A patient with end-stage kidney disease on hemodialysis was admitted with pneumonia. The individual had a chronic tracheostomy and PEG tube and came from a nursing facility. Nephrology was following for dialysis needs during the admission. Over the weekend, the blood pressure fell into the 80s systolic and did not respond to intravenous fluids, prompting an ICU consult. By a neat twist of fate, the ICU fellow on call was me, a nephrologist training in critical care medicine at that time.

In any hypotensive patient, the very first step is a meticulous bedside assessment, where POCUS stands as an indispensable extension of the physical exam. Scanning from the subxiphoid window revealed a plethoric IVC and a large complex pericardial effusion surrounding the right-sided chambers with striking collapse, a finding also evident in the parasternal and apical views. The collapse was so pronounced that at first glance, the effusion itself could be mistaken for the right atrium and ventricle (see labelled images).

The patient was transferred to the ICU where I performed a pericardiocentesis through a parasternal pocket under attending supervision. About 500 mL of blood-tinged fluid was drained and the blood pressure improved almost immediately. A brief norepinephrine infusion was discontinued soon after. There was no history of trauma, but dialysis had been curtailed for several weeks because of persistent hypotension, even during the current admission (raising the possibility of a uremic contribution to the worsening effusion). Tuberculosis testing was negative. Follow-up images obtained the next day after drain removal confirmed sustained resolution, revealing the right-sided chambers beautifully expanded and unmistakably clear.

This experience shows how a simple five-minute POCUS examination by the nephrology team could have changed the course of care, avoiding a crash transfer and emergent procedure and allowing for an elective drainage in the cath lab instead. The goal is not to assign blame but to highlight an obvious opportunity. POCUS has already demonstrated its diagnostic power, and any improvement in patient outcomes depends on linking those diagnostic findings to a treatment that itself alters the course of illness – as in this case, where drainage of the effusion directly changed the outcome.

Some senior nephrologists argue that they will adopt POCUS only if it is proven to improve hard outcomes. In my view, that stance often reflects fear of the unknown more than a genuine evidence gap. POCUS is about reducing guesswork, yet many in traditional circles take pride in clinical intuition and enjoy the accolades when a “guess” proves correct. A tool that replaces guesswork can feel threatening.

A similar scenario occurred in another patient during cardiac arrest. I performed POCUS from the subxiphoid window (the preferred view during CPR because it avoids interrupting chest compressions), and identified a large effusion likely causing tamponade. Using a central venous catheter from the crash cart, we drained the effusion and achieved return of spontaneous circulation—something chest compressions alone could not have accomplished

I suggest checking out this post on RFN for more pericardial effusion images and a review of how to assess for tamponade. Not every case is as dramatic as the ones illustrated above.