Using Point-of-Care Ultrasound in the PICU: What We Now Know and What We Want to Know?

In 2021 two groups of clinical experts presented perspectives on the use of point-of-care ultrasound (POCUS) in the PICU by nonradiology and noncardiology clinicians; that is, by critical care fellowship trainees and pediatric intensivists (1,2). One group focused on the issue of “individual credentialing and certification, program oversight, and standardization of protocols,” while the other group gave insight into the provision of education and training to ensure competence in “pediatric critical care-specific POCUS guidelines” (2). Currently, 5 years later, in this issue of Pediatric Critical Care Medicine (PCCM), we have two reports from the Pediatric Research Collaborative on Critical Ultrasound (PeRCCUS) subgroup of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (https://www.palisi.org/subgroups). Many of the authors from the 2021 reports were involved in this new work, which used a Delphi consensus-based approach to provide recommendations for POCUS in the PICU (3,4). The first report involved 30 experts from 27 institutions in the United States, and there were 25 consensus-based recommendations about POCUS in the PICU, across five domains: clinical application, quality assurance, equipment, education, and research (3). The second report describes the work of 23 experts from 17 institutions in the U.S., which led to 14 entrustable professional activities (EPAs) for trainees in pediatric critical care POCUS (4). These EPAs offer a structured approach to fellow and trainee education, and assessment of competency. In conjunction, these four reports from 2021 and 2026 show how a discussion among clinician researchers can lay the groundwork for evolving standards in education and practice of POCUS in pediatric critical care. Even so, there is more to learn about critical care POCUS, and the progress that has been made between 2021 and 2026. Therefore, the topic of this month’s Editor’s Notes is critical care POCUS in children. PROGRAM DEVELOPMENT A 2023 report from 14 members of the PeRCCUS group outlined their opinion about a competency-based medical education program with seven principles or steps to ensure patient safety when using POCUS in the PICU (5). This report underlines the other work of the PeRCCUS group on EPAs in this issue of PCCM (4). We also have evidence from one center’s experience in developing a program for using diagnostic POCUS in the PICU (6,7). Over the 5 years, 2017−2022, the multidisciplinary team created an educational curriculum in POCUS for cardiac, thoracic, and abdominal diagnostics, as well as a process for credentialling faculty in this practice. The authors found that the introduction of the program was associated with increased use of diagnostic POCUS (as one would expect) but interestingly the results of imaging–particularly the cardiovascular ultrasound–led to altered diagnoses and changes in management. Therefore, what have we learned about POCUS-related diagnostics by pediatric intensivists? DIAGNOSTICS Two areas of POCUS diagnostic work have featured in PCCM. These are important because they have the prospect of helping clinicians make better-informed decisions. For example, assessing shock and resuscitation fluid-responsiveness, or evaluating the artificial airway. Shock and Fluid Responsiveness A systematic review of literature through to 2022 found that POCUS measurements of the cardiovascular system were limited as tools for predicting fluid responsiveness (8). Since that review, four reports have moved the field forward. Two reports described the experience in single centers, and the other reports involved prospective observational cohorts. The first retrospective study came from a single center in Vietnam (2013−2021), and the investigators focused on their use of hemodynamic monitoring in mechanically ventilated children with profound dengue shock syndrome (9). The authors reported that in their experience use of POCUS to assess and monitor hemodynamic response during the course of cumulative fluid administration was associated with lower odds of death, a higher volume of resuscitation fluid administered, and improvements in blood lactate levels, vasoactive-inotrope score and the pediatric logistic organ dysfunction score. The second retrospective study came from the U.S. (2011−2020) and the authors described using POCUS to assess the presence of depressed cardiac function (10,11). In such cases, the clinicians’ practice was to switch treatment with vasoconstrictors and support the patient with inotropes; these patients were more likely to be extubated and to be weaned off vasoactive support compared with those who remained on vasoconstrictors. The two prospective observational reports included a 2019 cohort in Malawi (12–14) and a 2021−2023 multicenter cohort in France (15,16). The report from an emergency department (ED) in Malawi described using a p-RUSH (pediatric Rapid Ultrasound for Shock and Hypotension) protocol and algorithm to identify shock phenotypes in pediatric patients presenting in undifferentiated shock (12). The report was highlighted in an editorial (13) and there has been subsequent correspondence to the Journal (14). Overall, the “at the bedside” message is that the p-RUSH protocol is feasible in the ED, and it may lead to individualizing shock resuscitation care. Of note, the p-RUSH protocol included data on inferior vena cava (IVC) diameter and collapsibility to assess apparent hypovolemia, which the authors conceded “may be more difficult to interpret.” Here, the French study may provide more insight (15). This work focused on evaluating fluid responsiveness during mechanical ventilation and sought to assess a relationship between central venous pressure (CVP) and IVC ultrasound parameters. The authors did not find a relationship between the POCUS measurements and CVP; but, by way of explanation, the accompanying editorial provides a detailed physiological account (16). Taking the above together along with the new critical care POCUS EPAs and best practice guidelines from PeRCCUS (3,4), the collection of PCCM reports shows a direction of progress and illustrates how this clinical investigation can be applied to improve our understanding and management of shock. Endotracheal Tube Another application of critical care POCUS is when evaluating the endotracheal tube (ETT). For example, consider the single-center, observational TRUCE (three-point ultrasound for confirmation of endotracheal tube position in children) study carried out in India in 2021 (17, 18). The “three points” used in the assessment of ETT position were the suprasternal notch and both sides of the anterior chest (17). Those measurements were then compared with the patient’s chest radiograph and the authors found that POCUS was “an effective, sensitive, safe, and reproducible method” for identifying correct ETT placement. The accompanying editorial saw much merit in that work but recognized that the anatomical landmarks needed standardizing, as well as the methods used to measure the dimensions (18). There is also a POCUS airway study dealing with one frequent question around the time of ETT extubation: is this patient at-risk of post-extubation stridor? In this single-center, prospective cohort from the U.S. (2021−2022), the authors examined whether ultrasound measurement of the laryngeal air column width could be used as a diagnostic test of subsequent post-extubation stridor (19). The findings were inconclusive and at present there is diagnostic uncertainty when using the test in patients younger than 5 years. Given that ETT-placement and removal is a common practice in the PICU it is surprising that the application of POCUS to this aspect of critical care is understudied. As such we welcome more work in this area, perhaps focused on the potential to limit chest radiograph exposure or patient intubation days. WHAT WE NEED TO KNOW ABOUT POCUS POCUS in pediatric critical care is here to stay. The new reports from the PeRCCUS group provide us with a framework for practice and training (3,4). We can also learn from how others have developed a PICU-based program (6), and how they have implemented practices for evaluating shock and fluid responsiveness (9,10,12,15), and ETT care (17,19). Add to this knowledge new research activity in the field that requires more widespread validation and examination. For example, in 2025, there were research reports on the following aspects of PICU care: muscle mass assessment for evaluation of nutritional state (20,21); respiratory muscle mass quantification as part of mechanical ventilation weaning (22); lung ultrasound as part of describing lung pathology (23,24); ultrasound to confirm gastric and postpyloric tube position (25); and measurement of optic nerve sheath diameter as part of intracranial pressure consideration (26–28). At PCCM we recognize that critical care POCUS is an important part of practice, and we welcome all new clinical investigations that validate our understanding of clinical physiology and best treatment.