Contrast-enhanced ultrasound in critical care: a problem-solving approach

When the body enters a rapidly progressive and life-threatening pathological state, it is defined as critical illness. At this stage, respiratory and circulatory dysfunction are the most prevalent clinical manifestations. During disease progression and therapeutic interventions, persistent pathological insults, sustained microcirculatory hypoperfusion, and systemic inflammatory responses further contribute to complications such as coagulopathy, acute kidney injury, gastrointestinal dysfunction, and ICU-acquired weakness. Contrast-enhanced ultrasound (CEUS), as a non-invasive and bedside-applicable imaging modality, enables sensitive detection of tissue-level perfusion changes and provides crucial insights for the early identification of organ dysfunction and disease progression. Based on recent advances and our clinical experience, this article focuses on the evaluation and interventional strategies for perfusion-related pathophysiological processes in vulnerable organs within the ICU setting. In particular, we highlight the value of CEUS in assessing hemodynamics in the kidney, gastrointestinal tract, and skeletal muscle, emphasizing its role in microcirculatory monitoring, early disease recognition, CEUS-guided percutaneous interventions, and optimization of thrombus-related therapeutic decision-making. Collectively, these applications could support more precise interventions and have potential to improved patient outcomes.