Although PAC or PiCCO have been used to monitor fluid volume status of shock patients, US at the bedside has also been used in emergent circumstances, however this does not provide a continuous measurement but purely a "snapshot". Using "PVI" (Plethysmographic Variability Index) has not only revealed promise but is non-invasive, easily obtained, and monitors continuously. Forget, P., et al (2010) Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management (Anesth Analg. 2010 Oct; 111(4):910-4), Cannesson, M., et al (2008) Pleth variability index to monitor the respiratory variations in the pulse oximeter plethysmographic waveform amplitude and predict fluid responsiveness in the operating theater (Br J Anaesth 2008 Aug; 101(2):200-6), and Shamir, M, et al (1999) Pulse oximetry plethysmographic waveform during changes in blood volume (Br J Anaesth 1999 82(2): 178-81) are great examples of the usefulness of this technology.

More than 400 times by years for our ten beds medical ICU.

In case of shock unknown origin, Ultrasound (US) may be used for hemodynamic assessment in the ED and during the first hours in the ICU, time to insert arterial line and CVP and to evaluate further crystalloids need or not. Moreover, US may be useful for a rapid and accurate examination of the abdomen (intraperitoneal fluid, obstructive uropathy, bladder distension?) and of course to detect potential large pericardial effusion, marked RV dilatation, severe abnormal contractility.

US may be considered as the most rapid initial accurate care, but they need training. Today, all the minimally trained operators of an ICU are able to perform a correct US screening, furthermore all ICU’s physicians should be trained. Of course, US could also be used during the ICU stay to evaluate cardiac performance and response to treatment.

Our ICU own one US device, which can be used at any time by the young fellows and intensivists on duty. For a ten beds medical ICU, we perform by year, more than 400 hundreds US examinations, less than ten PAC and near 30-40 of

PICCO2, for 150 to 180 admissions for shock, more than two third requiring arterial lines and CVP, vasopressors and mechanical ventilation. Our hospital mortality rate being in the range of a large regional database.

Of course, the source of the sepsis and or the etiology of the shock is suspected very rapidly, thus majority of our US use concerns hemodynamic assessment and response to treatment.

FATE (Focus Assessd Transthoracic Echocardiography) echo can be helpful in hemodynamically unstable patients in the ICU