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Annals of Intensive Care
Fig. 5 | Annals of Intensive Care

Fig. 5

From: Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy

Fig. 5

The different fluid phases during shock. Adapted from Malbrain et al. with permission [1]. a Graph showing the four-hit model of shock with ebb and flow phases and evolution of patients’ cumulative fluid volume status over time during the five distinct phases of resuscitation: resuscitation (1), optimization (2), stabilization (3) and evacuation (4) (ROSE), followed by a possible risk of Hypoperfusion (5) in case of too aggressive de-resuscitation. See text for explanation. b Graph illustrating the four-hit model of shock corresponding to the impact on end-organ function in relation to the fluid status. On admission patients are hypovolemic (1), followed by normovolemia (2) after fluid resuscitation, and fluid overload (3), again followed by a phase going to normovolemia with de-resuscitation (4) and hypovolemia with risk of hypoperfusion (5). In case of hypovolemia (phases 1 and 5), O2 cannot get into the tissues because of convective problems, in case of hypervolemia (phase 3) O2 cannot get into the tissue because of diffusion problems related to interstitial and pulmonary oedema, gut oedema (ileus and abdominal hypertension). See text for explanation

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