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Practice Guideline
. 2025 Mar;51(3):461-477.
doi: 10.1007/s00134-025-07840-1. Epub 2025 Mar 31.

European Society of Intensive Care Medicine (ESICM) 2025 clinical practice guideline on fluid therapy in adult critically ill patients: part 2-the volume of resuscitation fluids

Armand Mekontso Dessap  1   2 , Fayez AlShamsi  3 , Alessandro Belletti  4 , Daniel De Backer  5 , Anthony Delaney  6 , Morten Hylander Møller  7 , Segolène Gendreau  8   9 , Glenn Hernandez  10 , Flavia R Machado  11 , Mervyn Mer  12 , Manuel Ignacio Monge Garcia  13 , Sheila Nainan Myatra  14 , Zhiyong Peng  15 , Anders Perner  7 , Michael R Pinsky  16 , Sameer Sharif  17 , Jean-Louis Teboul  18 , Antoine Vieillard-Baron  19 , Waleed Alhazzani  20   21 ; European Society of Intensive Care Medicine
Collaborators, Affiliations
Practice Guideline

European Society of Intensive Care Medicine (ESICM) 2025 clinical practice guideline on fluid therapy in adult critically ill patients: part 2-the volume of resuscitation fluids

Armand Mekontso Dessap et al. Intensive Care Med. 2025 Mar.

Abstract

Objective: This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommendations on the volume of early resuscitation fluid for adult critically ill patients.

Methods: An international panel of experts developed the guideline, focusing on fluid resuscitation volume in adult critically ill patients with circulatory failure. Using the PICO format, questions were formulated, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to assess evidence and formulate recommendations.

Results: In adults with sepsis or septic shock, the guideline suggests administering up to 30 ml/kg of intravenous crystalloids in the initial phase, with adjustments based on clinical context and frequent reassessments (very low certainty of evidence). We suggest using an individualized approach in the optimization phase (very low certainty of evidence). No recommendation could be made for or against restrictive or liberal fluid strategies in the optimization phase (moderate certainty of no effect). For hemorrhagic shock, a restrictive fluid strategy is suggested after blunt trauma (moderate certainty) and penetrating trauma (low certainty), with fluid administration for non-traumatic hemorrhagic shock guided by hemodynamic and biochemical parameters (ungraded best practice). For circulatory failure due to left-sided cardiogenic shock, fluid resuscitation as the primary treatment is not recommended. Fluids should be administered cautiously for cardiac tamponade until definitive treatment and guided by surrogate markers of right heart congestion in acute pulmonary embolism (ungraded best practice). No recommendation could be made for circulatory failure associated with acute respiratory distress syndrome.

Conclusions: The panel made four conditional recommendations and four ungraded best practice statements. No recommendations were made for two questions. Knowledge gaps were identified, and suggestions for future research were provided.

Keywords: Critical care; Fluid therapy; Individualization; Liberal; Practice guidelines; Restrictive; Shock; Volume.

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Conflict of interest statement

Declarations. Conflicts of interest: Daniel De Backer: received remuneration from Fresenius, Baxter, Pfizer, Edwards, Philips, and has published and presented on the topic. Armand Mekontso Dessap: reports grants from Air Liquide, and Addmedica, all outside the submitted work. Sameer Sharif: supported by the McMaster University Department of Medicine Early Career Award. Jean Louis Teboul: received fees from Edwards Lifesciences and from Getinge. Manuel Ignacio Monge Garcia: received remuneration from Edwards Lifesciences, Dynocardia and Deltex Medical. Anthony Delaney: received a MRFF grant (MRFF-1200084). Other authors reported no conflict of interest.

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