TABLE 6.
ROSE diagram illustrating the dynamic phases during fluid therapy (adapted from Malbrain et al. with permission [3])
| R (Resuscitation) | O (Optimization) | S (Stabilization) | E (Evacuation) | ||
|---|---|---|---|---|---|
| Hit | First | Second | Second | Third | Fourth |
| Cause | Inflammatory response (burn, sepsis, trauma, etc.) | ischemia reperfusion | ischemia reperfusion | Global Increased Permeability Syndrome (GIPS) | Hypoperfusion |
| Phase | Ebb | Flow | Flow/no Flow | No Flow | No Flow |
| Type | Severe shock | Unstable | Stable | Recovering | Unstable |
| Example | Septic shock, burn, multiple trauma, haemorrhagic shock | Less severe burns, diabetic ketoacidosis, gastrointestinal losses | Post-surgical patients with TPN or EN, Replacement of losses in mild pancreatitis | Patients with complete enteral nutrition in critical disease recovery phase, polyuric phase of renal failure | Patients with cirrhosis, anasarca and oedema, GIPS, hepatosplenic hypoperfusion |
| Question | When to start IV fluids? | When to stop IV fluids? | When to stop IV fluids? | When to start fluid removal? | When to stop fluid removal? |
| Alternative question | Benefit of IV fluids | Risk of IV fluids | Risk of IV fluids | Benefit of fluid removal | Risk of fluid removal |
| O2 transport | Convective alterations | Euvolaemia, normal diffusion | Diffusion alterations | Euvolaemia, normal diffusion | Convective disturbances |
| Fluids | Mandatory | Critical illness biomarker | Critical illness biomarker | Toxic | – |
| Fluid therapy | Quick bolus (4 mL kg-1 in 10–15 minutes) | Assess fluid balance, use bolus conservatively | Minimal maintenance if oral intake is inadequate, provide replacement fluids | Oral intake if necessary, avoid unnecessary intravenous fluids | Avoid hypoperfusion |
| Fluid balance | Positive | Neutral | Neutral/Negative | Negative | Neutral |
| Result | Life saved (rescue) | Organs saved (maintenance) | Organ support (Homeostasis) | Organ recovery (removal) | Organ support |
| Goals | Macro haemodynamics | Organ perfusion | Organ function | Organ function evolution | Avoid organ hypoperfusion |
| Objectives | Correct the shock status | Maintain tissue perfusion | Maintain neutral to negative fluid balance | Eliminate fluid build-up | Maintain tissue perfusion |
| Time to act | Minutes | Hours | Days | Days to weeks | Weeks |
GIPS – global increased permeability syndrome, TPN – total parenteral nutrition, EN – enteral nutrition.