Fluid de-escalation therapy in critically ill patients: A comprehensive review: Fluid de-escalation therapy

Tewa Sanla-ead; Thummaporn Naorungroj

doi:10.54205/ccc.v34.275491

Authors

Tewa Sanla-ead Division of Critical Care, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700
Thummaporn Naorungroj Division of Critical Care, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700

DOI:

https://doi.org/10.54205/ccc.v34.275491

Keywords:

Fluid restriction, Fluid de-escalation therapy, Shock, Phase of fluid therapy, Diuretic, Mechanical fluid removal

Abstract

Fluid overload is a common complication following fluid therapy in patients with circulatory shock, and fluid de-escalation therapy plays a vital role in preventing this condition. This article aims to explore the management of fluid de-escalation across different phases, highlights the appropriate timing for its implementation, and discusses the roles of diuretics and mechanical fluid removal. Practical strategies for monitoring are also explored.

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References

Prescott C, Ruff S. The shocked patient. Medicine. 2017;45:81-5.

Malbrain M, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, et al. 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. Ann Intensive Care. 2018;8:66.

Willam C HLDR-K. The ROSE concept: modern fluid management in intensive care medicine. Med Klin Intensivmed Notfmed. 2024;119:634-9.

Malbrain M, Martin G, Ostermann M. Everything you need to know about deresuscitation. Intensive Care Med. 2022;48:1781-6.

Malbrain MLNG, Martin G, Ostermann M. Everything you need to know about deresuscitation. Intensive Care Medicine. 2022;48:1781-6.

Messmer AS, Zingg C, Muller M, Gerber JL, Schefold JC, Pfortmueller CA. Fluid Overload and Mortality in Adult Critical Care Patients-A Systematic Review and Meta-Analysis of Observational Studies. Crit Care Med. 2020;48:1862-70.

Pfortmueller CA, Dabrowski W, Wise R, van Regenmortel N, Malbrain M. Fluid accumulation syndrome in sepsis and septic shock: pathophysiology, relevance and treatment-a comprehensive review. Ann Intensive Care. 2024;14:115.

Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009;76:422-7.

Costa C, Gouveia I, Cunha P, Milheiro R, Bartolo A, Goncalves C, et al. 25th International symposium on intensive care and emergency medicine, Brussels, Belgium, 21-25 March 2005. Abstracts. Crit Care. 2005;9 Suppl 1:P1-P416.

Nisula S, Kaukonen KM, Vaara ST, Korhonen AM, Poukkanen M, Karlsson S, et al. Incidence, risk factors and 90-day mortality of patients with acute kidney injury in Finnish intensive care units: the FINNAKI study. Intensive Care Med. 2013;39:420-8.

Finfer S, Myburgh, J. & Bellomo, R. Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol. 2018;14:541–57.

Claure-Del Granado R, Mehta RL. Fluid overload in the ICU: evaluation and management. BMC Nephrol. 2016;17:109.

Herbert P Wiedemann APW, Gordon R Bernard, B Taylor Thompson, Douglas Hayden, Ben deBoisblanc, Alfred F Connors Jr, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564–75.

Van Regenmortel N, Verbrugghe W, Roelant E, Van den Wyngaert T, Jorens PG. Maintenance fluid therapy and fluid creep impose more significant fluid, sodium, and chloride burdens than resuscitation fluids in critically ill patients: a retrospective study in a tertiary mixed ICU population. Intensive Care Med. 2018;44:409-17.

Peter B. Hjortrup NH, Helle Bundgaard, Simon L. Thomsen, Robert Winding, Ville Pettilä, Anne Aaen, et al. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med. 2016;42:1695-705.

Messina A, Albini M, Samuelli N, Brunati A, Costantini E, Lionetti G, et al. Fluid boluses and infusions in the early phase of resuscitation from septic shock and sepsis-induced hypotension: a retrospective report and outcome analysis from a tertiary hospital. Ann Intensive Care. 2024;14:123.

Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47:1181-247.

Investigators A, Group ACT, Peake SL, Delaney A, Bailey M, Bellomo R, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496-506.

Pro CI, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683-93.

Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-11.

Frédéric Michard J-LT. Predicting fluid responsiveness in ICU patients: A critical analysis of the evidence. Chest. 2002;121:2000-8.

Silversides JA, Perner A, Malbrain M. Liberal versus restrictive fluid therapy in critically ill patients. Intensive Care Med. 2019;45:1440-2.

Mekontso Dessap A, AlShamsi F, Belletti A, De Backer D, Delaney A, Møller MH, et al. European Society of Intensive Care Medicine (ESICM) 2025 clinical practice guideline on fluid therapy in adult critically ill patients: part 2-the volume of resuscitation fluids. Intensive Care Med. 2025;51:461-77.

Prescott HC, Antonelli M, Alhazzani W, Møller MH, Alshamsi F, Azevedo LCP, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026.

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early use of norepinephrine in septic shock resuscitation (CENSER). A randomized trial. Am J Respir Crit Care Med. 2019;199:1097-105.

Monnet X, Lai C, Ospina-Tascon G, De Backer D. Evidence for a personalized early start of norepinephrine in septic shock. Crit Care. 2023;27:322.

Ahn C, Yu G, Shin TG, Cho Y, Park S, Suh GY. Comparison of early and late norepinephrine administration in patients with septic shock: A systematic review and meta-analysis. Chest. 2024;166:1417-30.

Hernandez G, Ospina-Tascon GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-Day mortality among patients with septic shock: The ANDROMEDA-SHOCK randomized clinical trial. JAMA. 2019;321:654-64.

Hernandez G, Ospina-Tascón GA, Kattan E, Ibarra-Estrada M, Ramasco F, Orozco N, et al. Personalized hemodynamic resuscitation targeting capillary refill time in early septic shock: The ANDROMEDA-SHOCK-2 randomized clinical trial. Jama. 2025;334:1988-99.

Kattan E, Castro R, Miralles-Aguiar F, Hernández G, Rola P. The emerging concept of fluid tolerance: A position paper. J Crit Care. 2022;71:154070.

Munoz F, Born P, Bruna M, Ulloa R, Gonzalez C, Philp V, et al. Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study. Crit Care. 2024;28:52.

Naorungroj T, Prajantasen U, Sanla-Ead T, Viarasilpa T, Tongyoo S. Restrictive fluid management with early de-escalation versus usual care in critically ill patients (reduce trial): a feasibility randomized controlled trial. Crit Care. 2025;29:405.

Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136:102-9.

Saravi B, Goebel U, Hassenzahl LO, Jung C, David S, Feldheiser A, et al. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intensive Care Med Exp. 2023;11:96.

Silversides JA, McMullan R, Emerson LM, Bradbury I, Bannard-Smith J, Szakmany T, et al. Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial. Intensive Care Med. 2022;48:190–200.

Murugan R, Kerti SJ, Chang CH, Gallagher M, Clermont G, Palevsky PM, et al. Association of net ultrafiltration rate with mortality among critically ill adults with acute kidney injury receiving continuous venovenous hemodiafiltration: A secondary analysis of the randomized evaluation of normal vs augmented level (RENAL) of renal replacement therapy trial. JAMA Netw Open. 2019;2:e195418.

Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med. 2017;43:155-70.

Salvador DR, Rey NR, Ramos GC, Punzalan FE. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev. 2005;3:CD003178.

Alqahtani F, Koulouridis I, Susantitaphong P, Dahal K, Jaber BL. A meta-analysis of continuous vs intermittent infusion of loop diuretics in hospitalized patients. J Crit Care. 2014;29:10-7.

Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol. 2021;17:262–76.

Hall A, Crichton S, Dixon A, Skorniakov I, Kellum JA, Ostermann M. Fluid removal associates with better outcomes in critically ill patients receiving continuous renal replacement therapy: a cohort study. Crit Care. 2020;24:279.

Bige N, Lavillegrand JR, Dang J, Attias P, Deryckere S, Joffre J, et al. Bedside prediction of intradialytic hemodynamic instability in critically ill patients: the SOCRATE study. Ann Intensive Care. 2020;10:47.

Monnet X, Cipriani F, Camous L, Sentenac P, Dres M, Krastinova E, et al. The passive leg raising test to guide fluid removal in critically ill patients. Ann Intensive Care. 2016;6:46.

Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564-75.

Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12:16.

Kitsios GD, Mascari P, Ettunsi R, Gray AW. Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: a meta-analysis. J Crit Care. 2014;29:253-9.

Fahim YA, Hasani IW, Kabba S, Ragab WM. Artificial intelligence in healthcare and medicine: clinical applications, therapeutic advances, and future perspectives. Eur J Med Res. 2025;30:848.

Hansen B. Fluid Overload. Front Vet Sci. 2021;8:668688.

Hoste EA, Maitland K, Brudney CS, Mehta R, Vincent JL, Yates D, et al. Four phases of intravenous fluid therapy: a conceptual model. Br J Anaesth. 2014;113:740-7.

Fluid de-escalation therapy in critically ill patients: A comprehensive review