The "STePs to SAVE LIVES" Framework: A Holistic Approach to Early Systemic Hypoperfusion Assessment

Introduction: Systemic hypoperfusion (SH) is a life‑threatening state that predisposes critically ill patients to organ dysfunction, prolonged hospitalization, and increased mortality. The STePs to SAVE LIVES framework aims to provide a holistic approach for the initial assessment of SH by integrating clinical, radiological, and PoCUS findings.


Methods: We conducted a comprehensive literature review to identify key components related to SH, including systemic perfusion, cardiac function, fluid overload, fluid responsiveness, and afterload. Following Haynes’ evidence‑based pyramid, we synthesized clinical practice guidelines, systematic reviews, and original studies to develop the algorithm. Validation was performed through a modified Delphi process, starting with predefined statements and steps. We invited physicians experienced in SH from Emergency Medicine, Internal Medicine, Critical Care, Cardiology, and Nephrology. The survey contained eight items (flowchart structure, conceptual definitions, and measurements) evaluated using a 7‑point Likert scale (1. strongly disagree to 7. strongly agree). Consensus was defined as ≥ 80% agreement or disagreement. The framework is part of the HAHA protocol (Holistic Approach to systemic Hypoperfusion Assessment) registered on OSF (osf.io/8pksm) and approved by our local ethics committee. LLM was employed to enhance writing style.


Results: Thirteen experts responded, from Mexico (84.6%), Ecuador (7.7%), and Colombia (7.7%). Their specialties were critical Care (30.8%), Internal Medicine (23.0%), Nephrology (15.4%), Emergency Medicine (15.4%), and Cardiology (15.4%), with a median of 12.5 years of clinical experience (IQR 8–15.5). The STePs to SAVE LIVES algorithm comprises three steps: (1) SH assessment, (2) Etiology identification using the STePs to SAVE LIVES acronym (e.g., S for STEMI), and (3) PoCUS to assess cardiac function and ruling-out kissing papillary muscle sign. If SH etiology remains unclear, patients can follow two pathways: SH with normal or abnormal cardiac function. All eight Delphi items reached > 80% agreement.


Conclusions: The "STePs to SAVE LIVES" algorithm optimizes early SH assessment with > 80% expert consensus; upcoming work will focus on clinical implementation and validation of the pathways for SH with normal and abnormal cardiac function.