What are the ESICM guidelines for fluid therapy in critically ill patients?

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

The European Society of Intensive Care Medicine (ESICM) recommends using balanced crystalloids as first-line fluid therapy for most critically ill patients, with specific considerations for different clinical scenarios based on the ROSE concept (Resuscitation, Optimization, Stabilization, Evacuation) of fluid management. 1

General Principles of Fluid Therapy

• ESICM guidelines emphasize that intravenous fluids should be considered as drugs, requiring careful selection based on patient condition, clinical scenario, and expected outcomes 2
• The ROSE concept provides a framework for fluid management through different phases of critical illness:
  • Resuscitation: Initial rapid fluid administration to restore tissue perfusion
  • Optimization: Guided fluid therapy based on hemodynamic monitoring
  • Stabilization: Maintenance phase with neutral fluid balance
  • Evacuation: Active de-resuscitation to remove excess fluid 3, 4

Choice of Resuscitation Fluids

Crystalloids vs. Colloids

• ESICM conditionally recommends using crystalloids rather than albumin for volume expansion in:

  • General critically ill patients (moderate certainty of evidence)
  • Patients with sepsis (moderate certainty of evidence)
  • Patients with acute respiratory failure (very low certainty of evidence)
  • Perioperative patients and those at risk for bleeding (very low certainty of evidence) 1

• Specific exceptions where albumin may be preferred:

  • Patients with cirrhosis (conditional recommendation, very low certainty of evidence) 1
  • Selected patients with sepsis after initial crystalloid resuscitation (conditional recommendation) 2

Balanced vs. Non-balanced Crystalloids

• ESICM conditionally recommends balanced crystalloids (e.g., Ringer's lactate, Plasma-Lyte) rather than isotonic saline (0.9% NaCl) in:

  • General critically ill population (low certainty of evidence)
  • Patients with sepsis (low certainty of evidence)
  • Patients with kidney injury (very low certainty of evidence) 1

• Exception: Isotonic saline is conditionally recommended over balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence) 1

Hypertonic Solutions

• ESICM conditionally recommends against using small-volume hypertonic crystalloids for general fluid resuscitation in critically ill patients (very low certainty of evidence) 1
• This aligns with other guidelines that specifically recommend against using 3% or 7.5% hypertonic solutions as first-line treatment in hemorrhagic shock to reduce mortality (Grade 1- recommendation) 2

Fluid Administration Strategy

• Initial fluid challenge should be at least 30 mL/kg of crystalloids in patients with sepsis-induced tissue hypoperfusion (Grade 1C) 2

• Fluid challenges should follow a structured approach:

  • Define type of fluid to be administered
  • Rate and volume of infusion
  • Endpoints to assess response
  • Safety limits to prevent fluid overload 5

• Dynamic tests of fluid responsiveness (when applicable) are preferred over static measurements:

  • Pulse pressure variation
  • Stroke volume variation
  • Passive leg raising test 3, 5

Special Clinical Scenarios

Sepsis and Septic Shock

• Crystalloids are recommended as first-line fluid therapy 2, 1
• Balanced crystalloids are preferred over 0.9% NaCl to reduce mortality and adverse renal events 1
• Albumin may be considered in patients requiring substantial amounts of crystalloids 2
• Avoid hydroxyethyl starches due to increased risk of acute kidney injury and mortality 2

Hemorrhagic Shock

• Balanced crystalloids are probably recommended over 0.9% NaCl as first-line fluid therapy (Grade 2+ recommendation) 2
• Avoid albumin administration in most cases of hemorrhagic shock 2
• Hypertonic solutions (3% or 7.5%) are not recommended as first-line treatment 2

Traumatic Brain Injury

• Isotonic saline is conditionally recommended over balanced crystalloids 1
• Isotonic saline is conditionally recommended over albumin 1

Common Pitfalls in Fluid Management

• Failure to recognize the transition between phases of fluid therapy (resuscitation to de-escalation) 3
• Over-reliance on static measures of preload (CVP) which poorly predict fluid responsiveness 5
• Inadequate monitoring for signs of fluid overload during resuscitation 4
• Not considering the chloride content of fluids and potential impact on acid-base balance and kidney function 2, 6
• Continuing fluid administration despite lack of hemodynamic improvement from previous fluid challenges 5

By following the ROSE concept and these evidence-based recommendations, clinicians can optimize fluid therapy in critically ill patients while minimizing potential complications related to inappropriate fluid selection or volume.