Introducing the ROSE Concept: A Framework for Fluid Stewardship 

Dr Neeraj Manikath , claude.ai

Abstract

Fluid management remains one of the most fundamental yet controversial aspects of critical care medicine. The ROSE concept—Resuscitation, Optimization, Stabilization, and Evacuation—provides a dynamic, physiologically grounded framework for fluid stewardship across the trajectory of critical illness. This review explores the theoretical underpinnings and practical applications of each phase, synthesizing contemporary evidence to guide rational fluid therapy in the intensive care unit.

Introduction

Intravenous fluid therapy represents one of the most common interventions in critical care, yet inappropriate fluid administration contributes significantly to morbidity and mortality. The pendulum has swung from liberal "early goal-directed therapy" to more restrictive approaches, reflecting our evolving understanding that fluids behave as drugs—with therapeutic windows, dose-dependent effects, and potential toxicity.

The ROSE concept, first articulated by Malbrain et al., offers a temporal framework that acknowledges the changing physiology of critical illness and adapts fluid strategy accordingly. This paradigm shift moves beyond simplistic "wet versus dry" debates toward precision fluid management tailored to disease trajectory.

The Four Phases of ROSE

Phase 1: Resuscitation (Salvage)

Timeframe: Initial presentation through the first 24-48 hours

Primary Goal: Restore tissue perfusion and prevent irreversible organ injury

The resuscitation phase addresses life-threatening circulatory shock where inadequate tissue perfusion threatens cellular viability. The fundamental question is not whether to give fluid, but rather: Will this patient respond to fluid?

Physiological Principles:

The Frank-Starling mechanism dictates that fluid responsiveness exists only on the ascending limb of the cardiac function curve. Approximately 50% of critically ill patients are fluid responsive at any given time. Static markers (CVP, PAOP) have been thoroughly discredited; dynamic assessment is paramount.

Evidence-Based Approach:

The ANDROMEDA-SHOCK trial demonstrated that perfusion-targeted resuscitation (capillary refill time <3 seconds) resulted in lower 28-day mortality compared to lactate-targeted approaches (34.9% vs 43.4%, p=0.06). The CLASSIC trial showed that restrictive fluid strategies in septic shock (median 1.3L in first 24h after ICU admission) were noninferior to standard care regarding 90-day mortality, challenging aggressive resuscitation dogma.

Practical Application:

1. Dynamic assessment: Passive leg raise (PLR) with cardiac output monitoring remains the gold standard, predicting fluid responsiveness with 85% accuracy. Pulse pressure variation (PPV >13%) and stroke volume variation (SVV >12%) are reliable in mechanically ventilated patients without arrhythmias.

2. Fluid challenge technique: Administer 250-500mL crystalloid over 10-15 minutes, reassessing hemodynamics immediately. The "mini-fluid challenge" (100mL over 1 minute) may predict responsiveness before full bolus administration.

3. Choice of fluid: Balanced crystalloids (Ringer's lactate, Plasmalyte) are preferred over normal saline. The SMART trial demonstrated reduced composite adverse kidney events with balanced solutions (14.3% vs 15.4%, OR 0.90, 95% CI 0.82-0.99).

Pearl: Use the "TROL" mnemonic for fluid responsiveness: Tachycardia, Respiratory variation, Oliguria, Lactate elevation suggest potential (but don't confirm) responsiveness.

Oyster: The mean arterial pressure (MAP) target of 65 mmHg is not universal. The 65 trial showed no benefit to higher targets (75-85 mmHg) except possibly in chronic hypertension. Personalize based on autoregulation and end-organ perfusion.

Phase 2: Optimization (Ebb to Flow)

Timeframe: 24-72 hours after initial resuscitation

Primary Goal: Achieve neutral to slightly positive fluid balance while ensuring adequate oxygen delivery

This transitional phase represents the shift from life-saving resuscitation to fine-tuning hemodynamics. The patient transitions from the "ebb phase" (low cardiac output, high systemic vascular resistance) to the "flow phase" (increased cardiac output, vasodilation).

Physiological Principles:

Excessive fluid accumulation during this phase contributes to the development of fluid overload syndrome, characterized by tissue edema, increased intra-abdominal pressure, impaired microcirculatory flow, and organ dysfunction. The glycocalyx—the endothelial surface layer crucial for vascular barrier function—is disrupted in critical illness, promoting fluid extravasation.

Evidence-Based Approach:

The FACCT trial demonstrated that conservative fluid management in ARDS improved ventilator-free days (14.6 vs 12.1 days, p<0.001) and ICU-free days without increasing shock or need for dialysis. Cumulative fluid balance >10% body weight at 72 hours consistently predicts worse outcomes across multiple studies.

Practical Application:

1. Stop fluid boluses: Unless clear evidence of fluid responsiveness and ongoing perfusion deficits exist. The default should be maintenance fluids only.

2. Calculate fluid balance: Daily and cumulative. Use adjusted body weight for percentage calculations: [Cumulative fluid in (L) - out (L)] / admission weight (kg) × 100.

3. Implement "fluid stewardship rounds": Systematically assess fluid needs, similar to antimicrobial stewardship. Question every maintenance fluid order.

4. Optimize cardiac output non-fluidly: Address afterload, contractility, and heart rate. Vasopressors prevent further fluid accumulation while maintaining perfusion pressure.

Pearl: The "3-6-9 rule" offers pragmatic guidance—aim for fluid balance of +3L at 24h, +6L at 48h, and begin de-escalation before +9L cumulative.

Hack: Use the inferior vena cava (IVC) collapsibility index to guide fluid removal: IVC collapse >50% with inspiration suggests volume depletion; <20% suggests fluid tolerance for diuresis.

Oyster: Oliguria doesn't equal hypovolemia in this phase. Stress-induced acute kidney injury (AKI) may produce oliguria despite adequate perfusion. Forcing urine output with fluids may worsen outcomes—the RELIEF trial showed that higher urine output targets (≥2 mL/kg/h) increased risk of fluid overload.

Phase 3: Stabilization (Maintenance)

Timeframe: Beyond 72 hours through resolution of acute illness

Primary Goal: Achieve neutral or negative fluid balance while maintaining hemodynamic stability

In the stabilization phase, inflammatory mediators subside, capillary leak resolves, and the glycocalyx begins restoration. The focus shifts entirely toward reversing fluid accumulation.

Physiological Principles:

Persistent fluid overload increases mortality independent of underlying disease severity. Each 1L positive fluid balance beyond day 3 associates with 4% increased mortality risk. Mechanisms include: abdominal compartment syndrome, pulmonary edema, impaired oxygen diffusion, renal congestion, and wound healing impairment.

Evidence-Based Approach:

The REVERSE trial found that fluid removal within 24 hours after resuscitation improved survival in patients with AKI and volume overload (hazard ratio for death 0.61, 95% CI 0.40-0.92). Protocolized diuretic therapy in mechanically ventilated patients decreased duration of ventilation and hospital stay.

Practical Application:

1. Active de-resuscitation: Use loop diuretics (furosemide 20-200mg) titrated to achieve negative balance of 0.5-1L daily. Consider continuous infusion for diuretic resistance.

2. Monitor renal function: Accept small creatinine increases (<0.3 mg/dL) during diuresis if other perfusion markers remain adequate—this often represents hemoconcentration, not true AKI.

3. Hypertonic saline-furosemide combination: The DRAIN trial showed that 3% NaCl plus furosemide produces greater diuresis than furosemide alone in volume overload, without worsening renal function.

4. Ultrafiltration: Consider renal replacement therapy (RRT) primarily for fluid removal in diuretic-refractory patients, even without traditional dialysis indications. The REVERSE trial supports this approach.

Pearl: The "TIDE" protocol (Timing, Intensity, Duration, Endpoints) structures de-resuscitation: begin early (within 24h of stability), target 1-2L negative daily, continue until euvolemia, monitor perfusion not pressure.

Hack: Physical examination rebounds in reliability during this phase. Resolution of peripheral edema, jugular venous distention, and pulmonary rales indicates successful de-resuscitation better than numbers.

Oyster: Avoid nephrotoxic agents during active diuresis. NSAIDs, aminoglycosides, and contrast should be minimized. ACE inhibitors may be temporarily held during aggressive diuresis.

Phase 4: Evacuation (Recovery)

Timeframe: Recovery and rehabilitation phase

Primary Goal: Complete restoration of euvolemia and physiologic homeostasis

The evacuation phase represents the transition from critical illness to recovery, where spontaneous diuresis often occurs as inflammation resolves and normal capillary integrity returns.

Physiological Principles:

As capillary leak reverses, mobilization of interstitial fluid back into the intravascular space occurs naturally. The renin-angiotensin-aldosterone system normalizes, and the kidneys regain full concentrating ability. Patients may experience spontaneous diuresis of 3-5L daily.

Practical Application:

1. Allow autoresuscitation: Minimize iatrogenic fluid administration. Patients often require no IV fluids once tolerating oral intake.

2. Transition to oral diuretics: For patients with residual fluid overload, oral furosemide facilitates gradual fluid removal through convalescence.

3. Nutritional optimization: Adequate protein (1.2-2.0 g/kg/day) supports oncotic pressure restoration as albumin synthesis recovers.

4. Mobilization: Early physical therapy promotes lymphatic drainage and fluid redistribution.

Pearl: This phase requires the least intervention—resist the urge to "do something." Primum non nocere applies particularly to fluid therapy.

Integrating ROSE into Clinical Practice

The ROSE Bundle Checklist:

Daily Assessment:

• Current phase identification
• Fluid responsiveness testing (if considering bolus)
• Cumulative fluid balance calculation
• Physical examination findings
• Kidney function and electrolytes

Decision Framework:

• Is the patient still in shock? → Continue resuscitation
• Is perfusion adequate? → Stop boluses, begin optimization
• Is the patient stable >72h? → Active de-resuscitation
• Is acute illness resolving? → Allow natural evacuation

Special Populations

ARDS: Particularly benefits from restrictive strategies (FACCT trial). Target negative 0.5-1L daily balance once shock resolved.

Septic Shock: Early appropriate resuscitation (first 3-6 hours) followed by rapid transition to restrictive management improves outcomes.

Cardiac Surgery: Implement restrictive protocols perioperatively—the RELIEF trial showed harm from excessive fluids.

Burns: Traditional Parkland formula often results in over-resuscitation; consider reduced volumes with early albumin.

Monitoring Tools

Non-invasive: Ultrasound (IVC, lung B-lines, LVOT VTI), capillary refill, lactate clearance

Minimally invasive: Arterial waveform analysis (FloTrac, LiDCO), esophageal Doppler

Invasive: Pulmonary artery catheter (reserved for complex cases)

Future Directions

Emerging technologies including point-of-care ultrasound, bioimpedance spectroscopy, and machine learning algorithms promise more precise, individualized fluid management. The concept of "personalized fluid therapy" using multi-parameter phenotyping represents the next evolution beyond ROSE.

Conclusion

The ROSE concept provides an elegant, physiologically sound framework for fluid stewardship that acknowledges the dynamic nature of critical illness. By recognizing that fluid requirements change dramatically across disease trajectory, intensivists can avoid both under-resuscitation in shock and harmful fluid overload during recovery. Implementing ROSE principles requires cultural change—moving from reflexive fluid administration to thoughtful, evidence-based fluid stewardship. As Malbrain stated: "Fluid is a drug: it has both indication and contraindication."

The path forward demands that we ask not simply "Should I give fluid?" but rather "Where is my patient on the ROSE trajectory, and what does their physiology demand at this moment?" This nuanced approach represents the maturation of critical care fluid management from art toward science.

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Key References

1. Malbrain MLNG, 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.

2. Hernández G, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock (ANDROMEDA-SHOCK). JAMA. 2019;321(7):654-664.

3. Meyhoff TS, et al. Restriction of intravenous fluid in ICU patients with septic shock (CLASSIC). N Engl J Med. 2022;386(26):2459-2470.

4. Semler MW, et al. Balanced crystalloids versus saline in critically ill adults (SMART). N Engl J Med. 2018;378(9):829-839.

5. National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury (FACCT). N Engl J Med. 2006;354(24):2564-2575.

6. Gaudry S, et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome (REVERSE). Am J Respir Crit Care Med. 2021;204(11):1278-1285.

7. Ostermann M, et al. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) conference. Kidney Int. 2020;98(2):294-309.

8. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726-1734.