The_MINUTES_bundle_for_the_initial_30 min_management_of_undifferentiated.pdf

Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 International Journal of https://doi.org/10.1186/s12245-024-00660-y...

Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 International Journal of https://doi.org/10.1186/s12245-024-00660-y Emergency Medicine REVIEW Open Access The MINUTES bundle for the initial 30 min management of undifferentiated circulatory shock: an expert opinion Ahmed Hasanin1*, Filippo Sanfilippo2,3, Martin W Dünser4, Hassan M Ahmed5, Laurent Zieleskiewicz6, Sheila Nainan Myatra7 and Maha Mostafa1 Abstract Acute circulatory shock is a life-threatening emergency requiring an efficient and timely management plan, which varies according to shock etiology and pathophysiology. Specific guidelines have been developed for each type of shock; however, there is a need for a clear timeline to promptly implement initial life-saving interventions during the early phase of shock recognition and management. A simple, easily memorable bundle of interventions could facilitate standardized management with clear targets and specified timeline. The authors propose the “MINUTES” acronym which summarizes essential interventions which should be performed within the first 30 min following shock recognition. All the interventions in the MINUTES bundle are suitable for any patient with undifferentiated shock. In addition to the acronym, we suggest a timeline for each step, balancing the feasibility and urgency of each intervention. The MINUTES acronym includes seven sequential steps which should be performed in the first 30 min following shock recognition: Maintain “ABCs”, INfuse vasopressors and/or fluids (to support hemodynamic/ perfusion) and INvestigate with simple blood tests, Ultrasound to detect the type of shock, Treat the underlying Etiology, and Stabilize organ perfusion. Keywords Shock, Ultrasound, Vasopressors, Fluids, Norepinephrine, Hypotension, Congestion Background Acute circulatory shock is a life-threatening and highly time-sensitive emergency. For its acute nature, circu- *Correspondence: latory shock is usually managed by frontline physicians, Ahmed Hasanin who are, sometimes, of limited knowledge and experi- [email protected] 1 Department of Anesthesia and Critical Care Medicine, Faculty of ence. Moreover, they may work in limited resource set- Medicine, Cairo University, Cairo, Egypt tings. Hence, having a clear, timely, easily memorizable 2 University Hospital Policlinico, G. Rodolico - San Marco, Catania, Italy approach may facilitate their performance and finally 3 Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy improve patient’s management. 4 Department of Anaesthesiology and Intensive Care Medicine, Kepler According to the type of shock, clinical guidelines have University Hospital and Johannes Kepler University, Krankenhausstrasse been developed and are regularly updated to optimize 9, Linz, Austria 5 Leeds Teaching Hospitals NHS Trust, Leeds, UK patient’s management. Once the specific diagnosis of 6 Service d’anesthésie réanimation hôpital nord Marseille APHM, C2VN Aix shock has been made, evidence-based management for Marseille Université, Marseille, France each type (e.g., septic, hemorrhagic, cardiogenic shock) 7 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National University, Mumbai, India is well established by international guidelines [2–6]. © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 2 of 8 However, it is critical to minimize the time between shock not only the most important and initial actions but also recognition and initiation of shock- or disease-specific to focus on the importance of a timely and sequential therapies. Currently, specific recommendations for the approach for the main supportive and diagnostic steps. management of shock due to any etiology in the initial We believe that under most circumstances, the bundle few minutes are lacking. can be accomplished within the first 30 min after shock All physicians, especially junior staff, may benefit from recognition. a common pathway to manage patients with undifferen- tiated shock during the first minutes. Such a common Do the current guidelines cover the early phase of pathway should be applicable to all patients, indepen- shock adequately? dently of what type of shock is subsequently diagnosed. Despite the presence of dedicated guidelines for several In case of rapid clinical deterioration, it is widely types of shock, most of these represent recommenda- accepted that provision of basic and advanced life sup- tions in separate statements without specific order of port must be the first priority. However, it is unclear interventions nor a timeframe for achieving each man- how these first steps should be implemented, specifically agement step [2–6]. For instance, the Surviving Sepsis regarding their timing and order. Campaign considers several interventions according to The aim of this review is to propose a simplified bundle different sections (hemodynamic, infection, initial resus- for the initial management of patients with undifferenti- citation, etc.), but a timely approach is not present for all ated shock. Based on pathophysiological knowledge and interventions. Moreover, actions should be undertaken to scientific evidence, the expert panel suggests an acronym stabilize the patient and decrease mortality and morbid- that could help acute care physicians in this task by apply- ity before the cause of shock is recognized. ing a bundle of sequential interventions. The acronym Indeed, several guidelines focus on the management “MINUTES” was intentionally selected to summarize of the cause of shock. A summary of the existing guide- lines for different types of circulatory shock and the recommendations of its initial management is shown in Table 1 Guidelines for different types of circulatory shock and recommendations to be implemented within the first 30 min Table 1. Considering the identified potential gap in clin- Latest guidelines Recommendations to be ically-oriented guidelines for the initial management of implemented within the undifferentiated shock, the expert panel thinks that more first 30–60 min attention is required towards common major supportive Septic shock Surviving sepsis Measure lactate levels. steps. We think that the proposed first management steps campaign 2021 Obtain blood cultures before should be implemented independently from the cause of administering antibiotics. shock and before diagnosis is made, in order to reduce Administer broad-spectrum antibiotics. the period of “under-perfusion” and organ damage. Nota- Begin to rapidly administer bly, the expert panel also suggests a timeframe for the 30 ml/kg crystalloid for hypo- accomplishment of each phase. tension or lactate ≥ 4 mmol/L. Cardiogenic shock American Heart No specific timeline The rationale of prioritizing an intervention over Association 2022 recommendations other in the bundle Hypovolemic European Society Control any external bleeding The initial management of patients with undifferentiated hemorrhagic of Anaesthesiol- and maintain SBP < 90 mmHg shock needs a clear timeline with a pragmatic approach shock ogy 2023 [4, 6] (higher target in patients with focusing on both the urgency of the interventions as well brain trauma) until bleeding is as the feasibility of such interventions within given time controlled frames. For example, emergency physicians, intensivists, Hypovolemic No guidelines and anesthesiologists who care for patients with undif- non-hemorrhagic identified shock ferentiated shock face the challenge of balancing two Obstructive European Society No specific timeline guidelines key priorities: (1) the need to treat the underlying cause (pulmonary of Cardiology except of urgent echocardiog- of shock (etiological management); and (2) the need to embolism) 2019 raphy to detect RV failure for rapidly restore organ perfusion (pathophysiological man- possible reperfusion. agement). Scientific evidence underlines the time Obstructive (car- No guidelines sensitivity of the latter intervention (restoration of vital diac tamponade) identified and systemic organ perfusion). Indeed, every additional Obstruc- No guidelines minute of hypotension is associated with poor outcomes tive (tension identified pneumothorax). Moreover, certain causes of shock may require lon- MAP: mean arterial pressure, RV: right ventricle, SBP: systolic arterial blood ger time to achieve diagnosis, hence it would be harm- pressure ful to delay hemodynamic support until the etiology has Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 3 of 8 been clarified. Finally, in the vast majority of patients of adequate arterial blood pressure levels to ensure vital with shock, early initiation of vasopressors is needed, organ perfusion using vasopressors and/or fluids, as well and in most cases their potential harm is limited. There- as performing simple tests like an electrocardiogram or fore, the expert panel suggests that vasopressors and/or a VBG should be the essential subsequent steps before fluids should be infused early in the management, after implementing point-of-care ultrasound to identify the basic and advanced life support has been implemented. type of shock. Of course, such clinical decision should be undertaken only after certain etiologies (e.g., tension pneumothorax), Components of the MUNITES bundle which are rapidly fatal, easily detectable without imaging, The First-MINUTES bundle includes six sequential steps: and reversible (e.g., decompression), have been ruled out. Maintain “ABCs”, INfuse vasopressors and/or fluids, The second consideration we took in order to justify INvestigate, Ultrasound, Treat Etiology, and Stabilize. the priorities in the acronym was the feasibility and time The First-MINUTES bundle is summarized in Table 2, needed for each intervention. We believe that all sup- and graphically displayed in Fig. 1. In the subsequent portive and diagnostic tasks should be done whenever manuscript, rationale behind each step with its associ- possible; however, simple blood investigations (as venous ated time frame is explained. blood gases [VBG]) were prioritized for being easier to obtain and would provide answers within a couple of Recognition of shock minutes only. Accurate and timely detection is essential and unequiv- For the above reasons, we suggest that the logical ocally the most important step in managing patients in approach and timeline for the early management of shock. Well-known bedside features of poor systemic patients with undifferentiated shock should always start perfusion are the three clinical windows: the brain (men- with basic and advanced life support, ensuring instant tal state), the kidneys (urine output), and most impor- management of rapidly fatal conditions such as massive tantly the skin. A recent systematic review of the external bleeding or tension pneumothorax. Restoration literature has identified that reduced peripheral perfu- sion/temperature, prolonged capillary refill time, and a Table 2 The MINUTES acronym to guide the initial management shock index (heart rate divided by systolic arterial blood of undifferentiated shock pressure) ≥ 0.7–0.8 are valid clinical indicators of shock. Letters Description of the item Objectives It is important to note that the presence of arterial hypo- of the tension, although commonly present in patients with acronym shock, must not be considered a prerequisite to define Maintain Provide basic and advanced life Control rapidly shock. Compensatory vasoconstriction, particularly “ABCs” support (e.g., compress external lethal etiologies. bleeding, decompress tension in young patients, may maintain arterial blood pressure pneumothorax) within the normal range despite critical systemic hypo- INfuse Reverse life-threatening arterial Achieve perfusion. Although serum lactate level is a sensi- vasopres- hypotension using vasopressors and/ MAP ≥ 65 mmHg tive indicator of the presence of shock, hyperlactatemia sors and/or or rapid fluid bolus according to the as soon as can be rather unspecific. Once shock is identified, the fluids clinical scenario and gestalt. possible MINUTES bundle should be promptly implemented. INvestigate Perform ECG, blood gas analysis, and Conduct essen- main causes send cardiac enzymes. tial and simple tests to identify M - Maintain “ABCs” (minute 0) the underlying This step should be provided within the first minute of etiology. shock recognition. Providing basic and advanced life sup- Ultrasound Conduct cardiac ultrasound to iden- Use point-of- port has been well established as the initial and crucial tify the type of shock. Conduct lung care ultrasound step of resuscitation in any acutely ill patient. Therefore, ultrasound to identify congestion and to identify the pneumothorax. shock type. ensuring airway patency, adequate ventilation, as well as Treat Specific therapy of the underlying Reversal of the presence of central pulse should be the first priorities in underlying etiology of shock (e.g., thrombolysis underlying pa- all patients [7, 12]. Similarly, rapidly fatal causes of shock Etiology for pulmonary embolism, drainage of thology causing must be identified and treated immediately (e.g., com- pericardial tamponade, revasculariza- shock. pression of external bleeding, needle-decompression of tion of coronary occlusion, control of tension pneumothorax) (Table 3). the infectious source). Stabilize sys- Evaluate (e.g., urine output, liver Optimize sys- temic organ function, electrolytes) and stabilize temic organ per- IN - INfuse vasopressors – INfuse fluids (minutes 0–10) perfusion systemic organ perfusion. fusion and avoid Following the ABC assessment, the mainstay of patient fluid overload. salvage is to restore vital organ (e.g., heart, lungs and ECG: electrocardiogram; MAP: mean arterial blood pressure brain) perfusion. Severe arterial hypotension can rapidly Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 4 of 8 Fig. 1 Description of the MINUTES acronym. PNX: pneumothorax Table 3 Rapidly-fatal easily-detectable shock pathologies Sepsis Campaign within the first 3 h in patients with sep- Active external Proper patient exposure – Compress bleeding site. bleeding inspect surgical wounds Apply tourniquet. sis-induced hypoperfusion or septic shock. However, Pelvic binder. fluid requirements vary substantially and such predefined Replacement according volumes may result in over-resuscitation in some patients to the guidelines. Therefore, an alternate approach has been pro- Tension Acute severe hypoxia and Needle decompression posed, starting with 10 mL/kg crystalloids followed by an pneumothorax hypotension at the 2nd intercostal individualized approach based on the patient response Unequal chest expansion space in the midcla- Diminished air entry vicular line within a shorter period (one hour) than that described Congested neck veins in the surviving sepsis campaign guidelines. A simi- lar regimen has been suggested by other authors unless clinical signs of congestion are present [13, 17]. It should lead to myocardial hypoperfusion and death within a be noted that fluid administration should be carefully short period of time. The term “infuse” mainly stands individualized as it might be detrimental in some types of for infusion of vasopressors and/or fluids within a few shock (e.g., cardiogenic and obstructive shock). minutes. Though fluid infusion is the first line of therapy Whether to initiate vasopressors early or to wait for the in the initial management of shock when fluid deficit is clinical response to fluid challenge remains still debatable clear, growing evidence suggests that it is safe to initiate and likely depends on the clinical scenario and gestalt. vasopressors early in patients with septic shock in order Vasopressors may be considered early in the presence of to maintain tissue perfusion and improve venous return life-threatening arterial hypotension , a low diastolic [13, 14]. Furthermore, excessive vasodilatation represents blood pressure < 40 mmHg, diastolic shock index > 3, or the most common pathophysiology of shock and requires when there is a risk of fluid overload [16, 18]. It is worth vasopressor therapy. Thus, initiation, and probably mentioning that vasopressor administration could be ini- escalation, of vasopressors within the first five minutes tiated peripherally in low dilution without wasting time until the etiology and type of shock have been identified for central venous catheter insertion. The first line is reasonable to limit the occurrence of under-perfusion vasopressor in the majority of patients with shock is nor- and organ damage. epinephrine. In case of septic shock, intravenous infusion of 30 ml/ A mean arterial blood pressure ≥ 65 mmHg appears kg crystalloids has been suggested by the Surviving as a suitable target during the initial salvage stage in Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 5 of 8 most types of shock. However, confirming adequate appropriate ultrasound integration in the management peripheral perfusion should not be ignored using the of patients with shock is likely to improve survival of available indices of tissue prefusion (e.g., serum lactate, these patients [26–28]. There is an increasing role for capillary refill time). In patients with hemorrhagic hand-held ultrasound which showed promising results in shock, lower targets of blood pressure values (systolic resource-limited settings [29, 30]. For all these reasons, blood pressure ≈ 90 mmHg) seems more appropriate in we suggest early use of focused ultrasound examination patients without brain injury, until the source of bleeding as a crucial diagnostic step in the assessment of circu- is secured [4, 6]. latory shock. It is clinically reasonable to perform this scan within the first 10–20 min after shock recognition, IN – Investigate (minutes 0–10) according to the availability of the device and presence of After provision of life support and implementation of a skilled operator. interventions to ensure vital organ perfusion, clinicians Once started, a focused ultrasound exam should should swiftly proceed to basic investigations. Among answer the several questions. Does the patient have criti- these, VBG certainly seems one of the most appropri- cal obstructive pathology? Does the patient have severe ate for its ability to provide point-of-care results with systolic dysfunction? Is there an obvious anatomical left- information on several variables that may be useful for sided valvopathy (i.e., large vegetation)? Could the patient the management of shock and/or its underlying etiol- benefit from (or at least tolerate) a fluid bolus? These ogy. Indeed, results of serum lactate, hemoglobin, and questions can be easily answered through a brief focused glucose levels will provide ready-at-hand diagnostic and examination of the heart, lungs, and inferior vena cava therapeutic support for clinicians. Point-of-care labora-. Ultrasound can also rapidly detect intraabdominal tory tests are widely available nowadays and can provide collection, pneumothorax and some types of aortic dis- additional used data about electrolytes, cardiac mark- section. Several protocols for point-of-care ultrasound ers, and kidney functions. Of course, other laboratory examination are present for management of circulatory investigations (e.g., a complete blood count and, if appro- and/or respiratory failure (e.g., RUSH protocol). priate, cardiac enzymes) may provide invaluable informa- In case of inadequate views, ultrasound is still useful in tion, but their results are usually not available within the evaluation of fluid tolerance (through examination of the first hour. Finally, in all cases in whom acute myocardial lungs and inferior vena cava) and ruling our obstructive ischemia cannot be excluded, clinicians should perform shock. More sophisticated examination steps could be an electrocardiogram. We suggest that the timeframe considered at a later stage or be performed only by expe- to accomplish this step is within 10 min after shock has rienced echocardiographers. These may include precise been recognized, ABCs maintained, and treatments for measurement of the stroke volume using doppler echo- life-threatening arterial hypotension implemented. cardiography, fine evaluation of heart valves pathology and of diastolic function. U – Ultrasound (minutes 10–20) The timing of the ultrasound examination could vary Ultrasound has several key advantages which favor its use according to both hospital facilities and practices. Some as an initial and principal point-of-care diagnostic tool in centers may have the resources to perform ultrasound the primary management of patients with undifferenti- even earlier. This is likely to be beneficial by inform- ated shock. First, ultrasound can rapidly differentiate the ing clinicians on the previously discussed use of fluids pathophysiological type of shock with excellent accuracy and/or vasopressors to reverse critical arterial hypoten- , and this is particularly useful if fatal pathologies sion. However, this practice might not be feasible in set- (e.g., obstructive shock) are present [10, 20, 21]. Second, tings with limited resources. Therefore, maintaining ultrasound can provide useful information about fluid perfusion should be the first priority whatever the timing status (fluid responsiveness, congestion, and tolerance) of the ultrasound examination is. Nevertheless, once an whatever the type of shock is. Third, ultrasound is a cost- ultrasound identifiable cause is on the top of differential effective equipment which should be present in every diagnosis, point-of-care ultrasound should be a priority. emergency and critical care department. It is feasible in Several clinical signs can improve the diagnosis such most patients without the need for expensive consum- was the presence of acute hypoxia (obstructive pathol- ables. Fourth, point-of-care ultrasound is exponen- ogy), wide pulse pressure (distributive pathology), con- tially growing and has become an essential skill for gested neck veins (obstructive pathology), and lower limb all emergency and critical care physicians [24, 25]. Fifth, edema (cardiogenic pathology). ultrasound has the advantage of allowing a comprehen- sive evaluation of several organ systems in a short time TE – Treat the underlying Etiology (minutes 20–30) and without the need to mobilize patients, which is Besides the pathophysiological support of circula- highly desirable under shock conditions. Accordingly, tion, treatment of the etiology of shock is the second Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 6 of 8 cornerstone of shock management. Once etiology has to reflect patient progression in a short period. Capillary been identified, therapeutic interventions should be refill time might be more appropriate for follow up in directed to reverse the underlying pathology. We propose shorter periods. that the proper timing for this step lies after initial inves- Early management of shock usually includes infusion of tigations and ultrasound, unless the primary pathology fluid boluses unless clinical signs of congestion are pres- causing shock has become evident until then. ent. Indeed, despite the increasing use of dynamic indices At this stage, specific management of the cause of of fluid responsiveness to guide fluid administration, fluid shock should be initiated with the exception of conditions overload is still a common problem in some patients due already dealt with during the early stage of the MINUTES to capillary leak. Thus, searching for signs of fluid over- bundle. Pulmonary embolism and cardiac tamponade load and considering subsequent strategies for the evacu- are two important pathologies that should be managed ation of fluids (e.g., diuresis) should be part of the clinical appropriately in this phase. We placed these two patholo- assessment, once the primary goals have been achieved gies in this phase and not earlier as their diagnosis and/or [37, 38]. The wide use of focused ultrasound in critical management is usually ultrasound-based [33, 34]. care units over the last years has facilitated the chances to It should be remembered that ultrasound is not the detect patients suffering from congestion with the evalu- gold standard for diagnosis of pulmonary embolism and ation of excess of extravascular lung water using lung therefore, normal cardiac ultrasound does not rule out ultrasound [37, 39]. Interestingly, a recent multicenter pulmonary embolism. However, according to the study found the coexistence of fluid overload signals in European guidelines, a patient with arterial hypotension both fluid-responsive and non-responsive patients. This and shock due to pulmonary embolism typically shows finding highlights the importance of performing a simple signs of right ventricular dilatation/failure. If not, other lung ultrasound examination in critically ill patients and causes of shock must be considered. The accuracy of this might direct the management plan towards a more point-of-care ultrasound in ruling out pulmonary embo- fluid-conservative and vasopressor-based approach, if lism can be enhanced by a multiorgan approach which validated in larger studies. includes lung- and lower limb venous ultrasound exami- nation. Conclusions We also highlight the importance of initiating defini- The early phases of undifferentiated shock management tive management for other causes of shock such as early require a clear plan with well-defined steps, targets, and antibiotic, cultures and elimination of the source in cases timeline. Though specific guidelines exist for the man- of sepsis ; hemorrhage control, transfusion and treat- agement of specific types of shock, the initial supportive ment of coagulopathy in patients with hemorrhagic plan of undifferentiated shock should be unified. We pro- shock ; as well as medical and interventional manage- pose the MINUTES acronym to provide a simplified and ment of coronary pathologies. simultaneously memorable timeline for the initial steps of shock management to be implemented within the first S – Stabilize (from minute 30 on) 30 min after shock recognition. The acronym includes the This phase aims to stabilize systemic organ perfusion following components: Maintain “ABCs”, INfuse vaso- and continue vital organ support. The goal of the ear- pressors and/or fluids and INvestigate simple blood tests, lier phases of theMINUTES acronym was reversal of Ultrasound (point-of care) to detect the type of shock, life-threatening disorders. Once the initial resuscitation Treat the underlying Etiology, and Stabilize systemic goals have been achieved, physicians should rapidly move organ perfusion. We suggest that MINUTES would help towards a more sophisticated and tailored correction of emergency physicians to organize their management and existing pathologies in order to optimize systemic organ priorities in the early critical moments of shock. Future perfusion and attenuate organ injury. Among oth- studies are required to validate the impact of application ers, physicians will consider urine output, liver injury, of MINUTES on patient outcomes. electrolytes levels with re-evaluation and correction of Acknowledgements residual acid-base and electrolyte disorders. Notably, Not applicable. this phase also includes the de-escalation of unneces- sary hemodynamic and respiratory support, whenever Author contributions AH: this author was responsible for conception of the idea and writing the possible. More detailed imaging such as computed first manuscript. FS: this author shared in writing and revising the work until tomography and advanced ultrasound examination can reaching the current form. MD: this author shared in writing and revising be performed. Indices of peripheral perfusion should be the work until reaching the current form. HA: this author shared in writing and revising the work until reaching the current form. LZ: this author shared followed up to determine the patient response to resus- in writing and revising the work until reaching the current form especially citation. Lactate clearance could be evaluated; however, the point-of-care ultrasound section. SM: this author shared in writing and the kinetics of serum lactate are usually slow and unlikely revising the work until reaching the current form. MM: this author shared in Hasanin et al. International Journal of Emergency Medicine (2024) 17:96 Page 7 of 8 conception of the idea, writing the first manuscript and designed the figure.- in awake healthy volunteers. Anesth Analg. 2013;116:351–6. https://doi. All authors commented on previous versions of the manuscript. All authors org/10.1213/ANE.0b013e318274e151 read and approved the final manuscript. 12. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, et al. 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