Journal of Anaesthesia and Pain, 2023, Volume: 5, No.

1: 8-14 P-ISSN : 2722-3167

https://jap.ub.ac.id E-ISSN : 2722-3205

Review Article

Fluid Management for Critically Ill Patients, Based on the ROSE

Concept, an Old Method but Effective Enough
1
Ayu Yesi Agustina , Calcarina Fitriani Retno Wisudarti2, Untung Widodo2
1 Fellow Intensive Care in Department of Anesthesiology and Intensive Care, Gadjah Mada University, Yogyakarta, Indonesia
2 Department of Anesthesiology and Intensive Care, Gadjah Mada University, Yogyakarta, Indonesia

SUMMARY

Fluid therapy is one of the most essential things in managing critical patients, such as ICU patients.
Although it seems simple, this is difficult to do in this group of patients. The fluid needs of ICU patients
vary according to the course of the disease. Therefore, fluids must be given according to individual
needs, and each phase of the disease must be reassessed. To support this, there is a conceptual model
that explains fluid administration based on the phases of the disease that the patient is going through.
The ROSE concept (resuscitation, optimization, stabilization, and evacuation) describes the phases of
Correspondence: a patient's illness and how fluids should be administered. In the resuscitation phase, the goal is life-
Ayu Yesi Agustina, MD saving and is achieved by positive fluid balance. In the optimization phase, fluid balance is neutral and
Fellow Intensive Care
aims to save organs. In the stabilization phase, the fluid balance has started to move in a negative
Department of
Anesthesiology and Intensive direction and aims to support the organs. Finally, in the evacuation phase, fluid balance is negative
Care, Gadjah Mada University,
and organ repair has occurred. By implementing this model, it is hoped that ICU patients will have
Farmako Street, MO 55281,
Yogyakarta, Indonesia better outcomes.
e-mail:
[email protected]
Keywords: Critically ill, ROSE concept, fluid therapy, ICU

Received: December 2023, Revised: December 2023, Accepted: January 2024, Published: February 2024
How to cite this article: Agustina, AY, CFR Wisudarti, U Widodo. Fluid management for critically ill patients, based on the ROSE concept, an old
method but effective enough. Journal of Anaesthesia and Pain. 2024:5(1): 8-14. doi: 10.21776/ub.jap.2024.005.01.02

INTRODUCTION must be given according to individual needs and reassessed at

Fluid therapy is one of the most essential things in each phase of the disease.3 To support this, there is a conceptual
critical patient management, such as in intensive care unit (ICU) model that describes fluid administration based on the phases of
patients. Fluid balance in the body is regulated by the amount of the disease that the patient goes through. Malbrain et al.4
water “in and out” in the body. While this may seem simple, it is formulated the ROSE conceptual model, which has the acronym
difficult to do in this group of patients. ICU patients have Resuscitation, Optimisation, Stabilisation, and Evacuation. This
predisposing factors that cause fluid distribution to be disrupted, concept can be used in ICU patients to assist fluid management
and accelerated fluid loss conditions occur.1 This is also so that patient outcomes will improve later.
accompanied by changes in patient conditions, where fluid needs
can often change rapidly. DISCUSSION
There are still many problems that occur regarding the Physiology of body fluids
administration of fluid therapy. Hoste et al. mentioned that as In adults, water makes up 50% of the body components
many as one in five patients receive inappropriate fluid therapy. of men and 60% of women.1 Total body water (TBW) is found in
Lack of fluid administration during resuscitation or rehydration plasma, interstitial, and intracellular spaces. These intravascular
can lead to tissue hypoperfusion, whereas overuse of intravenous and interstitial spaces are also called extracellular spaces. Two-
fluids can lead to tissue edema and severe electrolyte thirds of TBW is in the intracellular space, and the remaining third
disturbances. This leads to high morbidity rates, prolonged is in the extracellular space.5 TBW will decrease with aging due to
lengths of hospitalization, and even increased mortality.2 loss of muscle mass. TBW comprises two compartments:
Therefore, prevention of this is essential. extracellular fluid (ECF) and intracellular fluid (ICF). Sodium will
There is no universal rule of thumb when giving fluids affect the volume regulation of ECF, while the amount of water
to ICU patients. Indeed, the fluid needs of patients vary according will affect the regulation of ICF. Hormonal and ECF volume
to the course of their illness. Therefore, fluids sensors determine sodium excretion, while hypothalamic

Journal of Anaesthesia and Pain. 2024. Vol.5(1): 8-14 8

osmolar sensors regulate the body's water balance.6 The example (CVP), so it is expected that venous return can be improved.
of the diagrams of the body fluid compartment in adults can be Elevated venous return can enhance cardiac output and cardiac
seen in Figure 1. index in individuals positioned on an ascending slope of the
Frank-Starling curve.4 Administration of resuscitative fluids
containing normal saline should not be given in large quantities
as it may increase the risk of hyperchloremic acidosis, acute renal
failure, hypernatremia, and death.8

2. Intravenous Fluid for Replacement

The replacement fluid should have the same
components as the lost fluid in volume and electrolytes. Causes
of loss include vomiting, diarrhea, hypothermia, excessive
diuresis, and adrenal hormone deficiency. Replacement fluids
Figure 1. Body fluid compartments in a 70 kg male patient, aim to prevent decompensation requiring resuscitation, restore
assuming a body density of 1.0 kg/L.6 electrolyte homeostasis, and maintain tissue perfusion.1
Replacement fluids are usually balanced isotonic solutions.
Extracellular fluid is all body fluids outside the cells and However, solutions containing high chloride content, e.g., NaCl
is divided into plasma and interstitial fluid volumes. ECF typically 0.9%, can be used as replacement fluids in patients who
contains 40% TBW. In acute or chronic illness cases, there is experience fluid deficiency due to loss of gastric acid.8
typically a decrease in intracellular fluid (ICF) and an increase in
extracellular fluid (ECF) within the patient's body. ECF volume 3. Intravenous Fluid for Maintenance
itself is divided into plasma volume, ECF volume, and interstitial Fluid maintenance aims to fulfill daily fluid, electrolyte,
volume. Intracellular fluid is all the fluid inside the cell; in contrast and glucose requirements. The basic daily fluid requirements are
to the ECF compartment, the water in the ICF compartment is 25-30 mL/kg BW, sodium 1-1.5 mmol/kg per day, potassium one
homogeneous; it is multicompartmental, with different pH and mmol/kg per day, and glucose 5%-10% as much as 1.4-1.6
ion content depending on the tissue or organ.7 The amount of grams/kg.8 Criteria for critical patients who need assistance in
ICF is calculated from the TBW and ECF volume. ICF volume is meeting their nutritional needs regularly, such as patients with
approximately 60% TBW or equivalent to 35% TBW. Fluid in the impaired gastrointestinal function, patients with neurological
transcellular space is fluid produced from active cellular injuries in the form of dysphagia, or patients with diseases that
transport. This fluid is naturally extracellular and is recognized as make them unable to receive food. Self-care liquids are not
part of the interstitial volume. The amount varies widely between recommended in patients still experiencing acute fluid loss or
1 L and 10 L, with high amounts of fluid occurring in severely ill acute electrolyte disturbances or to provide nutritional support.1
patients (e.g., colon obstruction), and this fluid is formed from
residual interstitial fluid and plasma volume.6 Fluid compartment Critically Ill Patient
indication can be seen in Table 1. According to Indonesian Ministry of Health Regulation
No.519 of 2019 concerning guidelines for the implementation of
Table 1. Fluid compartment indication for fluid administration.6 intensive therapy services in hospitals, it is stated that critical
Fluid Compartment Volume (mL/kg) % Total patients are patients who have diseases accompanied by organ
Body Weight failure where this occurs due to acute complications of the
Plasma volume 45 4.5 disease or due to sequelae of the therapy regimen provided. The
Blood volume 75 7.5 scope of critical patients in the ICU is vast but can be divided into
Interstitial volume 200 20 two broad lines, namely trauma and non-trauma patients.
Extracellular fluid volume 250 25 Although the causes and pathophysiology of essential conditions
Intracellular fluid volume 350 35 of patients are vast and different, the result of the disease process
Total body fluid volume 600 60 will lead to a condition of multiple organ failure, one of which is
the occurrence of cardiovascular failure. Cardiovascular failure is
Indication of Fluid Administration characterized by hypotension, hypoperfusion, metabolic
The study by Malbrain et al. suggested three main acidosis, and edema due to capillary leakage.
indications for intravenous fluid administration: resuscitation, Sepsis is a critical condition that often occurs in the ICU.
replacement, and maintenance. Resuscitative fluids primarily Sepsis is a necessary condition characterized by organ
serve to treat acute hypovolaemia. In contrast, replacement fluids dysfunction, resulting from an imbalanced host response to
are used to prevent ongoing or sustained fluid deficits due to infection, and poses a life-threatening risk.9 Septic shock is a
inadequate peroral fluid administration. In comparison, subset of sepsis accompanied by circulatory and
maintenance fluids are reserved for hemodynamically stable cellular/metabolic dysfunction. In sepsis conditions, capillary
patients who cannot drink water to replace their water and endothelial damage is accompanied by capillary leakage, in
electrolyte needs.3 which the intravascular fluid volume will decrease, and the
patient will show signs of hypovolaemia hypotension. Therefore,
1. Intravenous Fluids for Resuscitation intravenous fluid administration or fluid resuscitation is
Fluid resuscitation focuses on rapidly restoring considered the initial step in resuscitating critically ill patients
circulating volume. Increased venous return and increased with impaired organ perfusion.4 In one study, 67% of patients
volume during shock are the goals of fluid resuscitation. using the protocol of early goal-directed therapy (EGDT) suffered
Appropriate fluid administration is expected to increase from fluid overload after 24 hours and 48% continuously by the
intravascular blood volume and increase the gradient of mean third day of hospital stay. In addition, sepsis patients with high
systemic filling pressure (MSFP) and central venous pressure cumulative fluid totals are at risk of acute respiratory distress

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syndrome (ARDS) and/or acute lung injury (ALI) and poorer distributive shock. Administration of drugs to improve
outcomes.4 hemodynamics is essential for the survival of patients with septic
shock.9 In previous guidelines, patients with sepsis were given
Fluid Administration in Critical Patients copious fluids to stabilize hemodynamics.15 Recently, the
In administering fluids to patients, it is essential to approach to management with lots of fluids administration has
remember that both a lack and excess of fluids can adversely been questioned, as microvascular perfusion does not improve
affect the patient. Different patients have different fluid with stabilization of cardiovascular parameters. On the other
requirements depending on various factors such as age, current hand, glycocalyx damage and endothelial dysfunction may be
diagnosis, and existing comorbidities. Insufficient fluid exacerbated by aggressive fluid administration.16,17
administration can lead to hypovolaemia, resulting in decreased The exact amount of fluid administered to sepsis
cardiac output and decreased tissue perfusion. Hypovolaemia patients in the resuscitation phase is still debated until now.
can lead to organ failure and even death. Conversely, too much Based on the 2016 SSC, it is recommended that intravenous
fluid can cause edema, impairing organ function. One of the most crystalloids be given to sepsis patients at a minimum of 30 mL/kg
clinically apparent organs affected by edema is the lungs, which in the first 3 hours.18 The administration of fluids in this amount
disrupt gas exchange function, resulting in rapid blood gas has been debated in recent years. The study mentioned that the
changes.10 administration of resuscitation fluids to improve glycocalyx varies
Positive fluid balance is known to be related to bad significantly from person to person, which depends on the fluids'
outcomes in ICU patients.3 In their study, Malbrain et al. looked tolerance (FT) and fluids' response (FR).20 FT is defined as the
for associations of positive fluid balance with critical illness tolerance level of fluid administration without causing organ
outcomes in adults.4 Besides the restrictive fluid administration dysfunction.21 FR is an increase in stroke volume (SV) of at least
method, the cumulative fluid balance was 5.6 L more negative 10% after administering a 200-500 mL fluid bolus for 10-15
than the control patients after one week of ICU treatment.4 minutes.22 Another study suggested that excessive fluid
Excess fluid in the body is associated with adverse administration can damage glycocalyx, resulting in poor
effects in severely ill patients, which can affect the function of the outcomes.23 Recently, several methods have been used to
patient's organs.11 In patients undergoing an inflammatory monitor FR (i.e., passive leg raising test/PLR, stroke volume
phase, such as those with sepsis, interstitial edema can occur due calculation, and collapse index of inferior vena cava/CI-IVC).24
to various factors, such as vasodilation, endothelial glycocalyx Some studies stated that experts prefer using fluids with
degradation, and venous pooling. As a consequence, interstitial dynamic rather than static methods.20,24 It was also noted that the
edema will affect organ function, including the central nervous target of primary resuscitation is progressively improving
system, lung, cardiovascular system, liver, kidney, and GI tract microcirculation.20 In 2018, Perner suggested that the
system.4 administration of crystalloid fluid boluses can start at 250-500 mL
In septic shock, positive fluid balance is associated with with continuous FR monitoring, followed by the administration
increased patient mortality.8 After the patient has experienced of vasopressors from the beginning if hemodynamics fail to
the first insult (trauma, infection, etc.), there will be increased improve.25
organ dysfunction and increased capillary permeability due to
the response of systemic inflammation. This is followed by the 4D Concept in Fluid Management
Ebb phase, which is triggered by fluid overload and interstitial 1. Drug
edema. The Surviving Sepsis Campaign guidelines call for 30 Fluids are drugs with contraindications, indications, and
mL/kg intravenous fluid administration over the first 3 hours of side effects. Different types of fluids will be given on other
this initial phase.9 In ICU patients, considering the interactions indications. Replacement fluids should be similar to fluid loss;
between organs, such as the lungs and kidneys, is essential. The maintenance fluids should fulfill basic glucose metabolism needs,
lungs should generally be kept dry to minimize edema and while resuscitation fluid administration focuses more on rapid
maintain gas exchange, but the kidneys need adequate perfusion intravascular volume return.26 The study by Malbrain et al.
to perform their functions. In patients with fluid restriction, the mentioned that fluid administration that induces metabolic
lungs can survive more, while the kidneys suffer more damage.10 acidosis and contains excessive chloride can be avoided by giving
The Surviving Sepsis Campaign (SSC) 2016 recommends balanced solutions.3 Balanced solutions are crystalloid and
effective fluid administration in the early phase to stabilize colloidal fluids with minimal effect on extracellular compartment
hypoperfusion tissues due to sepsis or sepsis shock.9 As homeostasis, particularly on acid-base balance and electrolyte
prolonged hypotension is detrimental to multiple organs, fluid concentrations.
resuscitation in early sepsis should be initiated as soon as sepsis 2. Dosing
and/or hypotension is recognized and accompanied by elevated The rate and duration of fluid administration are equally
lactate levels. Intravenous fluid administration will increase important. However, there is no general formula for calculating
intravascular plasma volume and increase the gradient of MSFP fluid requirements in patients. The amount of fluid varies
with an increase in right atrial pressure/ RAP, so it is expected to considerably based on individual characteristics, individual
increase venous return.4 In a healthy person, 85% of the hemodynamic conditions, and the patient in a particular phase.10
crystalloid bolus will be redistributed to the interstitial If a patient is given 1 liter of fluid, only 10% of D10 fluid, 25-30%
compartment after four hours. In critically ill patients with of the crystalloid fluid, and 100% of colloid fluid remain
endothelial injury and capillary leakage, less than 5% of the fluid intravascular after 1 hour of administration.8 During critical
bolus remains intravascular after 90 minutes.13 conditions, the need for fluid and the response to fluid
In 2023, the concept of fluid management in sepsis administration will vary greatly. Dynamic tests such as passive leg
patients was updated. SSC Guideline 2023, the second point of raising or end-respiration occlusion tests can be performed to
management of sepsis patients is fluid resuscitation.14 Sepsis, predict the response to fluid therapy.26
accompanied by severe vasoplegia, is a secondary problem due
to the release of glycocalyx so that patients can experience

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3. Duration return to the heart, so cardiac output circulation and perfusion to
The longer fluid administration is delayed, the more critical organs will improve. The success of resuscitation can be
severe microvascular hypoperfusion and organ damage will be. assessed by clinical indicators tailored to the underlying cause,
In the study of Murphy et al., a comparison was obtained urine production > 0.5 mL/kg/hour, mean arterial pressure (MAP)
between the group given adequate conservative fluids from the > 65 mmHg, and patients can obtain lactate levels back to normal
beginning and the group given inadequate fluids from the in sepsis.1
beginning, also comparing late conservative fluid administration Fluid responsiveness can be assessed by looking at
with late liberal fluid administration. It was found that the best hemodynamic status, end-expiratory occlusion test, or passive
prognosis was for patients who received adequate and late leg raising test. Assessment can be done within 30 minutes. If
conservative fluid administration at the beginning.27 Another resuscitation is inadequate, additional crystalloid fluids of 2-4
study found that using late conservative fluid management is cc/kgBB may be given and re-evaluated. In critically ill patients
more important than early adequate fluid administration.8 with shock, fluid administration should be initiated along with
4. De-escalation vasopressor therapy. In patients with septic shock, hypotension
The next step in fluid therapy is the clinician's judgment is caused by decreased vascular tone, which cannot be corrected
of when to discontinue fluid resuscitation when they are no by giving fluid alone.10 In this regard, it is important to remember
longer needed. It is important to remember that resuscitative that each patient has an individual approach. The goal of this
fluid administration should be as short as possible and that phase is early adequate fluid management, which is positive fluid
administration should be gradually reduced as the shock is balance, and resuscitation targets: CI >2.5 L/min/m2, MAP ≥65
resolved.8 mmHg, left ventricle end-diastolic area index (LVEDAI) >8cm/m,

Figure 2. ROSE Concept Diagram3

ROSE Concept and pulse pressure variation (PPV) <12%. 28,29,30

The ROSE concept (resuscitation, optimization, 2. Optimisation
stabilization, and evacuation) describes the phases of a patient's The optimization phase begins when the patient is no
illness and how fluids should be administered. The summary of longer in a state of apparent absolute or relative hypovolaemia,
the ROSE concept can be seen in Figure 2 and Table 2. but their hemodynamics are still unstable. The goals of the
optimization phase are to maintain oxygenation to prevent organ
1. Resuscitation damage and adequate tissue perfusion.3 Fluids will be given
Resuscitation aims to restore intravascular volume in according to the patient's condition and assessed using several
patients with life-threatening shock and impaired organ assessments, such as fluid challenge techniques. Such a test
perfusion. In the resuscitation phase, fluid management aims to should be used when it is doubtful whether the patient needs
replace lost blood volume, establishing a positive fluid balance.3 fluids.
Resuscitative fluid administration can be initiated when It is also important to remember that there are four
hemodynamic instability is characterized by hypotension, essential components to consider: Type of fluid (e.g., crystalloid),
decreased urine output, tachycardia, or elevated lactate. If Rate (100-200 cc in 10 minutes), Objective (normal MAP or HR),
intravascular volume increases rapidly, it can increase venous and Limits (high CVP values).3 The patient should also be closely

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monitored in this phase to get a picture of the patient's (OGL) and other fluid redistribution issues (e.g., fluid loss from
hemodynamic status. Monitors may utilize arterial catheters, the GI with metabolic alkalosis). At this stage, fluid management
echocardiography, CVP, and BGA. Other assessments may also aims to ensure that the amount of electrolytes and water can
be performed, such as hypoperfusion markers (e.g., lactate, CRT). meet daily needs and maintain organ function. In this phase, it is
If the patient requires routine maintenance with IV fluids, the limit expected to reach zero or slightly negative fluid balance.3 If the
is approximately 25-30 mL/kg/day (1 mL/kg/hour) of water, 1 patient has stabilized or when the patient no longer responds to
mmol/kg/day of potassium, 1-1.5 mmol/kg/day of sodium, and fluid administration, aggressive fluid administration should be
1 mmol/kg/day of chloride.3 It is also expected that in this phase, stopped, and the patient should be started on minimal
the following parametric values will be achieved: mean arterial maintenance fluids if needed.10 If the patient has a persistent
pressure (MAP) ≥65 mmHg, cardiac index (CI) >2.5 L/min/m2, positive fluid balance, it is associated with poor outcomes. In a
pulse pressure variation (PPV) <14%, left ventricular end-diastolic study conducted by Intensive Care Over Nation on 1808 sepsis
area index 8-12/cm/m2, intra-abdominal pressure <15 mmHg, patients in the ICU, it was explained that mortality would increase
abdominal perfusion pressure >55 mmHg, and preload was if patients had a positive cumulative fluid balance at 72 hours
optimized with a global end-diastolic volume index of 640-800 after ICU admission.31
mL/m2.28,30
4. Evacuation or De-Resuscitation
3. Stabilisation The last phase is the deresuscitation, de-escalation, or
If the patient’s condition is stable, the stabilization fluid evacuation process, which aims to remove excess fluid. This
phase begins. Some patients may experience ongoing losses de-escalation phase can be spontaneous when the patient's

Table 2. Characteristics of the ROSE concept phase.4

Resuscitation (R) Optimisation (O) Stabilisation (S) Evacuation (E)
HIT First Second Second Third Fourth
Cause Inflammatory insult Ischaemia and Ischaemia and GIPS Hypoperfusion
(sepsis, SAP, burns, reperfusion reperfusion
trauma, etc.)
Phase Ebb Flow Flow/No Flow No Flow No Flow
Type Severe shock Unstable Stable Recover Unstable
Example Septic shock, major Intra-and Postoperative patient Patients on full Patient with cirrhosis
trauma, hemorrhagic perioperative GDT, (NPO or combination of enteral feed in the and anasarca edema
shock, ruptured AAA, less severe burns TEN/TPN), abdominal recovery phase of (GIPS) and no flow
SAP, severe burns (<25% TBSA), DKA, VAC, replacement of critical illness, state,
severe GI losses losses in less severe polyuric phase after hepatosplanchnic
pancreatitis recovering from ATN hypoperfusion
Question When to start fluid? When to stop fluid? When to stop fluid? When to start When to stop
unloading? unloading?
Subquestion Benefits of fluid? Risks of fluid? Risks of fluid? What are the benefits Risks of unloading?
of unloading?
O2 transport Convective problems Euvolemia, normal Diffusion problem Euvolemia, normal Convective problem
diffusion diffusion
Fluids Mandatory Biomarker of critical Biomarker of critical Toxic
illness illness
Fluid therapy Rapid bolus (4 mL/kg Titrate maintenance Minimal maintenance if Oral intake, if Avoid hypoperfusion
10-15 min) fluids, conservative oral intake is possible, avoid
use of fluid bolus inadequate; provide unnecessary IV fluids
replacement fluids
Fluid Balance Positive Neutral Neutral/ negative Negative Neutral
Results Life-saving (rescue, Organ rescue ( Organ support Organ Recovery Organ Support
salvage) Maintenance) (Homeostasis) (Removal)
Targets Macrohaemodynamics Organ Organ function (ELVWI, Organ function Organ microperfusion
(MAP,CO); lactate; macroperfusion PVPI, IAP, APP); evolution (P/F ratio, (pH, ScvO2, lactate,
volumetric preload (MAP,APP,CO, biomarkers (NGAL, EVLWI, IAP, APP, ICG-PDR);
(LVEDAI); functional ScvO2), volumetric cystatin-C, citrulline); PVPI), body biomarkers; negative
haemodynamics; fluid preload (GEDVI, capillary leak markers composition (ECW, cumulative FB
responsiveness (PLR, RVEDVI); GEF (COP, OSM, CLI, RLI); ICW, TBW, VE)
EEO) correction; R/L daily and cumulative FB,
shunts body weight
Monitoring A-line, CV-line, PPV or Calibrated CO (TPTD, Calibrated CO (TPTD); Calibrated CO (TPTD); LiMON, Gastric
tools SVV (manual or via PAC) Balance; BIA Balance; BIA; De- tonometry,
monitor), uncalibrated escalation Microdialysis
CO, TTE, TEE
Goals Correct shock (FAFM) Maintenance tissue Aim for zero or Mobilise fluid Maintain tissue
perfusion negative FB (LCFM) accumulation (LGFR) perfusion
= emptying or De-
resuscitation
Timeframe Minutes Hours Days Days to weeks Weeks

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condition has stabilized by diuresis. However, in some patients administration of diuretics is associated with poor outcomes.
who fail to experience spontaneous diuresis, patients can be However, when fluid overload occurs, diuretics still provide
given diuretics.3 In patients with acute renal failure, the benefits to achieving negative fluid balance. In contrast,
In patients with renal dysfunction, renal replacement therapy dysfunction.26 Cordeman et al. suggest taking a PAL approach to
(RRT) is more effective than diuretics.10 Malbrain et al. (2020) de-suscitation32: Using high positive end-expiratory pressure
mentioned that five steps in de-escalation need to be considered, (PEEP) for 30 minutes, this concept moves fluid from the alveoli
namely (1) determine clinical endpoints; (2) determine fluid to the interstitium.
balance goals (e.g., negative fluid balance); (3) determine • Administration of albumin (e.g., 2x100 ml of 20%
prevention to secure kidneys and perfusion (e.g., vasopressor albumin over 60 minutes on day 1, then titrated to
requirements); (4) reevaluate after 24 hours; (5) determine the albumin >30 g/L), used to draw fluid from the
next plan.3 In patients with fluid overload or fluid accumulation interstitium into the circulation
that impairs organ function, fluid resuscitation should be • Furosemide infusion is started 60 minutes after albumin
considered. Fluid resuscitation is mandatory if the patient has a administration. In patients with anuria, continuous renal
positive cumulative fluid balance with poor oxygenation (P/F replacement therapy (CRRT) can be added with
ratio <200), increased capillary leakage with PVPI value >2.5, ultrafiltration.
intra-abdominal pressure (IAP) >15 mmHg, extravascular lung
water index (EVLWI) >12 ml/kgBB, abdominal perfusion pressure SUMMARY
(APP) <50 mmHg, and high capillary leakage index (CLI).31 Critical patients in the ICU require a different approach
After the patient experiences a "second hit," there are than regular patients in managing fluid therapy. The ROSE
two possibilities: First, they may recover further and enter the conceptual model, consisting of dynamic phases of fluid
flow phase spontaneously by evacuating the excess fluid management such as resuscitation, stabilization, optimization,
administered earlier. Some ICU patients who do not experience and evacuation, can be applied to ICU patients. In the
improvement in their condition are characterized by continued resuscitation phase, a positive fluid balance is expected; in the
fluid accumulation due to capillary leakage so that the patient stabilization and optimization phase, the balance is neutral or
remains in the Ebb phase, followed by a "third hit" caused by negative; and in the evacuation phase, it should already be
globally increased permeability syndrome (GIPS). At this stage, negative. By applying this model, ICU patients are expected to
excessive fluid administration will worsen the patient's outcome. have better outcomes.
Peripheral edema and anasarka are not an easy problem, but they
are also detrimental to the patient as they can lead to organ

ACKNOWLEDGMENT
-
CONFLICT OF INTEREST
The author declares there is no conflict of interest.

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