What are the ESICM (European Society of Intensive Care Medicine) guidelines for fluid therapy in critically ill patients, specifically the ROSE (Resuscitation with Oriented Sequential Evaluation) concept of fluid resuscitation?

ESICM Guidelines on Fluid Therapy in Critically Ill Patients: The ROSE Concept

The European Society of Intensive Care Medicine (ESICM) recommends a structured approach to fluid management in critically ill patients using the ROSE (Resuscitation, Optimization, Stabilization, Evacuation) concept, which provides a framework for appropriate fluid therapy throughout different phases of critical illness to optimize outcomes and minimize complications.

Understanding the ROSE Concept

The ROSE concept divides fluid management into four sequential phases that guide clinicians through the fluid therapy journey:

1. Resuscitation Phase

• Initial phase focused on rapid restoration of tissue perfusion in patients with shock or severe hypoperfusion 1
• Key recommendations:
  • Begin with 30 mL/kg of crystalloid within the first 3 hours for patients with sepsis-induced tissue hypoperfusion 2
  • Target a mean arterial pressure (MAP) of 65 mmHg as the initial goal in patients requiring vasopressors 2
  • Consider guiding resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 2
  • Use balanced crystalloids rather than 0.9% saline as first-line fluid therapy to reduce the risk of hyperchloremic acidosis 2

2. Optimization Phase

• Once initial resuscitation is achieved, focus shifts to optimizing fluid status based on hemodynamic monitoring 1
• Key recommendations:
  • Use dynamic measures of fluid responsiveness rather than static variables (such as CVP) to guide further fluid administration 2, 3
  • Apply fluid challenge technique where fluid administration continues as long as there is hemodynamic improvement 2
  • Consider pulse pressure variation, stroke volume variation, or passive leg raise tests to assess fluid responsiveness in appropriate patients 2, 3
  • Avoid excessive fluid administration once hemodynamic goals are achieved 4

3. Stabilization Phase

• Period of hemodynamic stability where the focus shifts to maintaining adequate tissue perfusion while avoiding fluid overload 1
• Key recommendations:
  • Carefully balance ongoing fluid needs with the risk of fluid accumulation 3
  • Regularly reassess fluid status and perfusion parameters 3
  • Consider transitioning from fluid boluses to maintenance fluids 1
  • Be vigilant for signs of fluid overload (edema, pulmonary congestion, worsening oxygenation) 4

4. Evacuation/De-escalation Phase

• Final phase focused on active removal of excess fluid once the patient is hemodynamically stable 1
• Key recommendations:
  • Implement a de-resuscitation strategy to achieve negative fluid balance when clinically appropriate 1, 4
  • Consider diuretics as first-line therapy for fluid removal in patients with adequate kidney function 4
  • Use continuous renal replacement therapy with ultrafiltration for diuretic-resistant fluid overload 4
  • Monitor for signs of hypovolemia during fluid removal 3

Choice of Fluids in Critical Illness

Crystalloids vs. Colloids

• Crystalloids are recommended as first-line fluid therapy in most critically ill patients 2
• Synthetic colloids (particularly hydroxyethyl starches) should be avoided in patients with sepsis or septic shock due to increased risk of acute kidney injury 2
• Albumin may be considered in patients with sepsis requiring substantial amounts of crystalloids 2

Balanced vs. Unbalanced Crystalloids

• Balanced crystalloid solutions (e.g., Ringer's lactate, Plasma-Lyte) are preferred over 0.9% saline 2
• Balanced solutions have electrolyte compositions closer to plasma and reduce the risk of hyperchloremic metabolic acidosis 2
• Consider 0.9% saline in specific situations such as hypochloremic metabolic alkalosis or severe hyponatremia 2

Special Considerations in Specific Patient Populations

Sepsis and Septic Shock

• Initial fluid resuscitation with 30 mL/kg of crystalloids within the first 3 hours 2
• Use balanced crystalloids rather than 0.9% saline 2
• Avoid synthetic colloids due to increased risk of acute kidney injury 2
• Consider albumin when patients require substantial amounts of crystalloids 2

Hemorrhagic Shock

• Rapid crystalloid infusion to maintain tissue perfusion until blood products are available 2, 5
• Early transition to blood products for ongoing hemorrhage 5
• Balanced crystalloids preferred over 0.9% saline 2

Acute Brain Injury

• Avoid hypotonic solutions that may worsen cerebral edema 2, 5
• Maintain euvolemia to support cerebral perfusion 5
• Consider hypertonic solutions for management of increased intracranial pressure 5

Peripartum Period

• Balanced crystalloids are preferred for fluid resuscitation 2
• Careful fluid management to avoid both hypovolemia and fluid overload 2

Common Pitfalls and Caveats

• Fluid overload is associated with increased mortality and morbidity in critically ill patients 4
• Avoid using central venous pressure (CVP) alone to guide fluid therapy as it has poor predictive value for fluid responsiveness 2
• Regular reassessment of fluid status is essential as fluid requirements change throughout the course of critical illness 3
• Consider fluids as drugs with specific indications, contraindications, and potential adverse effects 1, 5
• The transition between ROSE phases should be individualized based on patient response and clinical context 1
• Fluid management goals should evolve from achieving adequate tissue perfusion to preventing complications of fluid overload 4, 6