The ultrasound gap in de-resuscitation trials: A systematic review of physiological assessment deficits.

BACKGROUND: Fluid overload is associated with increased mortality in critically ill patients, yet de-resuscitation trials frequently report negative or inconclusive results. This systematic review examines the relationship between parameter objectivity, ultrasound utilization, and trial outcomes in de-resuscitation research. METHODS: We conducted a comprehensive systematic review of randomized controlled trials investigating de-resuscitation interventions in critically ill adults. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool. Statistical analysis included comparison of ultrasound versus non-ultrasound studies and pooled outcome analysis. RESULTS: 13 studies were identified which randomised 2495 patients. Of the included studies, 4 (30.8%) performed some form of ultrasound assessment. However, only 1 study (7.7%) explicitly used ultrasound to guide de-resuscitation interventions. However, it did not achieve significant fluid separation between the control and interventional arm. No studies achieved positive hard clinical outcomes (mortality reduction or major morbidity reduction) from de-resuscitation interventions. However, several studies successfully achieved their stated primary endpoints: fluid balance separation was achieved in 7 of 13 studies (53.8%), feasibility objectives were met in 3 studies, and improvements in secondary endpoints including ventilator-free days and time to extubation were demonstrated in select studies. These findings suggest that achieving targeted fluid balance changes does not necessarily translate to improved clinical outcomes. CONCLUSIONS: Current research is characterized by a significant 'ultrasound gap,' where the theoretical benefits of POCUS are not yet integrated into interventional trials. Future research must bridge this gap using standardized, physiology-driven protocols.