Table 3 The ROSE concept avoiding fluid overload.

Hit sequence

First hit

Second hit

Second hit

Third hit

Time frame

Minutes

Hours

Days

Days to weeks

Underlying mechanism

Inflammatory insult

Ischaemia and reperfusion

Ischaemia and reperfusion

Global increased permeability syndrome

Clinical presentation

Severe shock

Unstable shock

Absence of shock or threat of shock

Recovery from shock, possible global increased permeability syndrome

Goal

Early adequate goal-directed fluid management

Focus on organ support and maintaining tissue perfusion

Late conservative fluid management

Late goal-directed fluid removal (de-resuscitation)

Fluid therapy

Early administration with fluid boluses, guided by indices of fluid responsiveness

Fluid boluses guided by fluid responsiveness indices and indices of the risk of fluid administration

Only for normal maintenance and replacement

Reversal of the positive fluid balance, either spontaneous or active

Fluid balance

Positive

Neutral

Neutral to negative

Negative

Primary result of treatment

Salvage or patient rescue

Organ rescue

Organ support (homeostasis)

Organ recovery

Main risk

Insufficient resuscitation

Insufficient resuscitation and fluid overload (e.g. pulmonary oedema, intra-abdominal hypertension)

Fluid overload (e.g. pulmonary oedema, intra-abdominal hypertension)

Excessive fluid removal, possibly inducing hypotension, hypoperfusion, and a “fourth hit”