ICU · Renal / fluids

Fluid Overload & Its Management — The ROSE Concept & De-resuscitation

Also known as Fluid overload · Positive fluid balance · Cumulative fluid balance · Per cent fluid overload · De-resuscitation · The ROSE concept · SOSD · Fluid responsiveness · Fluid stewardship · The 4 Ds of fluid · Furosemide · CLASSIC trial · FACTT trial · FEAST trial · SMART trial · Global Increased Permeability Syndrome · Passive leg raise

The fluid overload is common in the ICU and is associated with the worse outcomes (the mortality, the prolonged ventilation, the AKI). It is quantified as the cumulative fluid balance (the net fluid in minus out) and the per cent fluid overload (the cumulative balance divided by the baseline weight times 100; the over 10 per cent is the worse). The harm: the pulmonary oedema, the tissue oedema (the gut, the kidneys, the intra-abdominal pressure), the delayed wound healing, the prolonged ventilation, the mortality. The ROSE concept frames the fluid therapy into the four phases — the Resuscitation, the Optimisation, the Stabilisation, and the De-resuscitation (the late phase that mobilises the excess fluid). The management: stop the fluids (minimise the maintenance), the de-resuscitation (the titrated furosemide, the albumin co-therapy, the RRT for the diuretic-resistant), the fluid-responsiveness assessment (the SVV, the PPV, the passive leg raise — NOT the CVP), and the fluid stewardship (the 4 Ds: the drug, the dose, the duration, the de-escalation).