Fluid Stewardship in Critical Care

1️⃣ Introduction

Fluids are not just supportive therapy — they are powerful drugs with dose-dependent toxicity.

Persistent positive fluid balance has been independently associated with:

• Increased mortality in sepsis
• Worsened outcomes in ARDS
• Higher incidence of AKI
• Prolonged mechanical ventilation

2️⃣ Why Fluid Stewardship is Needed

The Problem of Liberal Fluid Use

Historically:

• Early aggressive fluid resuscitation became standard after early goal-directed therapy (EGDT).
• However, excessive fluid accumulation proved harmful.

Large ICU cohorts demonstrate:

• Cumulative positive balance correlates with mortality.
• Fluid overload >10% body weight significantly increases death risk.

3️⃣ Pathophysiology of Fluid Toxicity

1️⃣ Endothelial Glycocalyx Damage

In sepsis:

• Inflammation destroys glycocalyx.
• Capillary permeability increases.
• Fluids leak into interstitium → edema.

2️⃣ Organ-Specific Effects

4️⃣ Definition of Fluid Stewardship

Fluid stewardship is:

A systematic, goal-directed approach to fluid administration and removal across all phases of critical illness.

It integrates:

• Hemodynamic monitoring
• Dynamic assessment of fluid responsiveness
• Timely de-escalation
• Active fluid removal strategies

5️⃣ The ROSE Model of Fluid Therapy

Widely adopted conceptual framework:

 R – Resuscitation Phase

• Immediate life-saving fluids
• Correct hypotension & hypoperfusion
• Often positive balance unavoidable

 O – Optimization Phase

• Assess fluid responsiveness
• Avoid blind fluid boluses
• Introduce vasopressors early

 S – Stabilization Phase

• Maintenance only
• Replace ongoing losses
• Avoid accumulation

 E – Evacuation (Deresuscitation) Phase

• Remove excess fluid
• Diuretics or CRRT
• Target negative balance

6️⃣ Core Principles of Fluid Stewardship

1️⃣ Fluids Are Drugs

Each prescription must specify:

• Type
• Dose
• Rate
• Duration
• Indication
• Endpoint

2️⃣ Assess Fluid Responsiveness

Only 40–50% of hypotensive ICU patients respond to fluids.

Preferred Dynamic Tests

• Passive Leg Raise (PLR)
• Stroke Volume Variation (SVV)
• Pulse Pressure Variation (PPV)
• IVC ultrasound variability
• End-expiratory occlusion test

 CVP alone is unreliable.

VExUS (Venous Excess Ultrasound) in Fluid Stewardship

Evaluates:

• IVC size
• Hepatic vein Doppler
• Portal vein Doppler
• Renal vein Doppler

Helps detect venous congestion before organ failure.

3️⃣ Early Vasopressors

In septic shock:

• Start norepinephrine early.
• Do not keep giving fluids for hypotension alone.

4️⃣ Avoid Maintenance Fluids in Stable ICU Patients

Common error:
“Keep 100 mL/hr running”(it comes via holiday-segar formula  for 60 kg patient )

If:

• Patient on enteral feeds
• Hemodynamically stable
• No ongoing losses

→ Maintenance IV fluids often unnecessary.and dont use holiday segar formula 

Daily Reqirement is  – 25–30 mL/kg/day

5️⃣ Daily Fluid Balance Review

Every ICU round must include:

• 24-hour input/output
• Cumulative balance of all days since icu admission 
• Weight change
• Need for ongoing fluids