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. 2022 Dec;48(12):1781-1786.
doi: 10.1007/s00134-022-06761-7. Epub 2022 Aug 6.

Everything you need to know about deresuscitation

Manu L N G Malbrain  1   2   3 , Greg Martin  4 , Marlies Ostermann  5
Affiliations

Everything you need to know about deresuscitation

Manu L N G Malbrain et al. Intensive Care Med. 2022 Dec.
No abstract available

PubMed Disclaimer

Conflict of interest statement

MLNGM is co-founder, past-President and current Treasurer of WSACS (The Abdominal Compartment Society, http://www.wsacs.org). He is member of the medical advisory Board of Pulsion Medical Systems (part of Getinge group), Serenno Medical, Potrero Medical, and Baxter, and consults for BBraun, Becton Dickinson, ConvaTec, Spiegelberg, and Holtech Medical. He is co-founder and President of the International Fluid Academy (IFA). The IFA (http://www.fluidacademy.org) is integrated within the not-for-profit charitable organization iMERiT, International Medical Education and Research Initiative, under Belgian law. MO has received speaker honoraria and research funding from Fresenius Medical and Baxter and is a member of an advisory board for NxStage and Pfizer. GM has served on research or medical advisory boards or conducted funded research from Genentech, Grifols, Regeneron and Siemens.

Figures

Fig. 1
Fig. 1
The 4 phases conceptual model and deleterious effects of fluid accumulation syndrome. Panel A The four-hit model of shock with evolution of patients’ cumulative fluid volume status over time during the five phases of resuscitation: Resuscitation (R), Optimization (O), Stabilization (S), and Evacuation (E) (ROSE), followed by a possible risk of Hypoperfusion in case of too aggressive deresuscitation. On admission patients are often hypovolemic, followed by normovolemia after fluid resuscitation (escalation or EAFM, early adequate fluid management), and possible fluid overload, again followed by a phase returning to normovolemia with de-escalation via achieving zero fluid balance or late conservative fluid management (LCFM) and followed by late goal directed fluid removal (LGFR) or deresuscitation. In case of hypovolemia, O2 cannot get into the tissue because of convective problems, in case of hypervolemia O2 cannot get into the tissue because of diffusion problems related to interstitial and pulmonary edema, gut edema (ileus and abdominal hypertension). *Volumetric preload indicators like GEDVI, LVEDAI, or RVEDVI are preferred over barometric ones like CVP or PAOP. **Vasopressor can be started or increased to maintain MAP/APP above 55/45 during deresuscitation phase. #Can only be measured via Swan-Ganz pulmonary artery catheter (PAC) and became obsolete. Panel B Potential consequences of fluid accumulation syndrome (formerly known as fluid overload) and GIPS (global increased permeability syndrome) on end-organ function. Figures adapted from Malbrain et al. with permission, according to the Open Access CC BY Licence 4.0 [2, 7]. ACS abdominal compartment syndrome, APP abdominal perfusion pressure = MAP-IAP, BIA bio-electrical impedance analysis, CARS cardio-abdominal-renal syndrome, CI cardiac index, CLI capillary leak index (serum CRP divided by serum albumin), CO cardiac output, COP colloid oncotic pressure, CPP cerebral perfusion pressure, CS compartment syndrome, CVP central venous pressure, ECW/ICW extracellular/intracellular water, EVLWI extra-vascular lung water index, FAS fluid accumulation syndrome, GEDVI global end-diastolic volume index, GEF global ejection fraction, GFR glomerular filtration rate, IAH intra-abdominal hypertension, IAP intra-abdominal pressure, ICG-PDR indocyanine green plasma disappearance rate, ICH intracranial hypertension, ICP intracranial pressure, ICS intracranial compartment syndrome, IOP intra-ocular pressure, IVCCI inferior vena cava collapsibility index, LVEDAI left ventricular end-diastolic area index, MAP mean arterial pressure, OCS ocular compartment syndrome, PAOP pulmonary artery occlusion pressure, PF PaO2 over FiO2 ratio, pHi gastric tonometry, PLR passive leg raising, PPV pulse pressure variation, PVPI pulmonary vascular permeability index, RVEDVI right ventricular end-diastolic volume index, RVR renal vascular resistance, ScvO2 central venous oxygen saturation, SSCG surviving sepsis campaign guidelines, SvO2 mixed venous oxygen saturation, SV stroke volume, SVV stroke volume variation, VE volume excess (from baseline body weight), VExUS venous congestion by ultrasound
Fig. 1
Fig. 1
The 4 phases conceptual model and deleterious effects of fluid accumulation syndrome. Panel A The four-hit model of shock with evolution of patients’ cumulative fluid volume status over time during the five phases of resuscitation: Resuscitation (R), Optimization (O), Stabilization (S), and Evacuation (E) (ROSE), followed by a possible risk of Hypoperfusion in case of too aggressive deresuscitation. On admission patients are often hypovolemic, followed by normovolemia after fluid resuscitation (escalation or EAFM, early adequate fluid management), and possible fluid overload, again followed by a phase returning to normovolemia with de-escalation via achieving zero fluid balance or late conservative fluid management (LCFM) and followed by late goal directed fluid removal (LGFR) or deresuscitation. In case of hypovolemia, O2 cannot get into the tissue because of convective problems, in case of hypervolemia O2 cannot get into the tissue because of diffusion problems related to interstitial and pulmonary edema, gut edema (ileus and abdominal hypertension). *Volumetric preload indicators like GEDVI, LVEDAI, or RVEDVI are preferred over barometric ones like CVP or PAOP. **Vasopressor can be started or increased to maintain MAP/APP above 55/45 during deresuscitation phase. #Can only be measured via Swan-Ganz pulmonary artery catheter (PAC) and became obsolete. Panel B Potential consequences of fluid accumulation syndrome (formerly known as fluid overload) and GIPS (global increased permeability syndrome) on end-organ function. Figures adapted from Malbrain et al. with permission, according to the Open Access CC BY Licence 4.0 [2, 7]. ACS abdominal compartment syndrome, APP abdominal perfusion pressure = MAP-IAP, BIA bio-electrical impedance analysis, CARS cardio-abdominal-renal syndrome, CI cardiac index, CLI capillary leak index (serum CRP divided by serum albumin), CO cardiac output, COP colloid oncotic pressure, CPP cerebral perfusion pressure, CS compartment syndrome, CVP central venous pressure, ECW/ICW extracellular/intracellular water, EVLWI extra-vascular lung water index, FAS fluid accumulation syndrome, GEDVI global end-diastolic volume index, GEF global ejection fraction, GFR glomerular filtration rate, IAH intra-abdominal hypertension, IAP intra-abdominal pressure, ICG-PDR indocyanine green plasma disappearance rate, ICH intracranial hypertension, ICP intracranial pressure, ICS intracranial compartment syndrome, IOP intra-ocular pressure, IVCCI inferior vena cava collapsibility index, LVEDAI left ventricular end-diastolic area index, MAP mean arterial pressure, OCS ocular compartment syndrome, PAOP pulmonary artery occlusion pressure, PF PaO2 over FiO2 ratio, pHi gastric tonometry, PLR passive leg raising, PPV pulse pressure variation, PVPI pulmonary vascular permeability index, RVEDVI right ventricular end-diastolic volume index, RVR renal vascular resistance, ScvO2 central venous oxygen saturation, SSCG surviving sepsis campaign guidelines, SvO2 mixed venous oxygen saturation, SV stroke volume, SVV stroke volume variation, VE volume excess (from baseline body weight), VExUS venous congestion by ultrasound
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References

    1. Malbrain ML, Mythen M, Rice TW, Wuyts S. It is time for improved fluid stewardship. ICU Manag Pract. 2018;18(3):158–162.
    1. Malbrain MLNG, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, et al. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA) Ann Intensive Care. 2020;10(1):64. doi: 10.1186/s13613-020-00679-3. - DOI - PMC - PubMed
    1. Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014;46(5):361–380. doi: 10.5603/AIT.2014.0060. - DOI - PubMed
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    1. 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(2):155–170. doi: 10.1007/s00134-016-4573-3. - DOI - PubMed

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