrolled at 178 hospitals. After the exclusion of 27 duplicate patient records, data from 1015 individual patients were analysed. 373 (37%) patients were admitted ‘in-hours’ between Monday and Friday, 418 (41%) were admitted ‘out-of-hours’ between Monday and Friday, and 225 (22%) were admitted over a weekend or on a public holiday. 365 (36%) patients were deemed to have isolated distributive shock, 218 (21%) had isolated hypovolaemic shock, 207 (21%) had isolated cardiogenic shock, 23 (2%) had isolated obstructive shock and 203 (20%) had mixed shock (Fig. 1). England reported the highest number of patients admitted with shock (n = 848, 84%), followed by Scotland (n = 99, 10%), Wales (n = 46, 5%), Northern Ireland (n = 14, 1%) and the Crown Dependencies (n = 8, 1%). Timing and nature of echocardiography An echocardiogram was performed on 545 (54%) patients within 72 hours of admission, 463 (43%) within 24 hours of admission and 71 (7%) within one hour of admission. The proportion of patients receiving an echocardiogram by geographical region can be seen in Fig. 2 . Heat maps demonstrating: (a) regional variation in the proportion of patients with shock receiving echocardiography within 72 hours of admission to critical care (b) the proportion of echocardiograms performed by clinicians working as part of the critical care team. Initial echocardiography was performed by a member of the critical care team in 314 (58%) patients (Fig. 2 ). In patients that received an echocardiogram, 365 (67%) received a focussed scan, with the remaining 180 (33%) receiving a comprehensive examination. Focussed echocardiograms were performed significantly earlier than comprehensive scans (median = 4 hours [IQR 1–12] vs median = 16 hours [IQR 6.38–28.25] respectively, p = < 0.0001). Supplementary table 1 indicates the proportion of focussed and comprehensive scans performed by echocardiographers of differing clinical backgrounds within the study. Urgent echocardiography was recommended by the admitting critical care team for 386 (38%) patients. Patients deemed to require an urgent echocardiography as part of their initial critical care admission management plan were significantly more likely to receive this, compared to patients not deemed to require urgent echocardiography, at each time point post admission (72hrs: n = 332, 86% vs n = 213, 34%; p < 0.0001, 24hrs: n = 293, 76% vs n = 143, 24%; p < 0.0001, 1hr: n = 53, 14% vs n = 18, 3%; p < 0.0001). At each time point, a higher proportion of patients with obstructive shock received an echocardiogram than for other shock aetiologies (72hrs: n = 20/23, 87%; 24hrs: n = 18; 78%, 6hrs: n = 65%), followed by cardiogenic shock (72hrs: n = 171/207, 83%; 24hrs: n = 149, 72%; 6hrs: n = 95, 46%), mixed shock (72hrs: n = 116/203; 57%; 24hrs: n = 92; 46%, 6hr: n = 43, 21%), hypovolaemic shock (72hrs n = 93/218, 43%; 24hrs: n = 70, 32%; 6hrs: n = 43, 21%), and distributive shock (72hrs: n = 145/541, 40%; 24hrs: n = 106, 29%; 6hrs: n = 37, 17%) . Echocardiography was performed by a member of the critical care team in 16 (80%) patients with obstructive shock, 64 (69%) patients with hypovolaemic shock, 93 (64%) patients with distributive shock, 84 (56%) of patients with cardiogenic shock and 93 (46%) patients with mixed shock. Patients with cardiogenic shock were most likely to receive and echocardiogram from a member of the cardiology team (n = 71, [49%]), (Table 1 ). Table 1 Urgency and type of echocardiogram performed, and background of echocardiographer, categorised by shock classification. Critical care scan refers to any echocardiogram performed by a member of the critical care team and cardiology scan by a cardiology doctor or cardiac physiologist. Shock type Urgent scan recommended, n (%) Urgent scan performed, n (%) Focussed scans, n (%) Comprehensive scans, n (%) Critical care scan, n (%) Cardiology scan, n (%) Obstructive 16 (70) 16 (70) 17 (85) 3 (15) 16 (80) 3 (15) Cardiogenic 128 (62) 117 (57) 115 (67) 56 (33) 84 (56) 71 (49) Distributive 111 (30) 86 (24) 97 (67) 48 (33) 93 (64) 40 (28) Hypovolaemic 55 (25) 46 (21) 59 (63) 34 (37) 64 (69) 22 (25) Mixed 76 (37) 67 (33) 77 (57) 39 (29) 57 (49) 41 (35) Most patients with cardiogenic (n = 121/207, 58%), obstructive (n = 13/23, 57%), distributive (n = 277/365, 65%), hypovolaemic (n = 162/218, 62%) and mixed shock (n = 136/202, 67%) were admitted out of hours (Fig. 3 ). A lower proportion of patients admitted out of hours received an echocardiogram within one hour (n = 38, 6%) compared to patients admitted in hours (n = 33, 9%). Impact of echocardiography on diagnosis and management Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases, with a change of management reported in 270 (50%) and reduction of diagnostic uncertainty reported in 120 (22%) of patients. Echocardiograms deemed to be urgent (n = 56, 17%) were significantly less likely to be deemed to have reduced diagnostic uncertainty compared to those regarded as non-urgent (n = 64, 30%; p = 0.0003). Similarly, significantly fewer scans were reported to alter management where patients were deemed to require an urgent echocardiogram compared to those not deemed urgent (n = 144 [44%] vs n = 122 [57%] p = 0.0034)). Comprehensive scans, compared to focussed scans, were more likely to be deemed to alter patient management (n = 101 [56%] vs n = 169 [46%], p = 0.0366) and reduce diagnostic uncertainty (n = 46 [25%] vs n = 74 [20%], p = 0.042). Scans performed by cardiac physiologists led to a reported change in patient management in a higher proportion of patients (n = 74, 63%), than those performed by intensive care trainees (n = 57, 52%, p = 0.08), intensive care consultants (n = 56, 41%; p = 0.0003), or cardiologists (n = 27, 45%; p = 0.02). Echocardiography reduced diagnostic uncertainty or altered management in 15 (71%) patients presenting with obstructive shock, 100 (58%) patients presenting with cardiogenic shock, 41 (44%) patients presenting with hypovolaemic shock, 52 (36%) patients presenting with distributive shock, and 67 (58%) patients with mixed shock (Fig. 1). Echocardiography accreditation and adherence to national guidelines 308 (56%) scans were performed by clinicians accredited in echocardiography. The most common accreditations were Focused Ultrasound in Intensive Care (FUSIC), comprising 181 (59%) scans, followed by BSE Transthoracic (TTE) Level 2 (n = 77, 25%), BSE Level 1 (n = 19, 6%), and BSE Advanced Critical Care Echocardiography (n = 11, 4%). Other accreditations included the European Diploma in advanced critical care EchoCardiography (EDEC), the European Society of Cardiovascular Imaging TTE, transoesophageal (TOE) accreditation, and BSE TOE. Echocardiographic findings were documented via a free-text report in 297 (54%) cases, a structured report in 212 (39%) cases and 36 (7%) had no report documented. Images were stored on the ultrasound machine in 211 (39%) cases, in digital archiving systems in 182 (33%) cases and not stored in 211 (39%) cases. The location of image storage was documented in the notes for only 131 (24%) patients. Discussion This multicentre, prospective observational study represents the largest evaluation of critical care echocardiography use in the assessment of patients with undifferentiated shock. The key finding was that only 54% of patients received an echocardiogram within 72-hours of admission. We also identified three broad themes; the utility of echocardiography in influencing management and reducing diagnostic uncertainty in the management of shock; heterogeneity of application of critical care echocardiography in the assessment of shock; and low adherence to best practices guidelines regarding image storage and documentation. Echocardiography was reported to have reduced diagnostic uncertainty or altered patient management in 54% of patients. These findings align with previous smaller studies, demonstrating that echocardiography changed management in 38%-51% of patients and improved diagnostic certainty in 29%-37% of patients [ 4 , 15 , 28 , 29 ]. Patients with presumed obstructive or cardiogenic shock were more likely to have their management altered by the findings of the index echocardiogram (71% and 58% respectively). This likely reflects the association of these aetiologies with interventions, including thrombolysis, pericardiocentesis, percutaneous coronary intervention and use of mechanical circulatory support. These findings further emphasise the essential role of echocardiography in the assessment of shock, outlined in cardiogenic shock guidelines and the European Resuscitation Council Guidelines for identification of obstructive shock [ 1 , 30 – 33 ]. For patients with hypovolaemic and distributive shock echocardiography was reported to have influenced clinical management in 43% and 27% of cases respectively. Previous work has demonstrated the high sensitivity of emergency ultrasound for the identification of distributive (e.g., septic) and hypovolaemic (e.g., haemorrhagic) shock and there are established protocols that incorporate echocardiography (e.g., Focused Assessment with Sonography for Trauma and Rapid Ultrasound in Shock in the Evaluation of the Critically Ill) into the assessment of these syndromes [ 5 , 34 – 36 ]. Our study demonstrated geographical heterogeneity in the delivery of echocardiography throughout the UK and Crown Dependencies. These findings may be a result of numerous factors, including regional variability in the availability of accredited clinicians and differing opinions on the use of echocardiography in shock between centres. Minimal previous work has been performed investigating regional variability in echocardiography provision throughout UK critical care units but the work that has been done also demonstrates heterogeneity, a finding that is replicated in wider Europe and Australasia.[ 37 – 39 ] Improved training of critical care clinicians may help reduce reliance on cardiology teams and improve out-of-hours access, given the inevitable 24/7 onsite presence of critical care clinicians.[ 24 , 39 , 40 ] The majority of echocardiograms obtained were focussed scans, performed by critical care physicians. Whilst comprehensive scans and echocardiography performed by cardiac physiologists were more likely to be reported to alter patient management, focussed echocardiography was still reported to have altered management in 46% of cases. These findings highlight the role of both focussed and comprehensive echocardiography in patients with shock. Focussed echocardiography is more readily available at the patient’s bedside, more commonly performed by critical care teams and can aid initial diagnostic reasoning and patient management. In contrast, comprehensive echocardiography tends to be performed later during a patient’s admission, is more commonly performed by cardiac physiologists, and can add value beyond its focussed counterpart. In practice, the two modalities should be complimentary, with focussed echocardiography permitting rapid diagnostic ability at any time of day, and comprehensive echocardiography providing more detailed assessment of both structure and function to refine management. To support the provision of universal focussed echocardiography, critical care units should be encouraged to incorporate echocardiography education into their departments, as the development of trainees and trainers is vital. Comprehensive echocardiography requires more advanced training and a significant time commitment to both acquire and maintain the skillset. As a minimum standard, there should be 24/7 provision of focussed echocardiography in critical care units with the capability for comprehensive imaging in-hours, or certainly availability of expert (remote) review of focussed images. Broader democratisation of echocardiography accreditation is key to facilitate the expansion of its availability, with its inclusion into undergraduate and postgraduate curricula both feasible and effective. For example, it has previously been demonstrated that medical students with minimal echocardiography training were able to more accurately diagnose key cardiac pathologies than senior cardiologists performing a physical examination [ 38 ]. Moreover, several countries have already incorporated mandatory critical care echocardiography into their postgraduate Intensive Care Medicine training, including those in wider Europe, Australia and New Zealand, and other medical specialties in the UK have successfully assimilated emergency echocardiography into their curricula [ 37 , 41 , 42 ]. Artificial intelligence (AI) represents another tool to facilitate reliable expansion of echocardiography, with its correct application permitting faster training, increasing diagnostic accuracy and reducing interobserver variability [ 43 , 44 ]. The inverse association between perceived urgency and echocardiography informing management or diagnostic uncertainty supports the notion that routine and unbiased echocardiography may add value in cases of undifferentiated shock. Indeed, the ESICM consensus statement on circulatory shock and haemodynamic monitoring, recommends the use of echocardiography as a first-line imaging modality in any patient where the aetiology of shock is uncertain [ 7 ]. The majority of echocardiograms performed in this observational study did not comply with UK guidelines on image storage and reporting which recommend that all images should be securely stored for quality assurance purposes, whilst reliance on ultrasound machine storage is not a sufficiently secure method [ 8 ]. This guidance also states that when scans are performed to inform clinical decision making, a structured report should be generated and stored in the patient’s medical record. Further work to explore and understand barriers to compliance with these recommendations may help in the safe expansion of critical care echocardiography services. Strengths of this study include the involvement of 70% of critical care units across the UK and Crown Dependencies. This is the largest study of its kind conducted to date, including a broad range of critical care units, within rural and urban centres, improving the external validity of our findings. The acknowledgement of multi-professional sonographer skillsets in acquisition of the echocardiograms within this study, accurately represents current echocardiography provision in the emergent setting within the UK. This study has several limitations. A local clinician assessment was used to determine if echocardiography influenced diagnosis and patient management. This is subject to inherent bias and inaccuracy. The observational nature of this study cannot determine whether the critical treatment decisions based upon the results of the sonographic assessments truly had an effect on overall outcome. The conduct of the study may itself have resulted in the Hawthorne effect, whereby an echocardiogram is performed when it may not have been prior. This could lead to an overestimation of the utility of echocardiography in patients with shock. Additionally, we did not assess the availability of echocardiography as a potential barrier within this study. The quality and accuracy of image reporting was also beyond the scope of this study. Finally, the definition of shock to determine patient eligibility is challenging. The study used a pragmatic approach by undertaking expert consultation to reach a study definition for eligibility, in addition to providing case examples and offering support to sites with queries. Crucially, we acknowledge that critical care echocardiography is not a static test, but rather a tool that supports dynamic assessment and reassessment following interventions. Conclusion Urgent echocardiography is not routinely used in the assessment of critically ill patients with shock in the UK and Crown Dependencies, despite international guidance. This study suggests that echocardiography may alter management and improve diagnostic certainty in patients with undifferentiated shock. Future work should explore barriers to the expansion of echocardiography provision within critical care to permit improved equity of care amongst patients presenting with shock. Declarations Financial interests: None to declare. COI: AM, MP, JW and OO have received honoraria from GE healthcare. No other authors have relevant COI to declare. References Intensive Care Society | Shock to Survival Report https://ics.ac.uk/resource/shock-to-survival-report.html . Accessed 15 Mar 2023 Vieillard-Baron A, Millington SJ, Sanfilippo F, Chew M, Diaz-Gomez J, McLean A, Pinsky MR, Pulido J, Mayo P, Fletcher N (2019) A decade of progress in critical care echocardiography: a narrative review. 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Accessed 30 Apr 2024 McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A, de Boer RA, Christian Schulze P, Abdelhamid M, Aboyans V, Adamopoulos S, Anker SD, Arbelo E, Asteggiano R, Bauersachs J, Bayes-Genis A, Borger MA, Budts W, Cikes M, Damman K, Delgado V, Dendale P, Dilaveris P, Drexel H, Ezekowitz J, Falk V, Fauchier L, Filippatos G, Fraser A, Frey N, Gale CP, Gustafsson F, Harris J, Iung B, Janssens S, Jessup M, Konradi A, Kotecha D, Lambrinou E, Lancellotti P, Landmesser U, Leclercq C, Lewis BS, Leyva F, Linhart A, Løchen ML, Lund LH, Mancini D, Masip J, Milicic D, Mueller C, Nef H, Nielsen JC, Neubeck L, Noutsias M, Petersen SE, Sonia Petronio A, Ponikowski P, Prescott E, Rakisheva A, Richter DJ, Schlyakhto E, Seferovic P, Senni M, Sitges M, Sousa-Uva M, Tocchetti CG, Touyz RM, Tschoepe C, Waltenberger J (2022) 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail 24:4–131. https://doi.org/10.1002/EJHF.2333 Javali RH, Loganathan A, Srinivasarangan M, Patil A, Siddappa GB, Satyanarayana N, Bheemanna AS, Jagadeesh S, Betkerur S (2020) Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 24:313. https://doi.org/10.5005/JP-JOURNALS-10071-23429 Lan P, Wang T-T, Li H-Y, Yan R-S, Liao W-C, Yu B-W, Wang Q-Q, Lin L, Pan K-H, Yu Y-S, Zhou J-C (2019) Utilization of echocardiography during septic shock was associated with a decreased 28-day mortality: a propensity score-matched analysis of the MIMIC-III database. Ann Transl Med 7:662–662. https://doi.org/10.21037/ATM.2019.10.79 Perera P, Mailhot T, Riley D, Mandavia D (2010) The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically lll. Emerg Med Clin North Am 28:29–56. https://doi.org/10.1016/J.EMC.2009.09.010 Rajamani A, Knudsen S, Ngoc Bich Ha Huynh K, Huang S, Wong WT, Ting I, McLean AS, Chi Wa Ng J, Parmar J, Salvi M, Ramanathan K (2020) Basic echocardiography competence program in intensive care units: A multinational survey of intensive care units accredited by the College of Intensive Care Medicine. Anaesth Intensive Care 48:150–154. https://doi.org/10.1177/0310057X20911663 Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, Neuman Y, Mirocha J, Kar S, Forrester JS, Siegel RJ (2005) Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 96:1002–1006. https://doi.org/10.1016/j.amjcard.2005.05.060 Cooke A, Bruemmer-Smith S, McLoughlin J, McCaffrey J (2011) Survey of echocardiography provision and practice in ICUs in the United Kingdom. Critical Care 2011 15:1 15:1–190. https://doi.org/10.1186/CC9446 CICM - ICU training program https://www.cicm.org.au/Trainees-and-IMGs/Training-Program/General . Accessed 27 Apr 2024 Vieillard-Baron A, Mayo PH, Vignon P, Cholley B, Slama M, Pinsky MR, McLean A, Choi G, Beaulieu Y, Arntfield R, Koenig S, Colreavy F, Canivet JL, De Backer D (2014) International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med 40:654–666. https://doi.org/10.1007/S00134-014-3228-5/TABLES/8 Yang Y, Royse C, Royse A, Williams K, Canty D (2016) Survey of the training and use of echocardiography and lung ultrasound in Australasian intensive care units. Crit Care 20:339. https://doi.org/10.1186/s13054-016-1444-9 Alsharqi M, Woodward WJ, Mumith JA, Markham DC, Upton R, Leeson P (2018) Artificial intelligence and echocardiography. Echo Res Pract 5:R115–R126. https://doi.org/10.1530/ERP-18-0056 Barry T, Farina JM, Chao CJ, Ayoub C, Jeong J, Patel BN, Banerjee I, Arsanjani R (2023) The Role of Artificial Intelligence in Echocardiography. J Imaging 9. https://doi.org/10.3390/JIMAGING9020050 Supplementary Files NEATECHOSTROBEsubmissionchecklist.docx NEATECHOSuppMaterialSubmission.docx NEATECHOsupplementcollaborators.docx Cite Share Download PDF Status: Published Journal Publication published 19 Aug, 2024 Read the published version in Intensive Care Medicine → Version 1 posted Editorial decision: Major revisions 08 Jul, 2024 Reviewers agreed at journal 23 Jun, 2024 Reviewers invited by journal 23 Jun, 2024 Editor assigned by journal 23 Jun, 2024 First submitted to journal 20 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4611404","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317829402,"identity":"b25debdf-df88-49bb-b3b7-7743f71ad1f4","order_by":0,"name":"Luke Flower","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBACPgY2IGljAWIzPuBBkePBpoEBqAGkJU0CxGY2ACqSIEkLmwRxWiTSEh8wJEjIGRzvfVbxpsKujl/6+AOGj3tqGQzOHMCl5bABUIuxwZnjZjfnnEmWkOzLMWCc8ew4g8HZBhxa0tskGH9IJG67kcZ2m7ftgITBGR4GZp4DxxgMzuNyWHr7D6AtidvuP2Mrhmhhf0BAS9oxBrCWG2xszBAtDAZALTW4HcbzLFkiAegX+zNpzJJAv0jO7OExODjjwAEeSRze52dPM/zwIcFGTrL9GOMHYIjx8/OwP3zw4UCdHN+ZBOwuAwEMKaDxh3HECh5QR7KOUTAKRsEoGLYAACEBVnrn6B37AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0001-7204-609X","institution":"University of Cambridge","correspondingAuthor":true,"prefix":"","firstName":"Luke","middleName":"","lastName":"Flower","suffix":""},{"id":317829403,"identity":"d8a27554-9a3b-4367-9545-84b84186f11f","order_by":1,"name":"Alicia Waite","email":"","orcid":"","institution":"North Western Deanery: Health Education England North West; University of Liverpool, Liverpool, UK; Liverpool University Hospitals, NHS Trust, Liverpool, UK","correspondingAuthor":false,"prefix":"","firstName":"Alicia","middleName":"","lastName":"Waite","suffix":""},{"id":317829404,"identity":"0b977f7e-d76e-487e-a293-e813a0b9626c","order_by":2,"name":"Adam Boulton","email":"","orcid":"","institution":"Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Boulton","suffix":""},{"id":317829405,"identity":"c777d150-9909-4ef3-b26e-46836b7c30c0","order_by":3,"name":"Marcus Peck","email":"","orcid":"","institution":"Royal Hampshire County Hospital","correspondingAuthor":false,"prefix":"","firstName":"Marcus","middleName":"","lastName":"Peck","suffix":""},{"id":317829406,"identity":"6d68fa2e-2cb0-4988-8692-bc0decf3cbc2","order_by":4,"name":"Waqas Akhtar","email":"","orcid":"","institution":"Guy's and St Thomas' NHS Foundation 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Trust","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Marsh","suffix":""},{"id":317829412,"identity":"a10c5ae8-ced9-4239-94ff-e93ea542f3ff","order_by":10,"name":"Ashley Miller","email":"","orcid":"","institution":"Shrewsbury and Telford Hospital NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Miller","suffix":""},{"id":317829413,"identity":"cec01391-fc33-4a34-b2c1-0779648621f3","order_by":11,"name":"Amy Nash","email":"","orcid":"","institution":"NHS England Wessex School of Anaesthesia, Wessex, UK","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Nash","suffix":""},{"id":317829414,"identity":"99b6b94e-fb89-4dcb-959d-8ca49a7555ed","order_by":12,"name":"Olusegun Olusanya","email":"","orcid":"","institution":"Barts Health NHS Trust","correspondingAuthor":false,"prefix":"","firstName":"Olusegun","middleName":"","lastName":"Olusanya","suffix":""},{"id":317829415,"identity":"26c6e3ab-8921-43ed-838a-8ccbe7b5cf61","order_by":13,"name":"Prashant Parulekar","email":"","orcid":"","institution":"William Harvey Hospital","correspondingAuthor":false,"prefix":"","firstName":"Prashant","middleName":"","lastName":"Parulekar","suffix":""},{"id":317829416,"identity":"862d4c9f-75fc-4c25-abde-159658468ad4","order_by":14,"name":"Daniel Wagstaff","email":"","orcid":"","institution":"NHS England Wessex School of Anaesthesia; NHS England Wessex School of Intensive Care Medicine","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Wagstaff","suffix":""},{"id":317829417,"identity":"21aaa6b1-d47e-4c8e-a386-7304be4f2cc7","order_by":15,"name":"Jonathan Wilkinson","email":"","orcid":"","institution":"Northampton General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Wilkinson","suffix":""},{"id":317829418,"identity":"89823a2c-12aa-4b4f-8457-b28693f5507b","order_by":16,"name":"NEAT-ECHO Collaborators","email":"","orcid":"","institution":"NEAT-ECHO Collaborators, Trainee Research in Intensive Care Network","correspondingAuthor":false,"prefix":"","firstName":"NEAT-ECHO","middleName":"","lastName":"Collaborators","suffix":""},{"id":317829419,"identity":"0bb4194e-44ed-441a-a1fc-7b894a2ce035","order_by":17,"name":"Alastair Proudfoot","email":"","orcid":"","institution":"Barts Health NHS Trust; Critical Care and Perioperative Medicine Group, School of Medicine and Dentistry, Queen Mary University of London","correspondingAuthor":false,"prefix":"","firstName":"Alastair","middleName":"","lastName":"Proudfoot","suffix":""}],"badges":[],"createdAt":"2024-06-20 11:24:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4611404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4611404/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00134-024-07590-6","type":"published","date":"2024-08-19T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60616166,"identity":"3871afd3-594b-4e88-be6c-10dac17bec0e","added_by":"auto","created_at":"2024-07-18 20:17:21","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eShock aetiology and impact of echocardiography on management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA stacked bar chart demonstrating the number of patients with each shock aetiology (count), the proportion of those patients that received an echocardiogram that altered their management (green), the proportion of patients that had an echocardiogram that did not alter their management (yellow) and the proportion of patients that did not receive an echocardiogram (purple).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/6fc42a54b31b37d1448c7934.jpeg"},{"id":60616810,"identity":"b9013e3a-08b7-4dcd-8965-1a545c0080ac","added_by":"auto","created_at":"2024-07-18 20:25:20","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":438765,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProvision of echocardiography by geography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHeat maps demonstrating: (a) regional variation in the proportion of patients with shock receiving echocardiography within 72 hours of admission to critical care (b) the proportion of echocardiograms performed by clinicians working as part of the critical care team.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/c78c1145fde27e11d01b81f5.jpeg"},{"id":60616165,"identity":"89c0c8d3-6d3d-471c-b1e7-06cc32efb4e6","added_by":"auto","created_at":"2024-07-18 20:17:21","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":82608,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eShock aetiology and provision of echocardiography in vs out of hours Impact of echocardiography on diagnosis and management\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/156635d03bde5d315027b76c.jpeg"},{"id":63299935,"identity":"fee6da61-8e81-49fb-aac2-2c821c23c7fc","added_by":"auto","created_at":"2024-08-26 16:05:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1233566,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/a07bafb3-c04e-4cad-93d4-14096c04f58b.pdf"},{"id":60616164,"identity":"15469bf1-ef4c-403d-99f3-c57c784aae99","added_by":"auto","created_at":"2024-07-18 20:17:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33848,"visible":true,"origin":"","legend":"","description":"","filename":"NEATECHOSTROBEsubmissionchecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/fa081689317e2dde8dfd78b7.docx"},{"id":60616161,"identity":"2367983d-c69b-4b19-9cfe-d3d6684c57f0","added_by":"auto","created_at":"2024-07-18 20:17:20","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":817318,"visible":true,"origin":"","legend":"","description":"","filename":"NEATECHOSuppMaterialSubmission.docx","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/8eaf5e5acd6b2eb397e33144.docx"},{"id":60616162,"identity":"e639028c-a8ea-4113-98aa-da08deabd10a","added_by":"auto","created_at":"2024-07-18 20:17:20","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":77474,"visible":true,"origin":"","legend":"","description":"","filename":"NEATECHOsupplementcollaborators.docx","url":"https://assets-eu.researchsquare.com/files/rs-4611404/v1/0e30263b7a848cd3699f7960.docx"}],"financialInterests":"","formattedTitle":"The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study","fulltext":[{"header":"Take home message","content":"\u003cp\u003eEchocardiography use in the assessment of critically ill patients with shock remains heterogeneous and adherence to image storage and documentation guidelines is low. When echocardiography is utilised in shock, it alters management or improves diagnostic certainty in the majority of patients, with the strongest association seen in those presenting with obstructive or cardiogenic shock.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEchocardiography in critically ill patients with shock supports the identification of life-threatening pathology and guides patient management [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Its strength lies in its ability to provide a highly sensitive and rapid assessment of cardiac function and structure at the bedside. Accordingly, echocardiography is recommended as a first-line diagnostic tool in patients with undifferentiated shock [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHistorically, echocardiography was a tool of the cardiologist or cardiac physiologist [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over the last 15 years, an increasing cohort of current and emerging critical care practitioners have undertaken training in critical care echocardiography. This has been driven by increasing recognition of its clinical utility, alongside the publication of guidelines recommending that echocardiography should be readily accessible, and performed on admission to intensive care, for patients presenting with shock [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Numerous critical care echocardiography accreditations exist to support delivery, from basic focussed protocols, through to advanced comprehensive assessments [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Prior studies have demonstrated that both modalities offer diagnostic benefit, both in differentiation of shock phenotypes and guiding critical patient management [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite recommendations and a range of accreditation pathways, there exist limited data describing the contemporary provision of echocardiography in critical care units and specifically in the context of undifferentiated shock. The aims of this study were to describe the current provision and utilisation of echocardiography in patients presenting to critical care with shock, its impact on critical decision making and adherence to guidelines.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe conducted a multicentre, prospective, observational study in National Health Service (NHS) hospitals in England, Wales, Scotland, Northern Ireland and non-NHS hospitals in the Crown Dependencies of the Isle of Man and Jersey. The study met the criteria for a service evaluation according to the NHS Health Research Authority tool and ethical approval was therefore not required [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The study was prospectively approved by the Information Governance departments at all participating sites, and Caldicott approval from the lead site was obtained. Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed in the reporting of this study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e The study was led and delivered by the UK\u0026rsquo;s Trainee Research in Intensive Care Network (TRIC) Network and formally endorsed by the Intensive Care Society (ICS), the Faculty of Intensive Care Medicine (FICM), and the British Society of Echocardiography (BSE). Representatives of these organisations formed the study management group and contributed to the study design.\u003c/p\u003e\u003cp\u003eAll UK and Crown Dependency intensive care units (n\u0026thinsp;=\u0026thinsp;255) were invited to participate. Invitation was via mailing lists, newsletters, bulletins and through the national FICM Regional Advisor network. The eligibility time-period was a consecutive 7-day period, identified by individual sites, starting at 00:00 on any day between March 4th and March 25th 2024.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatients included were adults (\u0026ge;\u0026thinsp;18 years of age), admitted to a critical care setting, with shock of any aetiology [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Critical care was defined by UK societal guidance, but broadly described an area where there were higher staffing ratios than on wards, where immediate access to staff trained in critical care and organ support were available [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Patients were eligible for inclusion in the study as soon as a decision was made to admit to critical care. Shock was defined as a systolic blood pressure\u0026thinsp;\u0026lt;\u0026thinsp;90mmHg for \u0026ge;\u0026thinsp;30 min, or the need for vasopressors/inotropes to maintain systolic blood pressure\u0026thinsp;\u0026ge;\u0026thinsp;90mmHg, with evidence of hypoperfusion of the peripheries and vital organs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Example cases were provided to all sites in the study protocol and any individual site queries were discussed with the study management group. Patients were followed for 72-hours to ascertain whether an echocardiogram was performed following the decision to admit.\u003c/p\u003e \u003cp\u003eData collected included; time of admission (\u0026lsquo;in-hours\u0026rsquo; or \u0026lsquo;out-of-hours\u0026rsquo; was selected as per the local intensive care unit definition); whether an urgent echocardiogram was indicated on index assessment; whether an echocardiogram was performed within 72-hours of the decision to admit; information regarding the nature of echocardiogram performed and associated documentation; and whether it aided diagnosis or altered patient management. Focussed echocardiography referred to a targeted scan that requires a basic or intermediate accreditation, whilst comprehensive echocardiography referred to a detailed scan that requires advanced accreditation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The case report form is included in the Supplementary Material.\u003c/p\u003e \u003cp\u003eData were collected and uploaded by investigators at each site using an electronic data capture tool, hosted by Research Electronic Data Capture platform (REDCap) at the University of Liverpool [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Records with incomplete data were excluded.\u003c/p\u003e \u003cp\u003eData were summarised using counts and percentages. Differences between categorical variables were assessed using chi-squared tests. All analyses were performed using the R statistical software version 4.0.0 (The R Foundation for Statistical Computing, Vienna, Austria). Figures were produced using ggplot2 and the external package 'sf', with spatial data obtained from the ONS Open Geography Portal. A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAdmission summary\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e1042 patients were enrolled at 178 hospitals. After the exclusion of 27 duplicate patient records, data from 1015 individual patients were analysed. 373 (37%) patients were admitted \u0026lsquo;in-hours\u0026rsquo; between Monday and Friday, 418 (41%) were admitted \u0026lsquo;out-of-hours\u0026rsquo; between Monday and Friday, and 225 (22%) were admitted over a weekend or on a public holiday. 365 (36%) patients were deemed to have isolated distributive shock, 218 (21%) had isolated hypovolaemic shock, 207 (21%) had isolated cardiogenic shock, 23 (2%) had isolated obstructive shock and 203 (20%) had mixed shock (Fig.\u0026nbsp;1). England reported the highest number of patients admitted with shock (n\u0026thinsp;=\u0026thinsp;848, 84%), followed by Scotland (n\u0026thinsp;=\u0026thinsp;99, 10%), Wales (n\u0026thinsp;=\u0026thinsp;46, 5%), Northern Ireland (n\u0026thinsp;=\u0026thinsp;14, 1%) and the Crown Dependencies (n\u0026thinsp;=\u0026thinsp;8, 1%).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTiming and nature of echocardiography\u003c/h2\u003e \u003cp\u003eAn echocardiogram was performed on 545 (54%) patients within 72 hours of admission, 463 (43%) within 24 hours of admission and 71 (7%) within one hour of admission. The proportion of patients receiving an echocardiogram by geographical region can be seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cem\u003eHeat maps demonstrating: (a) regional variation in the proportion of patients with shock receiving echocardiography within 72 hours of admission to critical care (b) the proportion of echocardiograms performed by clinicians working as part of the critical care team.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInitial echocardiography was performed by a member of the critical care team in 314 (58%) patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In patients that received an echocardiogram, 365 (67%) received a focussed scan, with the remaining 180 (33%) receiving a comprehensive examination. Focussed echocardiograms were performed significantly earlier than comprehensive scans (median\u0026thinsp;=\u0026thinsp;4 hours [IQR 1\u0026ndash;12] vs median\u0026thinsp;=\u0026thinsp;16 hours [IQR 6.38\u0026ndash;28.25] respectively, p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Supplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e indicates the proportion of focussed and comprehensive scans performed by echocardiographers of differing clinical backgrounds within the study.\u003c/p\u003e \u003cp\u003eUrgent echocardiography was recommended by the admitting critical care team for 386 (38%) patients. Patients deemed to require an urgent echocardiography as part of their initial critical care admission management plan were significantly more likely to receive this, compared to patients not deemed to require urgent echocardiography, at each time point post admission (72hrs: n\u0026thinsp;=\u0026thinsp;332, 86% vs n\u0026thinsp;=\u0026thinsp;213, 34%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, 24hrs: n\u0026thinsp;=\u0026thinsp;293, 76% vs n\u0026thinsp;=\u0026thinsp;143, 24%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, 1hr: n\u0026thinsp;=\u0026thinsp;53, 14% vs n\u0026thinsp;=\u0026thinsp;18, 3%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eAt each time point, a higher proportion of patients with obstructive shock received an echocardiogram than for other shock aetiologies (72hrs: n\u0026thinsp;=\u0026thinsp;20/23, 87%; 24hrs: n\u0026thinsp;=\u0026thinsp;18; 78%, 6hrs: n\u0026thinsp;=\u0026thinsp;65%), followed by cardiogenic shock (72hrs: n\u0026thinsp;=\u0026thinsp;171/207, 83%; 24hrs: n\u0026thinsp;=\u0026thinsp;149, 72%; 6hrs: n\u0026thinsp;=\u0026thinsp;95, 46%), mixed shock (72hrs: n\u0026thinsp;=\u0026thinsp;116/203; 57%; 24hrs: n\u0026thinsp;=\u0026thinsp;92; 46%, 6hr: n\u0026thinsp;=\u0026thinsp;43, 21%), hypovolaemic shock (72hrs n\u0026thinsp;=\u0026thinsp;93/218, 43%; 24hrs: n\u0026thinsp;=\u0026thinsp;70, 32%; 6hrs: n\u0026thinsp;=\u0026thinsp;43, 21%), and distributive shock (72hrs: n\u0026thinsp;=\u0026thinsp;145/541, 40%; 24hrs: n\u0026thinsp;=\u0026thinsp;106, 29%; 6hrs: n\u0026thinsp;=\u0026thinsp;37, 17%) .\u003c/p\u003e \u003cp\u003eEchocardiography was performed by a member of the critical care team in 16 (80%) patients with obstructive shock, 64 (69%) patients with hypovolaemic shock, 93 (64%) patients with distributive shock, 84 (56%) of patients with cardiogenic shock and 93 (46%) patients with mixed shock. Patients with cardiogenic shock were most likely to receive and echocardiogram from a member of the cardiology team (n\u0026thinsp;=\u0026thinsp;71, [49%]), (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUrgency and type of echocardiogram performed, and background of echocardiographer, categorised by shock classification. Critical care scan refers to any echocardiogram performed by a member of the critical care team and cardiology scan by a cardiology doctor or cardiac physiologist.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrgent scan recommended, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrgent scan performed, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFocussed scans, n\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive scans, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCritical care scan, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCardiology scan, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstructive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 (15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiogenic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e84 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e71 (49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistributive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97 (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypovolaemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64 (69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22 (25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57 (49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e41 (35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMost patients with cardiogenic (n\u0026thinsp;=\u0026thinsp;121/207, 58%), obstructive (n\u0026thinsp;=\u0026thinsp;13/23, 57%), distributive (n\u0026thinsp;=\u0026thinsp;277/365, 65%), hypovolaemic (n\u0026thinsp;=\u0026thinsp;162/218, 62%) and mixed shock (n\u0026thinsp;=\u0026thinsp;136/202, 67%) were admitted out of hours (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A lower proportion of patients admitted out of hours received an echocardiogram within one hour (n\u0026thinsp;=\u0026thinsp;38, 6%) compared to patients admitted in hours (n\u0026thinsp;=\u0026thinsp;33, 9%).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eImpact of echocardiography on diagnosis and management\u003c/h2\u003e \u003cp\u003eEchocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases, with a change of management reported in 270 (50%) and reduction of diagnostic uncertainty reported in 120 (22%) of patients. Echocardiograms deemed to be urgent (n\u0026thinsp;=\u0026thinsp;56, 17%) were significantly less likely to be deemed to have reduced diagnostic uncertainty compared to those regarded as non-urgent (n\u0026thinsp;=\u0026thinsp;64, 30%; p\u0026thinsp;=\u0026thinsp;0.0003). Similarly, significantly fewer scans were reported to alter management where patients were deemed to require an urgent echocardiogram compared to those not deemed urgent (n\u0026thinsp;=\u0026thinsp;144 [44%] vs n\u0026thinsp;=\u0026thinsp;122 [57%] p\u0026thinsp;=\u0026thinsp;0.0034)).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eComprehensive scans, compared to focussed scans, were more likely to be deemed to alter patient management (n\u0026thinsp;=\u0026thinsp;101 [56%] vs n\u0026thinsp;=\u0026thinsp;169 [46%], p\u0026thinsp;=\u0026thinsp;0.0366) and reduce diagnostic uncertainty (n\u0026thinsp;=\u0026thinsp;46 [25%] vs n\u0026thinsp;=\u0026thinsp;74 [20%], p\u0026thinsp;=\u0026thinsp;0.042). Scans performed by cardiac physiologists led to a reported change in patient management in a higher proportion of patients (n\u0026thinsp;=\u0026thinsp;74, 63%), than those performed by intensive care trainees (n\u0026thinsp;=\u0026thinsp;57, 52%, p\u0026thinsp;=\u0026thinsp;0.08), intensive care consultants (n\u0026thinsp;=\u0026thinsp;56, 41%; p\u0026thinsp;=\u0026thinsp;0.0003), or cardiologists (n\u0026thinsp;=\u0026thinsp;27, 45%; p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003cp\u003eEchocardiography reduced diagnostic uncertainty or altered management in 15 (71%) patients presenting with obstructive shock, 100 (58%) patients presenting with cardiogenic shock, 41 (44%) patients presenting with hypovolaemic shock, 52 (36%) patients presenting with distributive shock, and 67 (58%) patients with mixed shock (Fig.\u0026nbsp;1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEchocardiography accreditation and adherence to national guidelines\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e308 (56%) scans were performed by clinicians accredited in echocardiography. The most common accreditations were Focused Ultrasound in Intensive Care (FUSIC), comprising 181 (59%) scans, followed by BSE Transthoracic (TTE) Level 2 (n\u0026thinsp;=\u0026thinsp;77, 25%), BSE Level 1 (n\u0026thinsp;=\u0026thinsp;19, 6%), and BSE Advanced Critical Care Echocardiography (n\u0026thinsp;=\u0026thinsp;11, 4%). Other accreditations included the European Diploma in advanced critical care EchoCardiography (EDEC), the European Society of Cardiovascular Imaging TTE, transoesophageal (TOE) accreditation, and BSE TOE.\u003c/p\u003e\u003cp\u003eEchocardiographic findings were documented via a free-text report in 297 (54%) cases, a structured report in 212 (39%) cases and 36 (7%) had no report documented. Images were stored on the ultrasound machine in 211 (39%) cases, in digital archiving systems in 182 (33%) cases and not stored in 211 (39%) cases. The location of image storage was documented in the notes for only 131 (24%) patients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multicentre, prospective observational study represents the largest evaluation of critical care echocardiography use in the assessment of patients with undifferentiated shock. The key finding was that only 54% of patients received an echocardiogram within 72-hours of admission. We also identified three broad themes; the utility of echocardiography in influencing management and reducing diagnostic uncertainty in the management of shock; heterogeneity of application of critical care echocardiography in the assessment of shock; and low adherence to best practices guidelines regarding image storage and documentation.\u003c/p\u003e \u003cp\u003eEchocardiography was reported to have reduced diagnostic uncertainty or altered patient management in 54% of patients. These findings align with previous smaller studies, demonstrating that echocardiography changed management in 38%-51% of patients and improved diagnostic certainty in 29%-37% of patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Patients with presumed obstructive or cardiogenic shock were more likely to have their management altered by the findings of the index echocardiogram (71% and 58% respectively). This likely reflects the association of these aetiologies with interventions, including thrombolysis, pericardiocentesis, percutaneous coronary intervention and use of mechanical circulatory support. These findings further emphasise the essential role of echocardiography in the assessment of shock, outlined in cardiogenic shock guidelines and the European Resuscitation Council Guidelines for identification of obstructive shock [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. For patients with hypovolaemic and distributive shock echocardiography was reported to have influenced clinical management in 43% and 27% of cases respectively. Previous work has demonstrated the high sensitivity of emergency ultrasound for the identification of distributive (e.g., septic) and hypovolaemic (e.g., haemorrhagic) shock and there are established protocols that incorporate echocardiography (e.g., Focused Assessment with Sonography for Trauma and Rapid Ultrasound in Shock in the Evaluation of the Critically Ill) into the assessment of these syndromes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOur study demonstrated geographical heterogeneity in the delivery of echocardiography throughout the UK and Crown Dependencies. These findings may be a result of numerous factors, including regional variability in the availability of accredited clinicians and differing opinions on the use of echocardiography in shock between centres. Minimal previous work has been performed investigating regional variability in echocardiography provision throughout UK critical care units but the work that has been done also demonstrates heterogeneity, a finding that is replicated in wider Europe and Australasia.[\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] Improved training of critical care clinicians may help reduce reliance on cardiology teams and improve out-of-hours access, given the inevitable 24/7 onsite presence of critical care clinicians.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe majority of echocardiograms obtained were focussed scans, performed by critical care physicians. Whilst comprehensive scans and echocardiography performed by cardiac physiologists were more likely to be reported to alter patient management, focussed echocardiography was still reported to have altered management in 46% of cases. These findings highlight the role of both focussed and comprehensive echocardiography in patients with shock. Focussed echocardiography is more readily available at the patient\u0026rsquo;s bedside, more commonly performed by critical care teams and can aid initial diagnostic reasoning and patient management. In contrast, comprehensive echocardiography tends to be performed later during a patient\u0026rsquo;s admission, is more commonly performed by cardiac physiologists, and can add value beyond its focussed counterpart. In practice, the two modalities should be complimentary, with focussed echocardiography permitting rapid diagnostic ability at any time of day, and comprehensive echocardiography providing more detailed assessment of both structure and function to refine management.\u003c/p\u003e\u003cp\u003eTo support the provision of universal focussed echocardiography, critical care units should be encouraged to incorporate echocardiography education into their departments, as the development of trainees and trainers is vital. Comprehensive echocardiography requires more advanced training and a significant time commitment to both acquire and maintain the skillset. As a minimum standard, there should be 24/7 provision of focussed echocardiography in critical care units with the capability for comprehensive imaging in-hours, or certainly availability of expert (remote) review of focussed images. Broader democratisation of echocardiography accreditation is key to facilitate the expansion of its availability, with its inclusion into undergraduate and postgraduate curricula both feasible and effective. For example, it has previously been demonstrated that medical students with minimal echocardiography training were able to more accurately diagnose key cardiac pathologies than senior cardiologists performing a physical examination [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Moreover, several countries have already incorporated mandatory critical care echocardiography into their postgraduate Intensive Care Medicine training, including those in wider Europe, Australia and New Zealand, and other medical specialties in the UK have successfully assimilated emergency echocardiography into their curricula [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Artificial intelligence (AI) represents another tool to facilitate reliable expansion of echocardiography, with its correct application permitting faster training, increasing diagnostic accuracy and reducing interobserver variability [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe inverse association between perceived urgency and echocardiography informing management or diagnostic uncertainty supports the notion that routine and unbiased echocardiography may add value in cases of undifferentiated shock. Indeed, the ESICM consensus statement on circulatory shock and haemodynamic monitoring, recommends the use of echocardiography as a first-line imaging modality in any patient where the aetiology of shock is uncertain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe majority of echocardiograms performed in this observational study did not comply with UK guidelines on image storage and reporting which recommend that all images should be securely stored for quality assurance purposes, whilst reliance on ultrasound machine storage is not a sufficiently secure method [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This guidance also states that when scans are performed to inform clinical decision making, a structured report should be generated and stored in the patient\u0026rsquo;s medical record. Further work to explore and understand barriers to compliance with these recommendations may help in the safe expansion of critical care echocardiography services.\u003c/p\u003e\u003cp\u003eStrengths of this study include the involvement of 70% of critical care units across the UK and Crown Dependencies. This is the largest study of its kind conducted to date, including a broad range of critical care units, within rural and urban centres, improving the external validity of our findings. The acknowledgement of multi-professional sonographer skillsets in acquisition of the echocardiograms within this study, accurately represents current echocardiography provision in the emergent setting within the UK.\u003c/p\u003e\u003cp\u003eThis study has several limitations. A local clinician assessment was used to determine if echocardiography influenced diagnosis and patient management. This is subject to inherent bias and inaccuracy. The observational nature of this study cannot determine whether the critical treatment decisions based upon the results of the sonographic assessments truly had an effect on overall outcome. The conduct of the study may itself have resulted in the Hawthorne effect, whereby an echocardiogram is performed when it may not have been prior. This could lead to an overestimation of the utility of echocardiography in patients with shock. Additionally, we did not assess the availability of echocardiography as a potential barrier within this study. The quality and accuracy of image reporting was also beyond the scope of this study. Finally, the definition of shock to determine patient eligibility is challenging. The study used a pragmatic approach by undertaking expert consultation to reach a study definition for eligibility, in addition to providing case examples and offering support to sites with queries. Crucially, we acknowledge that critical care echocardiography is not a static test, but rather a tool that supports dynamic assessment and reassessment following interventions.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eUrgent echocardiography is not routinely used in the assessment of critically ill patients with shock in the UK and Crown Dependencies, despite international guidance. This study suggests that echocardiography may alter management and improve diagnostic certainty in patients with undifferentiated shock. Future work should explore barriers to the expansion of echocardiography provision within critical care to permit improved equity of care amongst patients presenting with shock.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFinancial interests:\u003c/h2\u003e \u003cp\u003eNone to declare.\u003c/p\u003e \u003ch2\u003eCOI:\u003c/h2\u003e \u003cp\u003eAM, MP, JW and OO have received honoraria from GE healthcare. No other authors have relevant COI to declare.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIntensive Care Society | Shock to Survival Report \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ics.ac.uk/resource/shock-to-survival-report.html\u003c/span\u003e\u003cspan address=\"https://ics.ac.uk/resource/shock-to-survival-report.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Crit Care 20:339. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13054-016-1444-9\u003c/span\u003e\u003cspan address=\"10.1186/s13054-016-1444-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsharqi M, Woodward WJ, Mumith JA, Markham DC, Upton R, Leeson P (2018) Artificial intelligence and echocardiography. Echo Res Pract 5:R115\u0026ndash;R126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1530/ERP-18-0056\u003c/span\u003e\u003cspan address=\"10.1530/ERP-18-0056\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarry T, Farina JM, Chao CJ, Ayoub C, Jeong J, Patel BN, Banerjee I, Arsanjani R (2023) The Role of Artificial Intelligence in Echocardiography. J Imaging 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/JIMAGING9020050\u003c/span\u003e\u003cspan address=\"10.3390/JIMAGING9020050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"intensive-care-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"icme","sideBox":"Learn more about [Intensive Care Medicine](http://link.springer.com/journal/134)","snPcode":"134","submissionUrl":"https://www.editorialmanager.com/icme/default2.aspx","title":"Intensive Care Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"echocardiography, shock, ultrasound, intensive care, critical care","lastPublishedDoi":"10.21203/rs.3.rs-4611404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4611404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEchocardiography is an essential tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. We sought to evaluate the utilisation of echocardiography in patients presenting to critical care with undifferentiated shock and its impact on decision making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom and Crown Dependencies. The study was led by the UK’s Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 hours to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1015 patients with undifferentiated shock were included. An echocardiogram was performed on 545 (54%) patients within 72 hours and 463 (43%) within 24 hours of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive, cardiogenic, or mixed shock had their management altered numerically more often by echocardiography (n = 15 [71%], n = 100 [58%] and n = 67 [58%]). 24% of echocardiograms performed adhered to current national information governance and image storage guidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUse of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock.\u003c/p\u003e","manuscriptTitle":"The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:17:16","doi":"10.21203/rs.3.rs-4611404/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2024-07-08T12:35:32+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-06-23T08:46:18+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-23T08:17:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-23T05:41:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Intensive Care Medicine","date":"2024-06-20T07:24:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"intensive-care-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"icme","sideBox":"Learn more about [Intensive Care Medicine](http://link.springer.com/journal/134)","snPcode":"134","submissionUrl":"https://www.editorialmanager.com/icme/default2.aspx","title":"Intensive Care Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"83efc0d2-c1ff-4d2a-a9d6-114d84062ea1","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-26T15:58:23+00:00","versionOfRecord":{"articleIdentity":"rs-4611404","link":"https://doi.org/10.1007/s00134-024-07590-6","journal":{"identity":"intensive-care-medicine","isVorOnly":false,"title":"Intensive Care Medicine"},"publishedOn":"2024-08-19 15:56:50","publishedOnDateReadable":"August 19th, 2024"},"versionCreatedAt":"2024-07-18 20:17:16","video":"","vorDoi":"10.1007/s00134-024-07590-6","vorDoiUrl":"https://doi.org/10.1007/s00134-024-07590-6","workflowStages":[]},"version":"v1","identity":"rs-4611404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4611404","identity":"rs-4611404","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}