Ultrasound assessment of patients in shock is becoming the standard of care in emergency and critical care settings worldwide. One of the most common protocols used for this assessment is the rapid ultrasound in shock (RUSH) examination. The RUSH protocol is a rapid evaluation of cardiac function, key vascular structures, and likely sources of hypotension. Stroke volume is an established important value to assess in the setting of shock, allowing the provider to predict the patient's response to treatment. However, the calculation of stroke volume or its surrogates is not part of any protocol, including RUSH. We propose the addition of ultrasound calculation of stroke volume or surrogates to the RUSH protocol and provide support for its utility and relative ease of calculation. The resulting product would be the RUSH velocity-time integral protocol.

IntroductionVenous congestion is a pathophysiological state where high venous pressures cause organ oedema and dysfunction. Venous congestion is associated with worse outcomes, particularly acute kidney injury (AKI), for critically ill patients. Venous congestion can be measured by Doppler ultrasound at the bedside through interrogation of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV) and intrarenal veins (IRV). The objective of this study is to quantify the association between Doppler identified venous congestion and the need for renal replacement therapy (RRT) or death for patients with septic shock.Methods and analysisThis study is a prespecified substudy of the ANDROMEDA-SHOCK 2 (AS-2) randomised control trial (RCT) assessing haemodynamic resuscitation in septic shock and will enrol at least 350 patients across multiple sites. We will include adult patients within 4 hours of fulfilling septic shock definition according to Sepsis-3 consensus conference. Using Doppler ultrasound, physicians will interrogate the IVC, HV, PV and IRV 6–12 hours after randomisation. Study investigators will provide web-based educational sessions to ultrasound operators and adjudicate image acquisition and interpretation. The primary outcome will be RRT or death within 28 days of septic shock. We will assess the hazard of RRT or death as a function of venous congestion using a Cox proportional hazards model. Sub-distribution HRs will describe the hazard of RRT given the competing risk of death.Ethics and disseminationWe obtained ethics approval for the AS-2 RCT, including this observational substudy, from local ethics boards at all participating sites. We will report the findings of this study through open-access publication, presentation at international conferences, a coordinated dissemination strategy by investigators through social media, and an open-access workshop series in multiple languages.Trial registration numberNCT05057611.

Dear editor,We would like to call attention upon the fact that currently there are two paths or modi operandi that can be recognized when working with critical care patients: the traditional paradigm and the ultrasound-supported paradigm [1]. The first consists in using ultrasonography (US) ''inconstantly'' in sick patients, in other words, in an oncall manner and performed by specialists (e.g., radiologists and/or echocardiographers). By contrast, the US-supported paradigm consists in using US by intensivists at the patientś bedside with the purpose to add valuable information to further support, refute or change a clinical diagnostic hypothesis and also to assist in common interventional procedures. In the latter paradigm, the US is extensively available and specialistś consulting is seldom required.In terms of the paradigm that is being currently used, it seems that US use is growing up in critical care settings, but, still, it does not win the fight against its former competitor. Some numbers allow us to affirm this concept. A recent multicenter study involving 142 adult intensive care unit (ICU) patients of France, Belgium and Switzerland [2], showed that point-of-care US (POCUS) was used in approximately one-third (36 %) of the patient population/day, predominantly for diagnostic purposes in 87 % of the cases, whereas for interventional guidance was used in only 13 % of indications.Reasoning about these findings, it is intuitive asking how were managed the remaining 64 % (the most) who did not receive an US-based approach.It is supposed that deliberate US use is not a routine practice in intensive care settings, but according to diagnostic and procedural guidance capabilities of this noninvasive and indolent diagnostic imaging method, why not to extend POCUS to a 100 % of the patient population/day is a logical question that could naturally arise.Limitations for using POCUS are probably multiple, ranging from the common physicianś believe that US is a merely ''operator-dependent'' method, passing through the unproven fact that US has never demonstrated survival benefits to critically ill patients, up to the scarce monetary resources to purchase and maintain an ultrasound machine, being the last specially relevant in developing countries.It seems that a lot of reasons for not using POCUS exist; however, there is still an important amount of uncertainty from practitioners about using US, mostly related to the skepticism related to a technique which, at first glance, does not belong to the scope of intensivists.We encourage intensivists to change their work path from the traditional paradigm to the US-supported paradigm if they have not already done so. Benefits are clearly demonstrated for patients and also physicians and nurses working in ICU.On the contrary, changing from the US-supported paradigm to the other one is not possible due to the fact that POCUS seems to be a one-way directional road.Acknowledgments The authors would like to thank Mrs. Celeste Bruno for the language guidance.

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