European Society of Intensive Care Medicine Clinical Practice Guideline on fluid therapy in adult critically ill patients: Part 3-fluid removal at de-escalation phase

TY - JOUR

T1 - European Society of Intensive Care Medicine Clinical Practice Guideline on fluid therapy in adult critically ill patients

T2 - Part 3-fluid removal at de-escalation phase

AU - Ostermann, Marlies

AU - Alshamsi, Fayez

AU - Artigas Raventos, Antonio

AU - Cecconi, Maurizio

AU - Ichai, Carole

AU - Jones, Christina

AU - Malbrain, Manu L N G

AU - Monnet, Xavier

AU - Nalos, Marek

AU - Peng, Zhiyong

AU - Pfortmueller, Carmen A

AU - Prowle, John

AU - Ranzani, Otavio

AU - Shankar-Hari, Manu

AU - Wong, Adrian

AU - Møller, Morten Hylander

AU - De Backer, Daniel

AU - European Society of Intensive Care Medicine

N1 - © 2025. Springer-Verlag GmbH Germany, part of Springer Nature.

PY - 2025/8/19

Y1 - 2025/8/19

N2 - PURPOSE: This is the third of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on fluid management in adult critically ill patients. This part addresses fluid removal in the de-escalation phase of shock management.METHODS: This guideline was formulated by an international panel of clinical experts, methodologists, and patient representatives. A literature search was conducted to identify relevant randomized controlled trials (RCTs) in adults published up to February 2025. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.RESULTS: Based on data from 13 RCTs, the panel issued three conditional recommendations. The panel suggested de-escalation of fluid therapy over no de-escalation in critically ill adults after the acute phase of fluid resuscitation (low certainty evidence). They suggested protocolized fluid removal by diuretics over usual care in critically ill patients after the acute phase of fluid resuscitation (moderate certainty evidence). A conditional recommendation was issued against the routine use of ultrafiltration or extracorporeal fluid removal in critically ill adults after the acute phase of fluid resuscitation, without other indication for RRT (low certainty evidence). There was limited evidence to comment on fluid removal in specific patient cohorts.CONCLUSIONS: This ESICM guideline provides three recommendations to inform clinicians on fluid removal during the de-escalation phase in critically ill patients with shock who no longer need fluid resuscitation.

AB - PURPOSE: This is the third of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on fluid management in adult critically ill patients. This part addresses fluid removal in the de-escalation phase of shock management.METHODS: This guideline was formulated by an international panel of clinical experts, methodologists, and patient representatives. A literature search was conducted to identify relevant randomized controlled trials (RCTs) in adults published up to February 2025. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.RESULTS: Based on data from 13 RCTs, the panel issued three conditional recommendations. The panel suggested de-escalation of fluid therapy over no de-escalation in critically ill adults after the acute phase of fluid resuscitation (low certainty evidence). They suggested protocolized fluid removal by diuretics over usual care in critically ill patients after the acute phase of fluid resuscitation (moderate certainty evidence). A conditional recommendation was issued against the routine use of ultrafiltration or extracorporeal fluid removal in critically ill adults after the acute phase of fluid resuscitation, without other indication for RRT (low certainty evidence). There was limited evidence to comment on fluid removal in specific patient cohorts.CONCLUSIONS: This ESICM guideline provides three recommendations to inform clinicians on fluid removal during the de-escalation phase in critically ill patients with shock who no longer need fluid resuscitation.

KW - Humans

KW - Critical Illness/therapy

KW - Fluid Therapy/standards

KW - Critical Care/standards

KW - Adult

KW - Europe

KW - Societies, Medical/organization & administration

KW - Randomized Controlled Trials as Topic

U2 - 10.1007/s00134-025-08058-x

DO - 10.1007/s00134-025-08058-x

M3 - Article

C2 - 40828463

SN - 0342-4642

VL - 51

SP - 1749

EP - 1763

JO - Intensive Care Medicine

JF - Intensive Care Medicine

IS - 10

ER -