Figure 1.

The four hits of shock. Graph showing the four-hit model of shock with evolution of patients’ cumulative fluid volume status over time during the five distinct 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 de-resuscitation. On admission patients are hypovolemic, followed by normovolemia after fluid resuscitation (EAFM, early adequate fluid management), and possible fluid overload, again followed by a phase going to normovolemia with late conservative fluid management (LCFM) and late goal directed fluid removal (LGFR) or de-resuscitation. In the case of hypovolemia, O₂ cannot get into the tissue because of convective problems; in the 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). Adapted according to the Open Access CC BY License 4.0 from Malbrain et al., with permission [17].