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Practice Guideline
. 2025 Oct;51(10):1749-1763.
doi: 10.1007/s00134-025-08058-x. Epub 2025 Aug 19.

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

Marlies Ostermann #  1 , Fayez Alshamsi #  2   3 , Antonio Artigas Raventos  4 , Maurizio Cecconi  5   6 , Carole Ichai  7 , Christina Jones  8 , Manu L N G Malbrain  9   10   11   12 , Xavier Monnet  13 , Marek Nalos  14   15   16 , Zhiyong Peng  3 , Carmen A Pfortmueller  17   18 , John Prowle  19   20 , Otavio Ranzani  21   22 , Manu Shankar-Hari  23   24 , Adrian Wong  25 , Morten Hylander Møller #  26   27 , Daniel De Backer #  28 ; European Society of Intensive Care Medicine
Collaborators, Affiliations
Practice Guideline

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

Marlies Ostermann et al. Intensive Care Med. 2025 Oct.

Abstract

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.

Keywords: De-resuscitation; Diuretics; Extracorporeal fluid removal; Fluid; Fluid removal; Ultrafiltration.

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Conflict of interest statement

Declarations. Conflicts of interest: MO received research funding from Baxter and Biomerieux (paid to institution). AA received research funding grant from Grifols (paid to institution). CI received honoraria for lectures and speakers for educational events. CAP report grants from B. Braun Medical AG, CSEM AG outside of the submitted work. The funding was paid into departmental funds. MM 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 (now fully part of Getinge group), Sentinel Medical, Maltron, and Baxter. He consults for BBraun, Becton Dickinson, Fresenius Kabi, Grifols, Lexin, Spiegelberg, Medtronic, MedCaptain, and Holtech Medical, and received speaker’s fees from PeerVoice. He holds stock options for Sentinel, Serenno, and Potrero. 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. DdB has received honoraria for lectures from Edwards Lifesciences, Philips, AOP Health, Viatris, and Pharmazz. MC provides consultancy for GE Healthcare, Edwards Lifesciences, and Directed Systems. All other authors have nothing to declare.

References

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