What is the ROSE (Resuscitation‑Optimization‑Stabilization‑Evacuation) protocol for fluid resuscitation in critically ill adult patients with shock or severe sepsis?

ROSE Protocol for Fluid Resuscitation

The ROSE protocol (Resuscitation-Optimization-Stabilization-Evacuation) is a four-phase conceptual framework for fluid management in critically ill patients with septic shock that guides clinicians from initial aggressive resuscitation through eventual fluid removal to restore euvolemia. 1, 2

The Four Phases of ROSE

Phase 1: Resuscitation

This initial phase focuses on restoring tissue perfusion through aggressive fluid administration:

• Administer at least 30 mL/kg of balanced crystalloid solution within the first 3 hours (approximately 2,100 mL for a 70 kg patient) 3, 4
• Use fluid boluses of 1,000 mL of crystalloids or 300-500 mL of colloids over 30 minutes 5, 3
• Continue aggressive fluid administration for 24-48 hours, as more than 4 liters may be required in the first 24 hours 5, 3
• Target clinical indicators of adequate tissue perfusion: capillary refill time <2 seconds, warm extremities, normal mental status, urine output >0.5 mL/kg/hour, and mean arterial pressure ≥65 mmHg 5, 3

Key monitoring during resuscitation:

• Reassess after each bolus for improvement in blood pressure (≥10% increase), heart rate (≥10% reduction), peripheral perfusion, and mental status 3, 6
• Use dynamic measures of fluid responsiveness (pulse pressure variation, passive leg raise) rather than static measures like CVP when available 3, 4
• Stop fluid administration when signs of volume overload appear (pulmonary crackles, increased jugular venous pressure, worsening respiratory function) or when there is no improvement in tissue perfusion 3, 4

Phase 2: Optimization

During this phase, hemodynamic parameters are fine-tuned while limiting further fluid accumulation:

• Continue fluid administration guided by hemodynamic response, but with increasing caution 2
• Initiate norepinephrine as first-choice vasopressor if hypotension persists despite adequate fluid resuscitation, targeting MAP ≥65 mmHg 3, 4, 6
• Consider adding epinephrine when an additional vasopressor is necessary 3
• In patients requiring escalating vasopressor doses, administer hydrocortisone (up to 300 mg/day) or prednisolone (up to 75 mg/day) 5

Phase 3: Stabilization

This phase occurs as the patient recovers from shock and microcirculatory injury:

• Maintain euvolemia while avoiding additional fluid accumulation 1, 2
• Focus on organ support and treating the underlying infection source 5
• Monitor for signs of fluid overload that may delay organ recovery and prolong ICU stay 3

Phase 4: Evacuation (De-escalation)

The final phase involves active removal of accumulated fluid:

• Implement active de-escalation protocols to deplete fluid overload and restore euvolemia 2
• This reverses interstitial edema and improves organ dysfunction 1
• The goal is to return the patient to baseline fluid status 2

Critical Modifications for Special Populations

Patients with congestive heart failure or low ejection fraction require a modified approach:

• Use smaller boluses of 250-500 mL instead of the standard 30 mL/kg 4
• Clinically reevaluate after each bolus with heightened vigilance for fluid overload 4
• However, do not delay initial resuscitation due to concerns about fluid overload, as delayed resuscitation increases mortality 4

Common Pitfalls to Avoid

• Never rely solely on CVP to guide fluid therapy, as it has poor predictive ability for fluid responsiveness 4
• Avoid hydroxyethyl starches (HES) for fluid resuscitation due to increased mortality and acute kidney injury risk 4
• Prefer balanced crystalloids (Lactated Ringer's or Plasma-Lyte) over normal saline to reduce hyperchloremic metabolic acidosis and potentially lower mortality 4, 7
• Be aware that evidence from resource-limited settings has shown increased mortality with aggressive fluid resuscitation, though applicability to high-resource settings remains uncertain 3, 7, 8

Practical Implementation

The ROSE concept emphasizes that fluid therapy should be treated as a pharmacological prescription following the four Ds: drug, dosing, duration, and de-escalation 2. This dynamic approach maximizes the benefits of early aggressive resuscitation while minimizing the harms of fluid overload that can occur if fluids are continued indiscriminately throughout the patient's ICU course 2.