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Table 3 The 4 dynamic phases of fluid therapy according to the ROSE concept.

From: Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA)

  Resuscitation (R) Optimization (O) Stabilization (S) Evacuation (E)  
HIT First Second Second Third Fourth
Cause Inflammatory insult, e.g., sepsis, severe acute pancreatitis (SAP), burns, trauma, etc. Ischemia and reperfusion Ischemia and reperfusion GIPS (global increased permeability syndrome) Hypoperfusion
Phase Ebb Flow Flow/no flow No flow No flow
Type Severe shock Unstable Stable Recovering Unstable
Example Septic shock, major trauma, hemorrhagic shock, ruptured abdominal aortic aneurysm, severe acute pancreatitis, severe burns (> 25% TBSA) Intra- and perioperative goal-directed therapy, less severe burns (< 25% TBSA), diabetic keto-acidosis, severe gastro-intestinal losses (vomiting, gastroenteritis) Postoperative patient (nil per mouth or combination of total enteral plus parenteral nutrition), abdominal vacuum-assisted closure, replacement of losses in less-severe pancreatitis Patient on full enteral feed in recovery phase of critical illness, polyuric phase after recovering from acute tubular necrosis Patient with cirrhosis and anasarca edema (GIPS) and no Flow state, hepatosplanchnic hypoperfusion
Question When to start fluids? When to stop fluids? When to stop fluids? When to start unloading? When to stop unloading?
Subquestion Benefits of fluids? Risks of fluids? Risks of fluids? Benefits of unloading? Risks of unloading?
O2 transport Convective problems Euvolemia, normal diffusion Diffusion problems Euvolemia, normal diffusion Convective problems
Fluids Mandatory Biomarker of critical illness Biomarker of critical illness Toxic  
Fluid therapy Rapid bolus (4 ml/kg/10–15 min) Titrate maintenance fluids, conservative use of fluid bolus Minimal maintenance if oral intake inadequate, provide replacement fluids Oral intake if possible
Avoid unnecessary IV fluids
Avoid hypoperfusion
Fluid balance Positive Neutral Neutral/negative Negative Neutral
Result Life saving (rescue, salvage) Organ rescue (maintenance) Organ support (homeostasis) Organ recovery (removal) Organ support
Targets Macrohemodynamics (MAP, CO); lactate; volumetric preload (LVEDAI); functional hemodynamics; fluid responsiveness (PLR, EEO) Organ macroperfusion (MAP, APP, CO, ScvO2); volumetric preload (GEDVI, RVEDVI); GEF correction; R/L shunt; think of polycompartment syndrome, CARS Organ function (EVLWI, PVPI, IAP, APP); biomarkers (NGAL, cystatin-C, citrullin); capillary leak markers (colloid oncotic pressure, osmolality, CLI, RLI); daily and cumulative FB, body weight Organ function evolution (P/F ratio, EVLWI, IAP, APP, PVPI)
Body composition (ECW, ICW, TBW, VE)
Organ microperfusion (pHi, ScvO2, lactate, ICG-PDR); Biomarkers; Negative cumulative fluid balance
Monitoring tools Arterial-line, central venous-line, PPV or SVV (manual or via monitor), uncalibrated CO, TTE, TEE Calibrated CO (TPTD, PAC) Calibrated CO (TPTD); Balance; BIA (ECW, ICW, TBW, VE) Calibrated CO (TPTD); balance; BIA; DE-escalation LiMON, Gastric tonometry, micro-dialysis
Goals Correct shock (EAFM—early adequate fluid management) Maintain tissue perfusion Aim for zero or negative fluid balance (LCFM—late conservative fluid management) Mobilize fluid accumulation (LGFR—late goal-directed fluid removal = emptying) or DE-resuscitation Maintain tissue perfusion
Timeframe Minutes Hours Days Days to weeks Weeks
  1. APP abdominal perfusion pressure, = MAP − IAP, BIA bio-electrical impedance analysis, CARS cardio-abdominal renal syndrome, CLI capillary leak index, = serum CRP divided by serum albumin, CO cardiac output, ECW extracellular water, EEO end-expiratory occlusion test, EVLWI extravascular lung water index, GEDVI global end-diastolic volume index, GEF global ejection fraction, GIPS global increased permeability syndrome, IAP intra-abdominal pressure, ICG-PDR indocyaninegreen plasma disappearance rate, ICW intracellular water, IV intravenous, LVEDAI left ventricular end-diastolic area index, MAP mean arterial pressure, P/F pO2 over FiO2 ratio, PLRT passive leg raising, PPV pulse pressure variation, PVPI pulmonary vascular permeability index, RLI renal leak index, = urine albumin divide by urine creatinine, R/L right to left shunt, RVEDVI right ventricular enddiastolic volume index, SAP severe acute pancreatitis, ScvO2 central venous oxygen saturation, SVV stroke volume variation, TBSA total burned surface area, TBW total body water, TEE transesophageal echocardiography, TPTD transpulmonary thermodilution, TTE transthoracic echocardiograph, VE volume excess