Table 3 The 4 dynamic phases of fluid therapy according to the ROSE concept.
| Â | Resuscitation (R) | Optimization (O) | Stabilization (S) | Evacuation (E) | Â |
|---|---|---|---|---|---|
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 | Â |
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 |