Intensive Care Med

https://doi.org/10.1007/s00134-025-07840-1

CONFERENCE REPORTS AND EXPERT PANEL

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 Dessap1,18* , Fayez AlShamsi2 , Alessandro Belletti3 , Daniel De Backer4 ,
Anthony Delaney5 , Morten Hylander Møller6 , Segolène Gendreau1,18 , Glenn Hernandez7 ,
Flavia R. Machado8, Mervyn Mer9 , Manuel Ignacio Monge Garcia10 , Sheila Nainan Myatra11 ,
Zhiyong Peng12 , Anders Perner6 , Michael R. Pinsky13 , Sameer Sharif14 , Jean‑Louis Teboul15 ,
Antoine Vieillard‑Baron16 and Waleed Alhazzani17,19 on behalf of the European Society of Intensive Care
Medicine

© 2025 Springer-Verlag GmbH Germany, part of Springer Nature

Abstract
Objective: This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommen‑
dations 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 hem‑
orrhagic 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

*Correspondence: [email protected]
1
Medical Intensive Care, Henri-Mondor Hospital (AP-HP), UPEC, IMRB,
CARMAS Research Group, Creteil, France
Full author information is available at the end of the article

The members of the “European Society of Intensive Care Medicine” is

present in the electronic supplementary material.
 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: Shock, Fluid therapy, Volume, Liberal, Restrictive, Individualization, Practice guidelines, Critical care

Introduction
The administration of resuscitation fluids is common in Take‑home message
the management of critically ill patients. The European
In adults with sepsis or septic shock, we suggest to administer up to
Society of Intensive Care Medicine (ESICM) convened 30 ml/kg of intravenous crystalloids in the initial phase, with adjust‑
a group of content and methods experts to produce a ments based on clinical context and frequent reassessments, and to
clinical practice guideline (CPG) on fluid management use an individualized approach in the optimization phase. We were
unable to make a recommendation for or against systematic restric‑
in adult critically ill patients. This CPG was divided tive or liberal fluid administration in the optimization phase.
into three parts: the type of resuscitation fluids (Part
In adults with hemorrhagic shock, we suggest a restrictive
1), the volume of resuscitation fluids (Part 2), and fluid fluid resuscitation strategy (as part of a permissive hypotension
removal in the de-escalation phase (Part 3). The full approach) after blunt or penetrating trauma, and we recommend
contributors are presented in the electronic supple- (best practice statement) to guide fluid administration by hemody‑
namic and biochemical parameters for hemorrhagic shock of non-
mentary material. In this manuscript, the guideline on traumatic origin.
the volume of resuscitation fluid is presented.
We recommend (best practice statement) against the use of fluid
Resuscitation fluids are typically given as a bolus or resuscitation as the primary treatment for circulatory failure due to
challenge during circulatory failure. The primary goal left-sided cardiogenic shock, for the cautious administration of fluids
of fluid therapy is to increase stroke volume and cardiac as a temporary measure until definitive treatment can be given for
circulatory failure due to cardiac tamponade, and for the cautious
output to increase systemic blood flow and tissue per- administration of fluids with clinical decisions based on measured
fusion. In clinical practice, the volume of resuscitation surrogate markers of right heart congestion for circulatory failure
fluids may vary depending on the pathophysiology of cir- due to pulmonary embolism.
culatory failure, clinician preference, and practice setting. We were unable to make a recommendation for circulatory failure
associated with acute respiratory distress syndrome.
The aim of this ESICM guideline was to provide evi-
dence-based guidance on the volume of resuscitation
fluid in adult critically ill patients, supported by a criti-
cal analysis of the literature. Conflict of interest management
We applied the principles of conflict of interest manage-
Methods ment as previously described [2]. Panelists were asked
Guideline scope and target audience to declare any intellectual or financial conflict of inter-
The purpose of this guideline is to provide evidence- est (COI) that might influence their participation in the
based guidance on the volume of fluid resuscitation in guideline, by completing a specific form in accordance
adult critically ill patients with circulatory failure due to a with ESICM procedures. A summary of individual dec-
variety of causes. The target audience for this guideline is larations can be found at the end of the document under
frontline clinicians (physicians and nurses), allied health the COI section. Panelists received no financial incen-
professionals, and policy-makers in high-, low-, and mid- tives for their participation. In addition, no funding or
dle-income countries. input from industry was incorporated into the guideline.

Panel selection and organization Development of questions and outcomes selection

Panel members were appointed with diversity and inclu- This guideline addressed the volume of resuscitation fluid in
sivity in mind as previously described [1]. The panel con- adult critically ill patients with circulatory failure of various
sisted of two ESICM guideline co-chairs, a clinical chair, etiologies. One question addressed patients with circulatory
a methods chair, two methodologists and 13 clinical failure and acute respiratory distress syndrome. Studies on
experts, including methodologists and clinicians special- the intraoperative setting, maintenance fluid, fluid volume
ized in critical care, emergency medicine, and anesthesia. for burn management, or management of increased intracra-
nial pressure were excluded.
 Population, Intervention, Comparison, and Out- The certainty of the evidence for each recommendation
comes (PICO) questions were proposed, prioritized, was determined based on the panel’s deliberations, con-
and approved by all panelists. The guideline included sidering the totality of the evidence, including the level
recommendations for ten questions covering the fol- of certainty for the critical outcome with the lowest cer-
lowing areas (A) sepsis (three questions, in the initial tainty [8]. For each PICO, we report the level of certainty
and optimization phases); (B) hemorrhagic shock (three and the areas involved in the downgrading in the rel-
questions, for penetrating trauma, blunt trauma and non- evant Summary of Evidence section and provide a more
traumatic causes), (C) obstructive shock (two questions, detailed description in the Evidence Profile tables in the
for pulmonary embolism and cardiac tamponade), (D) electronic supplementary material. The GRADEpro GDT
left-sided cardiogenic shock (one question) and (D) acute (GRADEpro Guideline Development Tool [Software],
respiratory distress syndrome (one question). McMaster University and Evidence Prime, 2022 available
The panelists selected and prioritized patient-centered from www.​grade​pro.​org was used to generate evidence
outcomes for each PICO on a scale of 1 to 9 (from not profiles for each PICO. The evidence profiles included all
important to critical) [8]. The following outcomes were prioritized outcomes for which data were identified dur-
considered critical: short-term mortality, need for renal ing the literature search.
replacement therapy, ventilator-free days/duration of
mechanical ventilation, intensive care unit (ICU)-free Recommendation formulation
days/ICU length of stay, hospital-free days/hospital The panel met monthly online and used the Evidence-to-
length of stay, quality of life, and functional outcomes. Decision (EtD) framework to formulate recommenda-
The panel carefully deliberated the importance of out- tions [9]. As described in the GRADE methodology, the
comes throughout the process, from reviewing the evi- panel considered the following factors in deciding the
dence to formulating the recommendation [3]. direction and strength of recommendations: magnitude
of effect, certainty of evidence, patient values and prefer-
Literature search ences, resources and costs, equity, acceptability and feasi-
The methodologists searched for relevant systematic bility. For a strong recommendation, we used the phrase
reviews and meta-analyses and updated them as neces- “we recommend”, and for a conditional recommenda-
sary. If neither was available, we searched MEDLINE & tion (also called a weak recommendation), we used the
EMBASE from inception to June 2022 for randomized phrase “we suggest”. A strong recommendation in favor
clinical trials (RCTs). Search profiles are available in the of an intervention means that the desirable benefits of
electronic supplementary material. the intervention outweigh any significant adverse effects,
that most patients and clinicians would choose the rec-
Data analysis ommendation, and that it can be adopted as policy. On
The DerSimonian and Laird random effects model was the other hand, a conditional recommendation in favor
used to pool results of effect sizes across RCTs [4, 5]. of an intervention means that the desirable benefit of
Relative risks (RRs) with corresponding 95% confidence the intervention outweighs the undesirable effect, but
intervals (CIs) were used for binary outcomes, while with low confidence. It means that a majority, but not all,
mean differences (MDs) and 95% CIs were used for con- people are likely to be best served by the recommended
tinuous outcomes. The ­I2 statistics was used for descrip- intervention [9]. It also implies that most patients and cli-
tive rather than inferential purposes, and heterogeneity nicians would accept the proposed action of a conditional
was assessed primarily on a clinical basis. All analyses recommendation, but a significant number would not,
were performed using Review Manager (RevMan) ver- and for policy-makers, it would not be appropriate to
sion 5.4, The Cochrane Collaboration, 2000 [5]. adopt it as policy. To provide practical guidance to critical
practitioners, we presented recommendations in favor of
Risk of bias and overall certainty of evidence one approach rather than against an alternative [10]. The
The Cochrane Collaboration Risk of Bias (ROB) 1.0 tool panel used consensus to formulate recommendations and
was used to assess the risk of bias of individual RCTs. all members approved the final recommendations.
The Grading of Recommendations Assessment, Develop-
ment, and Evaluation (GRADE) methodology was used Results
to assess the certainty of the evidence [6]. The certainty of A. Sepsis
evidence from RCTs for each critical outcome starts with Question 1
a high rating, but can be lowered by one or two points Should 30 ml/kg fluid volume be used versus other
for each of the following domains: risk of bias, inconsist- approaches for initial resuscitation of circulatory
ency, indirectness, imprecision, and publication bias [7].
Table 1 Summary of clinical questions and recommendations for sepsis
Question Recommendation strength Certainty of evidence
and recommen‑
dation

Question 1 Should 30 ml/kg fluid volume be used versus other approaches

for initial resuscitation of circulatory failure in critically ill
patients with sepsis or septic shock?
Recommendation In adults with sepsis or septic shock who require fluid resuscitation Conditional Recommendation, For Very Low certainty of evidence
for circulatory failure, we suggest administering up to 30 ml/kg of
intravenous crystalloids in the initial phase (when hemodynamic
monitoring is not yet available, typically within the first 3 h), with
adjustments based on clinical context and frequent reassessments
Remark Clinicians may choose to administer different volumes of crystalloids
based on their clinical judgment, individual patient characteristics
and clinical context, such as the origin of sepsis (e.g., lung versus
abdomen), cardiovascular comorbidities, or the presence or not
of fluid losses
Remark Clinicians should assess their patients clinically and consider assess-
ing fluid responsiveness (if possible) before administering more crys-
talloids in the initial phase of resuscitation, recognizing that some
may require more or less than 30 mL/kg of intravenous crystalloids
Question 2 Should a liberal vs. restrictive strategy be used in the optimiza‑
tion phase of resuscitation of circulatory failure in critically ill
patients with sepsis or septic shock?
Recommendation In adults with sepsis or septic shock who need fluid resuscitation for No recommendation Moderate Certainty of evidence
circulatory failure, we cannot recommend for or against systematic
restrictive or liberal fluid administration
Remark In randomized trials, the use of a systematic restrictive strategy versus
a systematic liberal strategy in the optimization phase of resuscita-
tion had similar effects on patient-relevant outcomes (moderate
certainty of evidence)
Question 3 Should an individualized approach vs a non-individualized
approach be used for the optimization phase of resuscitation
of circulatory failure in critically ill patients with sepsis or septic
shock?
Recommendation In adults with sepsis or septic shock who require fluid resuscitation Conditional recommendation, For Very low certainty of evidence
for circulatory failure, we suggest using an individualized approach
compared with a non-individualized approach during the optimi-
zation phase

failure in critically ill patients with sepsis or septic shock? within 3 h in high-income countries. Since the first ver-
(Table 1). sion of the Surviving Sepsis Campaign (SSC) guidelines,
the administration of fluid resuscitation has been part of
Background Fluid resuscitation remains a cornerstone the initial resuscitation package for patients with septic
of septic shock management. The conceptual framework shock and may be associated with improved survival [13].
of fluid therapy for sepsis includes four phases. It begins However, the volume of fluid to be administered during
with rapid initial resuscitation, moves on to the optimiza- initial fluid resuscitation remains controversial [14]. The
tion of organ and tissue perfusion, is followed by a phase of SSC guidelines suggest an initial dose of at least 30 mL/
physiological stabilization, and concludes with the recov- kg of crystalloids to be administered within the first 3 h
ery phase [11]. The initial phase is the salvage phase, dur- of resuscitation. The choice of a fixed dose of 30 mL/kg
ing which the patient is first identified as being in shock from the SSC is somewhat arbitrary and based only on
and no hemodynamic monitoring is applied. The opti- observational data [13, 15–17] and has been questioned
mization phase follows, involving the assessment of the by some authors and trials [18, 19]. In addition, several
patient using various monitoring techniques [12]. In most observational studies have suggested possible harm from
studies on septic shock resuscitation, the initial phase cumulative positive fluid balance in septic patients [20–
generally covers the first 1 to 6 h of treatment. The timing 22]. Finally, the safety and the efficacy of a fixed dose of
of this transition can vary based on the organization and 30 mL/kg of fluid in patients at high risk of fluid overload
resources of different centers but is typically completed
(e.g., patients with heart failure or chronic kidney disease low-income countries found higher mortality in patients
requiring dialysis) remain unclear [23–25]. who received a fluid bolus of 20 to 40 ml/kg over 1 h
compared with patients who received no bolus (median
Summary of evidence A recent systematic review and 20 ml/kg in the first hour in both intervention groups,
meta-analysis of RCTs with pre-planned separation of i.e., albumin and saline vs 1.2 mL/kg in the no fluid bolus
intravenous fluid volumes or balances did not identify group, and median 40 mL/kg in both interventional
any RCT that specifically addressed the volume of 30 ml/ groups in the first 8 h vs. 10 mL/kg in the no fluid bolus
kg versus other volumes [26]. Our updated search did group) [30]. A recent meta-analysis reported that the
not identify any additional RCTs. Therefore, there is cur- effect of the fluid resuscitation approach differed by set-
rently no evidence from RCTs to support or discourage ting, with higher volumes of fluid resuscitation associated
the administration of 30 ml/kg crystalloids (or any other with increased mortality in LMICs and in settings with
volume) as initial resuscitation in patients with sepsis- limited access to mechanical ventilation [31]. These dif-
associated hypoperfusion or septic shock. ferences may not be generalizable to all LMICs, and the
According to recent RCTs investigating resuscitation exact reason for them is unclear and may in part be due
strategies in septic shock, current practice for initial to resource constraints, participant variation between tri-
resuscitation appears to be to administer a mean/median als, or other unmeasured factors [31]. However, they may
initial volume of 1 to 3 L of crystalloids, or 20–35 mL/kg, suggest caution when using large volumes of fluids in
within 3–6 h. However, this practice is associated with contexts similar to these trials, where immediate access
wide variability (lowest quartile: 500 mL, highest quartile: to additional monitoring and support systems (e.g., pulse
5 L) (see additional references in the electronic supple- oximetry, supplemental oxygen, ventilatory support) is
mentary material). In particular, most trials required at limited [31].
least 1 L of fluid to be administered as an inclusion crite- Observational studies conducted in high-risk popula-
rion, with some requiring at least 30 mL/kg. tions (congestive heart failure, chronic kidney disease,
Recent RCTs conducted in high-income countries eval- cirrhosis) have found conflicting results, with some sug-
uating different fluid management strategies after initial gesting improved outcomes with lower volume resusci-
resuscitation in septic patients showed no harm within tation (i.e. < 30 mL/kg) [24, 32, 33] and others finding no
the ranges of fluid volumes tested (the median difference signal of harm with standard volume resuscitation (≥ 30
between the restrictive and liberal groups at 24 h in the mL/kg) [34–37].
CLASSIC and CLOVERS trials was − 800 mL (500 mL vs. Panel discussions emphasized that clinical character-
1313 mL) and − 2100 mL (1267 mL vs. 3400 mL), respec- istics, such as the origin of sepsis (e.g., lung vs. abdo-
tively) [27, 28]. Hypothesis-generating pre-planned men), cardiovascular comorbidities, and the presence or
subgroup analyses of the CLASSIC trial suggested that absence of fluid losses, may help identify patients who are
patients who had received an initial volume < 30 mL/ more likely to have significant volume deficits or poorer
kg showed a trend toward benefiting from a subsequent fluid tolerance.
liberal strategy (absolute percentage point difference in
90-day mortality [95% CI] = 5.3 [− 3.1 to 13.5]; p-value for Recommendation In adults with sepsis or septic shock
interaction = 0.15) and vice versa [28]. who require fluid resuscitation for circulatory failure, we
A single RCT in a low-income country comparing a suggest administering up to 30 ml/kg of intravenous crys-
protocol-based initial resuscitation strategy (including talloids in the initial phase (when hemodynamic moni-
a fixed volume of up to 4 L of fluid) with standard care toring is not yet available, typically within the first 3 h),
(resuscitation strategy decided by the attending phy- with adjustments based on clinical context and frequent
sicians) found higher mortality with protocol-based reassessments (conditional recommendation, very low
care (including a median of 3.5 [2.7–4] liters of fluid in certainty of evidence).
6 h) [29]. Patients in the standard care group received a
median of 2 L (1–2.5) of fluid in 6 h. It should be noted Remark Clinicians may choose to administer different
that a fixed volume of fluids was administered, which volumes of crystalloids based on their clinical judgment,
meant that patients with lower body weight, such as individual patient characteristics and clinical context,
those who were malnourished, received a higher vol- such as the origin of sepsis (e.g., lung versus abdomen),
ume of fluids per kilogram of body weight. Furthermore, cardiovascular comorbidities, or the presence or not of
as this trial investigated a protocol-based strategy, we fluid losses.
cannot differentiate the effect of the different elements Clinicians should assess their patients clinically and
of the protocol on the outcome. An RCT in pediatric consider assessing fluid responsiveness (if possible)
patients with febrile illness and signs of hypoperfusion in before administering more crystalloids in the initial phase
of resuscitation, recognizing that some may require more tion and 10 trials assessed ventilator-free days, with no
or less than 30 mL/kg of intravenous crystalloids. significant difference between groups. For the latter, five
trials had a low risk of bias (3354 patients) with an RR of
Unresolved questions and research gaps Several ques- 0.99 (CI 1.89, 1.67; p = 0.87). There was also no significant
tions about initial resuscitation remain unanswered. RCTs difference between groups in vasopressor-free days, use
are needed to assess the safety and efficacy of initial resus- or duration of renal replacement therapy, or acute kidney
citation with 30 mL/kg crystalloids compared with other injury. No relevant subgroup effects were observed. The
approaches (e.g., lower volume resuscitation, individual- CLASSIC [28] and CLOVERS [27] trials contributed with
ized approach, vasopressor first approach) in patients most patients in this meta-analysis (3385 of 4006) [26].
with sepsis and hypoperfusion as there is currently no In the CLASSIC trial [28], the median cumulative fluid
high-certainty of evidence to support any approach. volume of all fluids given in the ICU was relatively high in
The application of the same strategy in different settings both groups (10,433 mL in the restrictive fluid group and
(high- versus low-income countries) may lead to differ- 12,747 mL in the standard-fluid group), which may have
ent outcomes, depending on factors that are still unclear, attenuated the potential effect of the intervention.
such as different patient characteristics, different etiologic
agents, availability of “rescue” strategies to treat possible Recommendation In adults with sepsis or septic shock
complications, and this warrants further investigation. who need fluid resuscitation for circulatory failure, we
cannot recommend for or against systematic restrictive or
Question 2 liberal fluid administration (no recommendation; moder-
Should a liberal vs. restrictive strategy be used in the ate level of evidence for no effect).
optimization phase of resuscitation of circulatory failure
in critically ill patients with sepsis or septic shock? Remark In RCTs, the use of a systematic restrictive strat-
egy versus a systematic liberal strategy in the optimization
Background The risk associated with fluid accumulation phase of resuscitation had similar effects on patient-rele-
or overload during sepsis has been highlighted by several vant outcomes (moderate certainty of evidence).
observational studies over the past decades [38]. Fluid
overload could increase the risk of organ dysfunction and Unresolved questions and research gaps Several ongo-
death. Despite this, it is still unclear whether a restrictive ing trials are trying to answer this question using different
or liberal intravenous fluid strategy should be used. In approaches [53]. The volume of fluid administered during
fact, the 2021 SSC guidelines found that there was insuffi- the resuscitation phase of sepsis and septic shock appears
cient evidence to recommend the use of restrictive versus to have decreased over time, making trial design more dif-
liberal fluid strategies in the first 24 h of resuscitation in ficult to detect differences between groups. Efforts to bet-
patients with sepsis or septic shock who still have signs of ter assess heterogeneity in treatment effects and to better
hypoperfusion and volume depletion after initial resusci- monitor perfusion signals for potential harm in restrictive
tation; this lack of recommendation was due to very low- or liberal arms are advisable.
certainty of evidence [13].
Question 3
Summary of evidence Physiological rationale and obser- Should an individualized approach vs a non-individu-
vational data provide some support for a strategy of lower alized approach be used for the optimization phase of
fluid volumes combined with earlier initiation of vaso- resuscitation of circulatory failure in critically ill patients
pressors during sepsis [39, 40]. However, current evidence with sepsis or septic shock?
from RCTs does not support the use of either exclusively
liberal or restrictive fluid administration. Two recent Background Individualization of fluid administration
meta-analyses have been reviewed to address this issue in sepsis or septic shock during the optimization phase
[26, 41]. The most recent meta-analysis [26] included 13 should include monitored fluid administration via fluid
RCTs with 4,006 patients [27, 28, 42–52]. There was no boluses aimed at improving preload/systemic blood flow
difference in mortality between the two strategies: risk and consequently reversing tissue hypoperfusion. Indi-
ratio (RR) 0.99, 97% confidence interval (CI) 0.89, 1.08; vidualization requires some form of hemodynamic moni-
p = 0.69; moderate certainty of evidence. Serious adverse toring and is usually performed in ICU, with the aim not
events (SAEs) were defined and reported in six trials and of restricting fluid but of administering it more optimally.
showed no difference between the two strategies: RR of Some key measures to individualize fluid administration
0.95 (97% CI 0.83, 1.07; p = 0.28; low certainty of evidence). may be the use of the fluid challenge approach [54], sys-
Seven trials reported the duration of mechanical ventila- tematic fluid responsiveness assessment [55], considera-
tion of basic hemodynamic phenotypes (e.g., vasoplegic a non-individualized approach during the optimization
vs persistently hypovolemic patients) [53], and selection phase (conditional recommendation, very low certainty of
of the most appropriate target to stop resuscitation in a evidence).
timely manner to reduce the risk of fluid overload [56].
Assessment of fluid responsiveness may be an impor- Unresolved questions and research gaps Given the lim-
tant part of this monitoring and, the first data have been ited data available, further research is urgently needed to
published on its potential impact on some secondary establish the role of systematic assessment of fluid respon-
outcomes [51] and on reducing fluid volume (in fluid siveness, specific targets and hemodynamic phenotype-
unresponsive patients) without compromising perfusion driven resuscitation strategies, among others, in sepsis or
[55]. Of note, in the latter study, 30% of patients in whom septic shock. These trials should be better designed and
fluid responsiveness could be assessed were already fluid adequately powered, considering more homogeneous
unresponsive shortly after admission to the ICU, but still populations and overcoming the enormous challenges of
achieved resuscitation goals with vasoactive-driven strat- testing individualized algorithms versus usual care [53].
egies [55].
Several studies of varying quality have shown that Hemorrhagic shock
perfusion-related targets, such as lactate, central venous Question 4
oxygen saturation, arterio-venous gradient of carbon Should a restrictive or liberal strategy be used for fluid
dioxide, or peripheral perfusion, show different dynam- resuscitation of circulatory failure in critically ill patients
ics of recovery after restoration of systemic blood flow with hemorrhagic shock following penetrating trauma?
or perfusion pressure [56]. Some recover very quickly, (Table 2)
such as capillary refill time, while others, such as lac-
tate, are still abnormal in 50% of survivors after 24 h [56]. Background Penetrating trauma accounts for 12–18%
Selecting a particular perfusion variable as a target may of all trauma in the United States and is associated with
therefore be associated with a different intensity of fluid a significantly higher mortality rate than other types of
resuscitation. This may influence the volume of fluid trauma. Rapid control of hemorrhage and restoration
given and potentially the outcome. of tissue perfusion are the cornerstones of the manage-
ment of penetrating trauma-induced hemorrhagic shock.
Summary of evidence Eight RCTs compared the use of However, the delicate balance between restoring perfu-
fluid responsiveness assessment with usual care in sepsis sion and avoiding complications from inappropriate fluid
resuscitation [42, 45, 49, 51, 57–60]. The trials were highly resuscitation requires careful consideration. The concept
heterogeneous in terms of inclusion criteria, definitions of a permissive approach to hypotension by the restric-
of fluid responsiveness, monitoring, fluid administra- tive fluid resuscitation strategy in hemorrhagic shock sec-
tion algorithm and outcomes. Short-term mortality was ondary to penetrating trauma has been proposed [61, 62].
assessed in 363 patients in the intervention arm vs. 321 Maintaining a lower blood pressure may slow the rate of
in the control arm, with 83 vs. 95 deaths, respectively (RR bleeding, particularly from arterial sources. In addition,
0.82, 95% CI 0.63, 1.07, I2 10%, p = 0.14). Four RCTs ana- lower blood pressure reduces the hydrostatic pressure in
lyzed ventilator-free days in 128 vs 131 patients with no the injured vessels, which may prevent the dislodgement
difference between groups (mean difference − 0.33, 95% of formed hemostatic clots and reduce hemorrhage. In
CI − 2.65, 2). There was also no difference in vasopressor- addition, limiting the volume of resuscitation fluids may
free days in one trial, similar to 3 trials analyzing renal prevent dilutional coagulopathy and mitigate hypother-
replacement therapy in 173 vs. 129 patients, with 36 vs. mia. While we recognize the importance of RBCs and
44 events (RR 0.69, 95% CI 0.38, 1.24, I2 56%, p = 0.21). No plasma in the management of hemorrhagic shock, this
trials comparing a perfusion-targeted strategy with usual topic falls outside the scope of the guideline.
care were identified.
Based on the scarce and heterogeneous evidence avail- Summary of evidence The most recent evidence comes
able, the panel issued a conditional recommendation from an updated meta-analysis (which includes three tri-
for individualized resuscitation vs. a non-individualized als and 831 patients with penetrating trauma) finding a
approach during the optimization phase based on very reduction in mortality with permissive hypotension in
low certainty of evidence. cases of hemorrhagic shock (RR = 0.80; 95% CI [0.65,
0.90]) [63–65]. However, the quality of the evidence is
Recommendation In adults with sepsis or septic shock low due to the limited number of trials included in the
who require fluid resuscitation for circulatory failure, we analysis. The fluid resuscitation endpoint was maintained
suggest using an individualized approach compared with at a systolic blood pressure of around 80–90 mmHg, or a
Table 2 Summary of clinical questions and recommendations for hemorrhagic shock
Question Recommendation strength Certainty of evidence
and recommen‑
dation

Question 4 Should a restrictive or liberal strategy be used for fluid resuscita‑

tion of circulatory failure in critically ill patients with hemor‑
rhagic shock following penetrating trauma?
Recommendation In adults with hemorrhagic shock after penetrating trauma, we Conditional recommendation, For Moderate Certainty of evidence
suggest using a restrictive fluid resuscitation strategy (as part of a
permissive hypotension approach) compared with a liberal fluid
resuscitation strategy prior to definitive hemorrhage control
Remark This recommendation does not apply to the intraoperative manage-
ment of these patients. In patients with penetrating trauma and
associated traumatic brain injury, there are insufficient data to
make a recommendation
Question 5 Should a restrictive or liberal strategy be used for fluid resuscita‑
tion of circulatory failure in critically ill patients with hemor‑
rhagic shock following blunt trauma?
Recommendation: In adults with hemorrhagic shock following blunt trauma, we sug- Conditional recommendation, For Low Certainty of evidence
gest a restrictive fluid resuscitation strategy (as part of a permissive
hypotensive approach) compared with a liberal fluid resuscitation
strategy before definitive hemorrhage control
Remark This recommendation does not apply to the intraoperative man-
agement of these patients. In patients with blunt trauma and
associated traumatic brain injury, there is insufficient data to make
a recommendation
Question 6 Should a restrictive or liberal strategy be used for fluid resuscita‑
tion of circulatory failure in critically ill patients with hemor‑
rhagic shock of non-traumatic origin?
Recommendation: The panel recommends (ungraded best practice statement) that Best Practice Statement Ungraded
in adults with hemorrhagic shock of non-traumatic origin, fluid
administration should be guided by hemodynamic and biochemi-
cal parameters in the context of the primary disease state prior to
definitive hemorrhage control
Remark The biochemical parameters that the clinician should aim to correct
include metabolic acidosis, hypothermia, platelet counts and
coagulation factors

mean arterial pressure of 50–60 mmHg [66]. Of note, the Unresolved questions and research gaps The current
Bickell et al. trial [63] contributed to 72% of the weight for evidence on low volume fluid resuscitation in trauma is
the mortality outcome. As such, newer evidence is needed limited, indicating a need for more large-scaled, well-
to advance the field, given the significant changes in the designed RCTs to assess its effectiveness. Critical ques-
trauma care landscape since the trial’s publication in 1994. tions remain unanswered: the specific systolic blood
pressure target, the recommended duration for permis-
Recommendation In adults with hemorrhagic shock sive hypotension, and alternative indicators for central
after penetrating trauma, we suggest using a restrictive and cerebral perfusion when blood pressure readings are
fluid resuscitation strategy (as part of a permissive hypo- unreliable or unavailable. Additionally, it is important to
tension approach) compared with a liberal fluid resus- explore whether individualized approaches, based on fac-
citation strategy prior to definitive hemorrhage control tors like age, comorbidities, and injury severity, lead to
(conditional recommendation, moderate certainty of evi- better outcomes.
dence).
Question 5
Remark This recommendation does not apply to intra- Should a restrictive or liberal strategy be used for fluid
operative management of these patients or after definitive resuscitation of circulatory failure in critically ill patients
hemorrhage control. In patients with penetrating trauma with hemorrhagic shock following blunt trauma?
and associated traumatic brain injury, there are insuffi-
cient data to make a recommendation. Background Blunt trauma is caused by direct physical
trauma or impact to a part of the body. It is common in
road traffic collisions, assaults and sports injuries and Question 6
is particularly common in older people who fall. Blunt Should a restrictive or liberal strategy be used for fluid
trauma can occur in the abdomen, chest, skull, pelvis and resuscitation of circulatory failure in critically ill patients
extremities. Theoretical frameworks and experimental with hemorrhagic shock of non-traumatic origin?
evidence do not provide a basis for distinguishing blunt
injuries from other types of trauma [67]. Background Non-traumatic hemorrhagic shock can
be caused by factors such as gastrointestinal bleeding
Summary of evidence Both penetrating and blunt or post-operative hemorrhage or ruptured aneurysm,
trauma require immediate hemostasis and fluid resuscita- where the primary concern is blood loss rather than tissue
tion to control blood loss and tissue perfusion. Permissive injury. Conservative approaches with low volume/restric-
hypotension is commonly used in both scenarios [68]. In tive fluid resuscitation and blood pressure management
blunt trauma without traumatic brain injury, a systolic may be useful in some cases to avoid surgery. Fluid resus-
blood pressure target of around 80–90 mmHg or a mean citation with permissive hypotension may also be applied
arterial pressure of 50–60 mmHg may be required [66]. in the management of non-traumatic hemorrhagic
However, in blunt trauma with traumatic brain injury, the shock. However, the target blood pressure is influenced
target systolic blood pressure may be around 100–110 by the primary etiology of the hemorrhage and requires
mmHg or a mean arterial pressure of at least 80 mmHg a nuanced approach that takes into account the specific
to ensure adequate cerebral perfusion pressure and pre- disease state of the patient [71–74].
vent secondary brain injury [13, 66]. We found only two
RCTs included mixed trauma types (penetrating and Summary of evidence A study of 51 patients by Lu et al.
blunt trauma) [69, 70], so a meta-analysis of permissive found that conservative fluid resuscitation was beneficial
hypotension or limited fluid resuscitation in blunt trauma in patients with hemorrhagic shock due to acute upper
could not be performed. However, the above-mentioned gastrointestinal hemorrhage [75]. The use of vasopressors
meta-analysis indicated that permissive hypotension was in non-traumatic hemorrhagic shock is controversial. They
protective in patients with hemorrhagic shock in general. can be used to support blood pressure, particularly if fluid
resuscitation is inadequate. However, their early adminis-
Recommendation In adults with hemorrhagic shock tration in high doses has been associated with increased
following blunt trauma, we suggest a restrictive fluid mortality [76]. An RCT of 249 patients found that restric-
resuscitation strategy (as part of a permissive hypoten- tive fluid resuscitation had no significant effect on throm-
sive approach) compared with a liberal fluid resuscitation boelastometric hemostatic and coagulation parameters in
strategy before definitive hemorrhage control (conditional women with postpartum hemorrhage < 1500 mL [77]. In
recommendation, for; low certainty of evidence). patients with non-traumatic hemorrhagic shock, several
conditions should be corrected, including metabolic aci-
Remark This recommendation does not apply to intra- dosis, hypothermia, and coagulopathy.
operative management of these patients or after definitive
hemorrhage control. In patients with blunt trauma and Recommendation The panel recommends (ungraded
associated traumatic brain injury, there is insufficient data best practice statement) that in adults with hemorrhagic
to make a recommendation. shock of non-traumatic origin, fluid administration should
be guided by hemodynamic and biochemical parameters
Unresolved questions and research gaps First, all the in the context of the primary disease state prior to defini-
unresolved questions and research gaps mentioned for tive hemorrhage control.
penetrating trauma apply to this question. As traumatic
brain injury from blunt trauma is more common than Remark The biochemical parameters that the clinician
from penetrating trauma, trials on the ideal blood pres- should aim to correct include metabolic acidosis, hypo-
sure for traumatic brain injury are needed. Future trials thermia, platelet counts, and coagulation factors.
should also assess whether there are differences in blood
pressure targets for specific subtypes of blunt trauma (e.g., Unresolved questions and research gaps Several areas
chest, abdominal or pelvic blunt trauma). The evidence warrant further investigations: defining specific hemody-
gap for intraoperative fluid management in these patients namic and biochemical thresholds for different etiologies
also needs to be addressed. of non-traumatic hemorrhagic shock; assessing functional
recovery of organ function and quality of life in addition
to mortality; evaluating the impact of early intervention
(e.g., within the first 6 h) on outcomes.
Table 3 Summary of the clinical question and recommendation for obstructive shock
Question Recommendation strength Certainty
and recommen‑ of evi‑
dation dence

Question 7 Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory
failure in critically ill patients with pulmonary embolism?
Recommendation: The panel recommends (ungraded best practice statement) that in adult patients with Best Practice Statement Ungraded
circulatory failure due to acute pulmonary embolism, clinicians should be cautious about
administering fluids and should base their decision on measured surrogate markers of
right heart congestion
Question 8 Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory
failure in critically ill patients with cardiac tamponade?
Recommendation: The panel recommends (ungraded best practice statement) that in adult patients with circu- Best Practice Statement Ungraded
latory failure due to cardiac tamponade, fluid should be given cautiously as a temporary
measure until definitive management can be undertaken

Obstructive shock together, these findings suggest that fluid resuscitation in

Question 7 patients with pulmonary embolism and shock may not be
Should a restrictive or liberal strategy be used for fluid beneficial in the presence of severe right heart conges-
resuscitation of circulatory failure in critically ill patients tion. The latter can be detected using various surrogate
with pulmonary embolism? (Table 3) markers, such as central venous pressure (if greater than
10 mmHg), echocardiography (if right ventricular size
Background The major cause of death in patients with is greater than left ventricular size), VEXUS (if greater
massive acute pulmonary embolism is circulatory failure. than grade 1), among others. In resource-limited set-
De-obstruction of the pulmonary circulation (primarily tings, the use of a clinical examination to determine con-
by thrombolytic therapy) is the mainstay of treatment for gestion may be used as a surrogate marker (e.g., jugular
circulatory failure, but hemodynamic support is essen- venous pressure, hepatomegaly). Fluids should probably
tial before substantial hemodynamic improvement is be avoided in these circumstances, especially when com-
achieved [78]. The use of fluid resuscitation in intermedi- bined. However, the uncertainty in this area is very high.
ate and high-risk pulmonary embolism remains contro-
versial. The European Society of Cardiology guidelines Recommendation The panel recommends (ungraded
suggest that modest fluid resuscitation may be given if best practice statement) that in adult patients with cir-
central venous pressure is low [79], but there is a risk of culatory failure due to acute pulmonary embolism, clini-
worsening right ventricular function. This concern has cians should be cautious about administering fluids and
recently been re-emphasized in the specific population of should base their decision on surrogate markers of right
ICU patients with pulmonary embolism [80]. heart congestion.

Summary of evidence Nine studies (4 animal, 5 human) Unresolved questions and research gaps There is insuf-
were identified [78, 81–88]. The human literature included ficient evidence to support either a liberal or restrictive
456 patients, with only one study (13 patients) including intravenous fluid strategy in patients with circulatory fail-
patients in shock (cardiac index < 2.5 L/min/m2) [78]. In ure due to pulmonary embolism. Most publications focus
the latter study [78], a fluid bolus (dextran 500 mL) was on patients with intermediate-risk pulmonary embolism
administered as part of the intervention. The increase without shock. RCTs are needed in patients with shock
in cardiac index induced by fluid loading was inversely with detailed phenotyping of right heart congestion.
related to the baseline right ventricular end-diastolic vol-
ume index [78].
The other 4 human trials in patients without shock Question 8
used a diuretic as the intervention and either placebo Should a restrictive or liberal strategy be used for fluid
(one trial) [84] or a saline fluid bolus (three trials) [83, resuscitation of circulatory failure in critically ill patients
87, 88] as the control. The diuretic was well tolerated with cardiac tamponade?
[83, 84, 87, 88], with some beneficial effects on surrogate
markers [83, 84, 87], including reduction in shock index, Background Cardiac tamponade is a life-threatening
oxygen requirements and plasma creatinine [88]. Taken compression of the heart due to increased pericardial
pressure associated with the accumulation of fluid, solid in this setting and identify hemodynamic profiles with the
or gas in the pericardium. In patients with hemodynamic best risk–benefit ratio. They should also compare fluid
instability, fluid boluses could maintain systemic venous with early vasopressor therapy to maintain arterial pres-
return, correct hypovolemia and prevent right ventricular sure.
diastolic collapse despite very high right atrial pressure
[89]. The latest European Society of Cardiology guidelines Left‑sided cardiogenic shock
recommend volume resuscitation in the management of Question 9
cardiac tamponade and discourage the use of vasodilators Should a restrictive or liberal strategy be used for fluid
and diuretics (recommendation IIIC) [90]. However, data resuscitation of circulatory failure in critically ill patients
to support this strategy are limited. with left-sided cardiogenic shock? (Table 4).

Summary of evidence Four studies (1 animal, 3 human) Background Left-sided cardiogenic shock is a life-
were identified [13–16]. The human literature included threatening condition characterized by the inability of the
88 patients who received intravenous fluid boluses (NaCl heart to pump enough blood to meet metabolic demands,
500 mL). Fluid boluses induced either no significant leading to inadequate tissue perfusion and organ failure
improvement in hemodynamics [91], or an improvement [95]. Unlike other types of shock, such as hypovolemic
in blood pressure and cardiac output [92, 93]. However, or septic shock, where fluid resuscitation is a critical
only 47% of patients were fluid responders (i.e., increase aspect of treatment, the management of fluid therapy in
in cardiac index > 10%), while the cardiac index remained left-sided cardiogenic shock is more complex and contro-
unchanged in 22% and decreased in 31%; predictors of a versial. This complexity arises because fluid administra-
favorable response were low systolic blood pressure and tion can exacerbate heart failure and lead to pulmonary
low cardiac index at baseline [92]. If fluid administration edema, further complicating the patient’s condition [96].
is chosen in this setting, its effects should be monitored
and it must not delay pericardial drainage, even in cases Summary of evidence Fluid management in patients with
of low-pressure cardiac tamponade [94]. left-sided cardiogenic shock remains an area of consider-
able uncertainty in clinical practice [95, 96]. Although the
Recommendation The panel recommends (ungraded primary goal of fluid administration is to improve car-
best practice statement) that in adult patients with circu- diac output and oxygen delivery by increasing preload,
latory failure due to cardiac tamponade, fluid should be it may also increase left ventricular filling pressures and
given cautiously as a temporary measure until definitive worsen pulmonary congestion, particularly in patients
management can be undertaken. with cardiogenic shock. The available literature suggests
that although some patients with cardiogenic shock may
Unresolved questions and research gaps Overall, there benefit from a cautious fluid challenge [97], the high risk
is insufficient evidence to support a systematic liberal of inducing or worsening pulmonary edema precludes
or restrictive intravenous fluid strategy in patients with widespread use of this strategy as an initial measure in the
obstructive shock due to tamponade. The volume of fluid hemodynamic resuscitation of patients with cardiogenic
required to stabilize patients with obstructive shock due shock [96].
to tamponade while awaiting pericardial drainage is still A tailored approach may be recommended, where fluid
unknown. Future studies should assess both the efficacy therapy is not applied universally but considered on a
and the tolerability of fluid management strategies tested case-by-case basis. In some cases, small fluid challenges

Table 4 Summary of the clinical question and recommendation for left-sided cardiogenic shock
Question Recommendation strength Certainty
and recommen‑ of evi‑
dation dence

Question 9 Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory failure
in critically ill patients with left-sided cardiogenic shock?
Recommendation: In adults with circulatory failure due to left-sided cardiogenic shock, the panel recommends Best Practice Statement Ungraded
(ungraded best practice statement) that fluid resuscitation should not be the primary
treatment
Remark If fluids are administered, the patient should be monitored closely, especially for pulmonary
edema
may be warranted to improve intravascular volume, par- Acute respiratory distress syndrome
ticularly if there is evidence of concurrent hypovolemia. Question 10
When considered, fluid administration requires careful Should a restrictive or liberal strategy be used for fluid
monitoring and individual assessment. The physiologi- resuscitation of circulatory failure in critically ill patients
cal approach to fluid administration in cardiogenic shock with acute respiratory distress syndrome (ARDS)?
involves close monitoring of the patient’s hemodynamic (Table 5)
status and adjustment of fluid therapy based on the
observed individual response. Advanced hemodynamic Background ARDS is characterized by varying degrees
monitoring may be used in the management of fluid of alteration in pulmonary capillary permeability and
therapy in cardiogenic shock. These techniques may help associated pulmonary edema. ARDS is frequently caused
assess fluid responsiveness and tolerance, thereby mini- by clinical conditions associated with relative or abso-
mizing the risk of fluid overload and pulmonary edema lute hypovolemia and hemodynamic instability requiring
[98]. some degree of fluid resuscitation (e.g., sepsis, trauma,
burns and thermal injury, non-infectious inflammatory
Recommendation In adults with circulatory failure due syndromes) [99]. In addition, the pathophysiology of
to left-sided cardiogenic shock, the panel recommends ARDS itself causes further fluid leakage from the intra-
(ungraded best practice statement) that fluid resuscitation vascular space into the interstitium, exacerbating hypov-
should not be the primary treatment. If fluids are admin- olemia [100]. On the other hand, fluid accumulation has
istered, the patient should be monitored closely, especially been associated with worsening pulmonary edema and
for pulmonary edema. increased mortality in patients with ARDS [38, 101–104].
Therefore, optimal fluid management in patients with
Unresolved questions and research gaps There is insuf- ARDS and circulatory failure is challenging as clinicians
ficient evidence to support any specific guidelines for must balance the need to optimize tissue perfusion with
fluid administration in patients with left-sided cardio- the risk of worsening lung injury [105, 106].
genic shock. Additionally, standardized definitions and
criteria for fluid status, responsiveness, and overload in Summary of evidence We found no RCT specifically
these patients are lacking. Furthermore, there is a need comparing a restrictive versus a liberal approach to fluid
for reliable and practical methods to assess fluid status resuscitation in patients with circulatory failure and
and responsiveness in left-sided cardiogenic shock as ARDS. There is a systematic review by Silversides et al.
commonly used indicators like central venous pressure, that analyzed the effect of a restrictive (or conservative)
pulmonary capillary wedge pressure, or echocardiogra- versus liberal fluid administration strategy in the de-
phy can be inaccurate, invasive, or unavailable, respec- resuscitation phase of patients with sepsis and/or ARDS
tively. Therefore, more RCTs are needed to evaluate the [107]. The authors identified seven RCTs that included
efficacy and the safety of fluid administration in left-sided patients with ARDS [108–114] and found that a con-
cardiogenic shock and to determine the optimal timing, servative fluid strategy was associated with an increased
the type, and the volume of fluid. Further research is also number of ventilator-free days and a decreased length of
needed to develop and validate novel and non-invasive stay in the ICU. However, the included studies (1) were
tools to monitor fluid status and guide fluid therapy in generally old (with ventilation and sedation management
left-sided cardiogenic shock. strategies that are no longer used today), (2) focused on
the de-resuscitation phase, (3) enrolled mostly hemody-

Table 5 Summary of the clinical question and recommendation for acute respiratory distress syndrome
Question Recommendation strength Certainty of evidence
and recommen‑
dation

Question 10 Should a restrictive or liberal strategy be used for fluid resuscitation

of circulatory failure in critically ill patients with acute respiratory
distress syndrome (ARDS)?
Recommendation: In adults with circulatory failure and ARDS, we cannot make a recom- No recommendation Very Low certainty of evidence
mendation about the volume of fluid administration
Remark Future trials should focus on patients with circulatory failure and ARDS,
taking into account its different subtypes
namically stable patients, (4) investigated complex hemo- statements) and were unable to make recommendations
dynamic management protocols that are difficult to apply for two questions. Additionally, research priorities for
in clinical practice, or (5) did not achieve a difference in future studies have been identified.
fluid balance between the two groups.
Supplementary Information
The largest RCT on this topic, the Fluids and Cath- The online version contains supplementary material available at https://​doi.​
eters Treatment Trial (FACTT), enrolled 1000 patients org/​10.​1007/​s00134-​025-​07840-1.
with acute lung injury, including about 30% with shock
at baseline (defined as mean arterial pressure < 60 mmHg Author details
or requiring vasopressors) [108]. It compared conserva- 1
Medical Intensive Care, Henri-Mondor Hospital (AP-HP), UPEC, IMRB, CARMAS
tive and liberal fluid strategies. The study found no differ- Research Group, Creteil, France. 2 Department of Internal Medicine, College
of Medicine and Health Sciences, Emirates University, Al Ain, United Arab
ence in 60-day mortality between the groups but noted Emirates. 3 Department of Anesthesia and Intensive Care, IRCCS San Raffaele
more ventilator-free and ICU-free days in the conserva- Scientific Institute, Milan, Italy. 4 Department of Intensive Care, CHIREC Hos‑
tive group. A subgroup analysis showed no significant pitals, Université Libre de Bruxelles, Brussels, Belgium. 5 Critical Care Program,
The George Institute for Global Health, Sydney, NSW, Australia. 6 Depart‑
interaction between fluid strategy and shock at baseline. ment of Intensive Care, Copenhagen University Hospital – Rigshospitalet
A long-term follow-up suggested that the conservative and Department of Clinical Medicine, University of Copenhagen, Copenha‑
group might have worse long-term cognitive outcomes gen, Denmark. 7 Departamento de Medicina Intensiva, Facultad de Medicina,
Pontificia Universidad Católica de Chile, Santiago, Chile. 8 Intensive Care
[115]. A re-analysis identified two subphenotypes Department, Hospital São Paulo, Escola Paulista de Medicina, Universidade
(hypoinflammatory and hyperinflammatory) [116] with Federal de São Paulo, São Paulo, Brazil. 9 Department of Medicine, Divisions
differing responses to fluid strategies [117]. In the hypo- of Critical Care and Pulmonology, Faculty of Health Sciences, Charlotte Maxeke
Johannesburg Academic Hospital, University of the Witwatersrand, Johannes‑
inflammatory group, mortality was 26% with the liberal burg, South Africa. 10 Unidad de Cuidados Intensivos, Hospital Universitario de
strategy versus 18% with the conservative. In the hyper- Puerto Real, Puerto Real, Spain. 11 Department of Anaesthesiology, Critical Care
inflammatory group, mortality was 40% with the liberal and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai,
India. 12 Department of Critical Care Medicine, Zhongnan Hospital of Wuhan
strategy versus 50% with the conservative. These find- University, Wuhan, China. 13 Department of Critical Care Medicine, University
ings suggest acute respiratory distress syndrome (ARDS) of Pittsburgh School of Medicine, Pittsburgh, USA. 14 Division of Critical Care
subphenotypes may require different fluid management and Emergency Medicine, Department of Medicine, McMaster University,
Hamilton, Canada. 15 Medical Intensive Care, Bicetre Hospital (AP-HP), Le
approaches. Although the hyperinflammatory subphe- Kremlin‑Bicêtre, France. 16 Medical and Surgical Intensive Care Unit, University
notype is associated with more hypotension, implying Hospital Ambroise Paré, APHP, UMR 1018, UVSQ, Boulogne‑Billancourt, France.
17
a potentially more liberal fluid strategy in ARDS with Critical Care and Internal Medicine Department, College of Medicine,
Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. 18 CARMAS
shock, there is no RCT to support this, indicating the research group, IMRB, UPEC, Créteil, France. 19 Health Research Center, Minis‑
need for a more personalized approach. try of Defense Health Services, Riyadh, Saudi Arabia.

Funding
Recommendation In adults with circulatory failure and Panelists received no financial incentive for their participation. In addition, no
ARDS, we are unable to make a recommendation about funding or input from industry was incorporated into the guidance.
the volume of fluid administration (no recommendation;
Declarations
very low certainty of evidence).
Conflicts of interest
Remark Future trials should focus on patients with cir- Daniel De Backer: received remuneration from Fresenius, Baxter, Pfizer,
Edwards, Philips, and has published and presented on the topic. Armand
culatory failure and ARDS, considering its different sub- Mekontso Dessap: reports grants from Air Liquide, and Addmedica, all outside
types. 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:
Unresolved questions and research gaps RCTs are received remuneration from Edwards Lifesciences, Dynocardia and Deltex
needed to determine the optimal fluid management strat- Medical. Anthony Delaney: received a MRFF grant (MRFF-1200084). Other
egy for patients with both circulatory failure and ARDS. authors reported no conflict of interest.
Trials should include patient subphenotyping and long-
term follow-up, as long-term effects of interventions may
Publisher’s Note
differ from short-term effects. Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.

Conclusions Received: 2 January 2025 Accepted: 11 February 2025

These guidelines explored the volume of fluids in adult
critically ill patients with circulatory failure of various eti-
ologies. They provide eight evidence-based recommen-
dations (four conditional and four ungraded best practice
References 21. Vaara ST, Korhonen A-M, Kaukonen K-M et al (2012) Fluid overload is
1. Cecconi M, Kesecioglu J, Azoulay E, European Society of Intensive Care associated with an increased risk for 90-day mortality in critically ill
Medicine (2021) Diversity and inclusivity: the way to multidisciplinary patients with renal replacement therapy: data from the prospective
intensive care medicine in Europe. Intensive Care Med 47:598–601. FINNAKI study. Crit Care 16:R197. https://​doi.​org/​10.​1186/​cc116​82
https://​doi.​org/​10.​1007/​s00134-​021-​06384-4 22. Wang N, Jiang L, Zhu B et al (2015) Fluid balance and mortality in
2. Alhazzani W, Lewis K, Jaeschke R et al (2018) Conflicts of interest critically ill patients with acute kidney injury: a multicenter prospec‑
disclosure forms and management in critical care clinical practice tive epidemiological study. Crit Care 19:371. https://​doi.​org/​10.​1186/​
guidelines. Intensive Care Med 44:1691–1698. https://​doi.​org/​10.​1007/​ s13054-​015-​1085-4
s00134-​018-​5367-6 23. Khan RA, Khan NA, Bauer SR et al (2020) Association between volume
3. Guyatt GH, Oxman AD, Kunz R et al (2011) GRADE guidelines: 2. of fluid resuscitation and intubation in high-risk patients with sepsis,
Framing the question and deciding on important outcomes. J Clin heart failure, end-stage renal disease, and cirrhosis. Chest 157:286–292.
Epidemiol 64:395–400. https://​doi.​org/​10.​1016/j.​jclin​epi.​2010.​09.​012 https://​doi.​org/​10.​1016/J.​CHEST.​2019.​09.​029
4. DerSimonian R, Laird N (2015) Meta-analysis in clinical trials revisited. 24. Beagle AJ, Prasad PA, Hubbard CC et al (2024) Associations between
Contemp Clin Trials 45:139–145. https://​doi.​org/​10.​1016/j.​cct.​2015.​09.​ volume of early intravenous fluid and hospital outcomes in septic
002 patients with and without heart failure: a retrospective cohort study.
5. Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring Crit Care Explor 6:e1082. https://​doi.​org/​10.​1097/​CCE.​00000​00000​
inconsistency in meta-analyses. BMJ 327:557–560. https://​doi.​org/​10.​ 001082
1136/​bmj.​327.​7414.​557 25. Herndon JM, Blackwell SB, Pinner N et al (2024) Assessment of out‑
6. Guyatt GH, Oxman AD, Vist GE et al (2008) GRADE: an emerging con‑ comes in patients with heart failure and end-stage kidney disease after
sensus on rating quality of evidence and strength of recommendations. fluid resuscitation for sepsis and septic shock. J Emerg Med. https://​doi.​
BMJ 336:924–926. https://​doi.​org/​10.​1136/​bmj.​39489.​470347.​AD org/​10.​1016/J.​JEMER​MED.​2024.​02.​001
7. Balshem H, Helfand M, Schünemann HJ et al (2011) GRADE guidelines: 26. Sivapalan P, Ellekjaer KL, Jessen MK et al (2023) Lower vs higher fluid
3. Rating the quality of evidence. J Clin Epidemiol 64:401–406. https://​ volumes in adult patients with sepsis: an updated systematic review
doi.​org/​10.​1016/j.​jclin​epi.​2010.​07.​015 with meta-analysis and trial sequential analysis. Chest 164:892–912.
8. Guyatt G, Oxman AD, Sultan S et al (2013) GRADE guidelines: 11. https://​doi.​org/​10.​1016/J.​CHEST.​2023.​04.​036
Making an overall rating of confidence in effect estimates for a single 27. Shapiro NI, Douglas IS, Brower RG et al (2023) Early restrictive or liberal
outcome and for all outcomes. J Clin Epidemiol 66:151–157. https://​doi.​ fluid management for sepsis-induced hypotension. N Engl J Med
org/​10.​1016/j.​jclin​epi.​2012.​01.​006 388:499–510. https://​doi.​org/​10.​1056/​NEJMO​A2212​663
9. Andrews J, Guyatt G, Oxman AD et al (2013) GRADE guidelines: 14. 28. Meyhoff TS, Hjortrup PB, Wetterslev J et al (2022) Restriction of intrave‑
Going from evidence to recommendations: the significance and pres‑ nous fluid in ICU patients with septic shock. N Engl J Med 386:2459–
entation of recommendations. J Clin Epidemiol 66:719–725. https://​doi.​ 2470. https://​doi.​org/​10.​1056/​NEJMO​A2202​707
org/​10.​1016/j.​jclin​epi.​2012.​03.​013 29. Andrews B, Semler MW, Muchemwa L et al (2017) Effect of an early
10. GRADE handbook. https://​gdt.​grade​pro.​org/​app/​handb​ook/​handb​ook.​ resuscitation protocol on in-hospital mortality among adults with sep‑
html. Accessed 29 Apr 2024 sis and hypotension: a randomized clinical trial. JAMA 318:1233–1240.
11. Malbrain MLNG, Van Regenmortel N, Saugel B et al (2018) Principles https://​doi.​org/​10.​1001/​JAMA.​2017.​10913
of fluid management and stewardship in septic shock: it is time to 30. Maitland K, Kiguli S, Opoka RO et al (2011) Mortality after fluid bolus
consider the four D’s and the four phases of fluid therapy. Ann Intensive in African children with severe infection. N Engl J Med 364:2483–2495.
Care 8:66. https://​doi.​org/​10.​1186/​s13613-​018-​0402-x https://​doi.​org/​10.​1056/​NEJMO​A1101​549
12. Vincent J-L, De Backer D (2013) Circulatory shock. N Engl J Med 31. Gendreau S, Frapard T, Carteaux G et al (2024) Geo-economic influence
369:1726–1734. https://​doi.​org/​10.​1056/​NEJMr​a1208​943 on the effect of fluid volume for sepsis resuscitation: a meta-analysis.
13. Evans L, Rhodes A, Alhazzani W et al (2021) Surviving sepsis campaign: Am J Respir Crit Care Med 209:517–528. https://​doi.​org/​10.​1164/​rccm.​
international guidelines for management of sepsis and septic shock 202309-​1617OC
2021. Intensive Care Med 47:1181–1247. https://​doi.​org/​10.​1007/​ 32. Rice DM, Ratliff PD, Judd WR et al (2020) Assessing the impact of CKD
s00134-​021-​06506-y on outcomes in septic shock patients receiving standard vs reduced
14. Marik PE, Byrne L, van Haren F (2020) Fluid resuscitation in sepsis: the initial fluid volume. Am J Emerg Med 38:2147–2150. https://​doi.​org/​10.​
great 30 mL per kg hoax. J Thorac Dis 12:S37–S47. https://​doi.​org/​10.​ 1016/j.​ajem.​2020.​07.​055
21037/​jtd.​2019.​12.​84 33. Jorda A, Douglas IS, Staudinger T et al (2024) Fluid management for
15. Levy MM, Rhodes A, Phillips GS et al (2014) Surviving Sepsis Campaign: sepsis-induced hypotension in patients with advanced chronic kidney
association between performance metrics and outcomes in a 7.5-year disease: a secondary analysis of the CLOVERS trial. Crit Care Lond Engl
study. Intensive Care Med 40:1623–1633. https://​doi.​org/​10.​1007/​ 28:231. https://​doi.​org/​10.​1186/​s13054-​024-​05019-6
S00134-​014-​3496-0 34. Rajdev K, Leifer L, Sandhu G et al (2021) Aggressive versus conservative
16. Rhodes A, Phillips G, Beale R et al (2015) The Surviving Sepsis Campaign fluid resuscitation in septic hemodialysis patients. Am J Emerg Med
bundles and outcome: results from the International Multicentre 46:416–419. https://​doi.​org/​10.​1016/j.​ajem.​2020.​10.​037
Prevalence Study on Sepsis (the IMPreSS study). Intensive Care Med 35. Rajdev K, Leifer L, Sandhu G et al (2020) Fluid resuscitation in patients
41:1620–1628. https://​doi.​org/​10.​1007/​S00134-​015-​3906-Y with end-stage renal disease on hemodialysis presenting with severe
17. Govero AB, Yarrarapu SNS, Harrison MF et al (2022) Surviving sepsis sepsis or septic shock: a case control study. J Crit Care 55:157–162.
guideline-directed fluid resuscitation: an assessment of practice https://​doi.​org/​10.​1016/j.​jcrc.​2019.​10.​008
patterns and impact on patient outcomes. Crit Care Explor 4:e0739. 36. Acharya R, Patel A, Schultz E et al (2021) Fluid resuscitation and
https://​doi.​org/​10.​1097/​CCE.​00000​00000​000739 outcomes in heart failure patients with severe sepsis or septic shock:
18. Seymour CW, Gesten F, Prescott HC et al (2017) Time to treatment and a retrospective case-control study. PLoS One 16:e0256368. https://​doi.​
mortality during mandated emergency care for sepsis. N Engl J Med org/​10.​1371/​journ​al.​pone.​02563​68
376:2235–2244. https://​doi.​org/​10.​1056/​NEJMO​A1703​058 37. Kuttab HI, Lykins JD, Hughes MD et al (2019) Evaluation and predictors
19. Truong TTN, Dunn AS, McCardle K et al (2019) Adherence to fluid of fluid resuscitation in patients with severe sepsis and septic shock.
resuscitation guidelines and outcomes in patients with septic shock: Crit Care Med 47:1582. https://​doi.​org/​10.​1097/​CCM.​00000​00000​
reassessing the “one-size-fits-all” approach. J Crit Care 51:94–98. https://​ 003960
doi.​org/​10.​1016/J.​JCRC.​2019.​02.​006 38. Messmer AS, Zingg C, Müller M et al (2020) Fluid overload and mortality
20. Boyd JH, Forbes J, Nakada T et al (2011) Fluid resuscitation in septic in adult critical care patients-a systematic review and meta-analysis of
shock: a positive fluid balance and elevated central venous pressure are observational studies. Crit Care Med 48:1862–1870. https://​doi.​org/​10.​
associated with increased mortality*. Crit Care Med 39:259–265. https://​ 1097/​CCM.​00000​00000​004617
doi.​org/​10.​1097/​CCM.​0b013​e3181​feeb15 39. Permpikul C, Tongyoo S, Viarasilpa T et al (2019) Early use of norepi‑
nephrine in septic shock resuscitation (CENSER). A randomized trial. Am
 J Respir Crit Care Med 199:1097–1105. https://​doi.​org/​10.​1164/​RCCM.​ noninvasive sepsis trial. Ann Emerg Med 67:367-378.e3. https://​doi.​org/​
201806-​1034OC 10.​1016/j.​annem​ergmed.​2015.​09.​010
40. Monnet X, Lai C, Ospina-Tascon G, De Backer D (2023) Evidence for a 59. Alhabashy WS, Shalaby OM, Elgebaly AS, Ghafar MSAE (2021) Echocardi‑
personalized early start of norepinephrine in septic shock. Crit Care ography-guided hemodynamic management of severe sepsis and
Lond Engl 27:322. https://​doi.​org/​10.​1186/​s13054-​023-​04593-5 septic shock in adults: a randomized controlled trial. Anaesth Pain
41. Meyhoff TS, Møller MH, Hjortrup PB et al (2020) Lower vs higher fluid Intensive Care 25:722–732. https://​doi.​org/​10.​35975/​apic.​v25i6.​1691
volumes during initial management of sepsis: a systematic review 60. Li G, Wei F, Zhang G et al (2019) Clinical value of early liquid resuscita‑
with meta-analysis and trial sequential analysis. Chest 157:1478–1496. tion guided by passive leg-raising test combined with transthoracic
https://​doi.​org/​10.​1016/j.​chest.​2019.​11.​050 echocardiography in patients with septic shock. Zhonghua Wei Zhong
42. Chen C, Kollef MH (2015) Targeted fluid minimization following initial Bing Ji Jiu Yi Xue 31:413–417. https://​doi.​org/​10.​3760/​cma.j.​issn.​2095-​
resuscitation in septic shock: a pilot study. Chest 148:1462–1469. 4352.​2019.​04.​008
https://​doi.​org/​10.​1378/​CHEST.​15-​1525 61. Tran A, Yates J, Lau A et al (2018) Permissive hypotension versus con‑
43. Hjortrup PB, Haase N, Bundgaard H et al (2016) Restricting volumes ventional resuscitation strategies in adult trauma patients with hemor‑
of resuscitation fluid in adults with septic shock after initial manage‑ rhagic shock: a systematic review and meta-analysis of randomized
ment: the CLASSIC randomised, parallel-group, multicentre feasibil‑ controlled trials. J Trauma Acute Care Surg 84:802–808. https://​doi.​org/​
ity trial. Intensive Care Med 42:1695–1705. https://​doi.​org/​10.​1007/​ 10.​1097/​TA.​00000​00000​001816
S00134-​016-​4500-7 62. Owattanapanich N, Chittawatanarat K, Benyakorn T, Sirikun J (2018)
44. Corl KA, Prodromou M, Merchant RC et al (2019) The restrictive IV fluid Risks and benefits of hypotensive resuscitation in patients with
trial in severe sepsis and septic shock (RIFTS): a randomized pilot study. traumatic hemorrhagic shock: a meta-analysis. Scand J Trauma Resusc
Crit Care Med 47:951–959. https://​doi.​org/​10.​1097/​CCM.​00000​00000​ Emerg Med 26:107. https://​doi.​org/​10.​1186/​s13049-​018-​0572-4
003779 63. Bickell WH, Wall MJ, Pepe PE et al (1994) Immediate versus delayed fluid
45. Cronhjort M, Bergman M, Joelsson-Alm E et al (2017) Fluid Responsive‑ resuscitation for hypotensive patients with penetrating torso injuries. N
ness assessment using passive leg raising test to reduce fluid adminis‑ Engl J Med 331:1105–1109. https://​doi.​org/​10.​1056/​NEJM1​99410​27331​
tration and weight gain in patients with septic shock. J Anesth Perioper 1701
Med 4:169–178. https://​doi.​org/​10.​24015/​JAPM.​2017.​0049 64. Carrick MM, Morrison CA, Tapia NM et al (2016) Intraoperative hypoten‑
46. Macdonald SPJ, Keijzers G, Taylor DMD et al (2018) Restricted fluid resus‑ sive resuscitation for patients undergoing laparotomy or thoracotomy
citation in suspected sepsis associated hypotension (REFRESH): a pilot for trauma: early termination of a randomized prospective clinical trial. J
randomised controlled trial. Intensive Care Med 44:2070–2078. https://​ Trauma Acute Care Surg 80:886–896. https://​doi.​org/​10.​1097/​TA.​00000​
doi.​org/​10.​1007/​S00134-​018-​5433-0 00000​001044
47. Lanspa MJ, Burk RE, Wilson EL et al (2018) Echocardiogram-guided 65. Schreiber MA, Meier EN, Tisherman SA et al (2015) A controlled resus‑
resuscitation versus early goal-directed therapy in the treatment of citation strategy is feasible and safe in hypotensive trauma patients:
septic shock: a randomized, controlled, feasibility trial. J Intensive Care results of a prospective randomized pilot trial. J Trauma Acute Care Surg
6:50. https://​doi.​org/​10.​1186/​S40560-​018-​0319-3 78:687–695. https://​doi.​org/​10.​1097/​TA.​00000​00000​000600. (discus‑
48. Semler MW, Janz DR, Casey JD et al (2020) Conservative fluid manage‑ sion 695-697)
ment after sepsis resuscitation: a pilot randomized trial. J Intensive Care 66. Rossaint R, Afshari A, Bouillon B et al (2023) The European guideline on
Med 35:1374–1382. https://​doi.​org/​10.​1177/​08850​66618​823183 management of major bleeding and coagulopathy following trauma:
49. Richard JC, Bayle F, Bourdin G et al (2015) Preload dependence indices sixth edition. Crit Care Lond Engl 27:80. https://​doi.​org/​10.​1186/​
to titrate volume expansion during septic shock: a randomized con‑ s13054-​023-​04327-7
trolled trial. Crit Care 19:5. https://​doi.​org/​10.​1186/​S13054-​014-​0734-3 67. Alsawadi A (2012) The clinical effectiveness of permissive hypotension
50. van Genderen ME, Engels N, van der Valk RJP et al (2015) Early periph‑ in blunt abdominal trauma with hemorrhagic shock but without head
eral perfusion–guided fluid therapy in patients with septic shock. Am or spine injuries or burns: a systematic review. Open Access Emerg Med
J Respir Crit Care Med 191:477–480. https://​doi.​org/​10.​1164/​rccm.​ 4:21–29. https://​doi.​org/​10.​2147/​OAEM.​S30666
201408-​1575LE 68. Lu KJ-Q, Chien L-C, Wo CCJ et al (2006) Hemodynamic patterns of blunt
51. Douglas IS, Alapat PM, Corl KA et al (2020) Fluid response evaluation and penetrating injuries. J Am Coll Surg 203:899–907. https://​doi.​org/​
in sepsis hypotension and shock: a randomized clinical trial. Chest 10.​1016/j.​jamco​llsurg.​2006.​08.​004
158:1431–1445. https://​doi.​org/​10.​1016/J.​CHEST.​2020.​04.​025 69. Dutton RP, Mackenzie CF, Scalea TM (2002) Hypotensive resuscitation
52. Jessen MK, Andersen LW, Thomsen MLH et al (2022) Restrictive fluids during active hemorrhage: impact on in-hospital mortality. J Trauma
versus standard care in adults with sepsis in the emergency depart‑ 52:1141–1146. https://​doi.​org/​10.​1097/​00005​373-​20020​6000-​00020
ment (REFACED): a multicenter, randomized feasibility trial. Acad Emerg 70. Morrison CA, Carrick MM, Norman MA et al (2011) Hypotensive
Med Off J Soc Acad Emerg Med 29:1172–1184. https://​doi.​org/​10.​1111/​ resuscitation strategy reduces transfusion requirements and severe
ACEM.​14546 postoperative coagulopathy in trauma patients with hemorrhagic
53. Kattan E, Bakker J, Estenssoro E et al (2022) Hemodynamic phenotype- shock: preliminary results of a randomized controlled trial. J Trauma
based, capillary refill time-targeted resuscitation in early septic shock: 70:652–663. https://​doi.​org/​10.​1097/​TA.​0b013​e3182​0e77ea
the ANDROMEDA-SHOCK-2 Randomized Clinical Trial study protocol. 71. Villanueva C, Colomo A, Bosch A et al (2013) Transfusion strategies for
Rev Bras Ter Intensiva 34:96–106. https://​doi.​org/​10.​5935/​0103-​507X.​ acute upper gastrointestinal bleeding. N Engl J Med 368:11–21. https://​
20220​004-​pt doi.​org/​10.​1056/​NEJMo​a1211​801
54. Cecconi M, Parsons AK, Rhodes A (2011) What is a fluid challenge? Curr 72. Kola G, Sureshkumar S, Mohsina S et al (2020) Restrictive versus liberal
Opin Crit Care 17:290–295. https://​doi.​org/​10.​1097/​MCC.​0b013​e3283​ transfusion strategy in upper gastrointestinal bleeding: a randomized
4699cd controlled trial. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc
55. Investigators T-SHOCK, Kattan E, Ospina-Tascón GA et al (2020) Sys‑ 27:13–19. https://​doi.​org/​10.​4103/​sjg.​SJG_​152_​20
tematic assessment of fluid responsiveness during early septic shock 73. Chang R, Cardenas JC, Wade CE, Holcomb JB (2016) Advances in the
resuscitation: secondary analysis of the ANDROMEDA-SHOCK trial. Crit understanding of trauma-induced coagulopathy. Blood 128:1043–1049.
Care 24:23. https://​doi.​org/​10.​1186/​s13054-​020-​2732-y https://​doi.​org/​10.​1182/​blood-​2016-​01-​636423
56. Hernandez G, Luengo C, Bruhn A et al (2014) When to stop septic 74. Jairath V, Kahan BC, Gray A et al (2015) Restrictive versus liberal blood
shock resuscitation: clues from a dynamic perfusion monitoring. Ann transfusion for acute upper gastrointestinal bleeding (TRIGGER): a
Intensive Care. https://​doi.​org/​10.​1186/​s13613-​014-​0030-z pragmatic, open-label, cluster randomised feasibility trial. Lancet Lond
57. Juneja D, Javeri Y, Bajaj P, et al (2009) Use of stroke volume variation to Engl 386:137–144. https://​doi.​org/​10.​1016/​S0140-​6736(14)​61999-1
guide fluid therapy in septic shock for prevention of acute kidney injury 75. Lu B, Li M-Q, Li J-Q (2015) The use of limited fluid resuscitation
58. Kuan WS, Ibrahim I, Leong BSH et al (2016) Emergency depart‑ and blood pressure-controlling drugs in the treatment of acute
ment management of sepsis patients: a randomized, goal-oriented, upper gastrointestinal hemorrhage concomitant with hemorrhagic
 shock. Cell Biochem Biophys 72:461–463. https://​doi.​org/​10.​1007/​ 94. Sagrista-Sauleda J, Angel J, Sambola A et al (2006) Low-pressure cardiac
s12013-​014-​0487-2 tamponade: clinical and hemodynamic profile. Circulation 114:945–
76. Aoki M, Abe T, Saitoh D et al (2018) Use of vasopressor increases the risk 952. https://​doi.​org/​10.​1161/​CIRCU​LATIO​NAHA.​106.​634584
of mortality in traumatic hemorrhagic shock: a nationwide cohort study 95. van Diepen S, Katz JN, Albert NM et al (2017) Contemporary manage‑
in Japan. Crit Care Med 46:e1145–e1151. https://​doi.​org/​10.​1097/​CCM.​ ment of cardiogenic shock: a scientific statement from the American
00000​00000​003428 Heart Association. Circulation 136:e232–e268. https://​doi.​org/​10.​1161/​
77. Schol PBB, de Lange N, Henskens Y et al (2023) Restrictive versus liberal CIR.​00000​00000​000525

and its effects on thromboelastometry ­(ROTEM®) values: a randomized,

fluid administration strategy (REFILL study) in postpartum hemorrhage 96. Proudfoot AG, Kalakoutas A, Meade S et al (2021) Contemporary
management of cardiogenic shock: a RAND appropriateness panel
controlled trial. J Int Med Res 51:3000605231171007. https://​doi.​org/​10.​ approach. Circ Heart Fail 14:e008635. https://​doi.​org/​10.​1161/​CIRCH​
1177/​03000​60523​11710​07 EARTF​AILURE.​121.​008635
78. Mercat A, Diehl JL, Meyer G et al (1999) Hemodynamic effects of 97. Thiele H, Ohman EM, de Waha-Thiele S et al (2019) Management of
fluid loading in acute massive pulmonary embolism. Crit Care Med cardiogenic shock complicating myocardial infarction: an update 2019.
27:540–544. https://​doi.​org/​10.​1097/​00003​246-​19990​3000-​00032 Eur Heart J 40:2671–2683. https://​doi.​org/​10.​1093/​eurhe​artj/​ehz363
79. Konstantinides SV, Meyer G, Becattini C et al (2020) 2019 ESC Guidelines 98. VanDyck TJ, Pinsky MR (2021) Hemodynamic monitoring in cardiogenic
for the diagnosis and management of acute pulmonary embolism shock. Curr Opin Crit Care 27:454–459. https://​doi.​org/​10.​1097/​MCC.​
developed in collaboration with the European Respiratory Society 00000​00000​000838
(ERS). Eur Heart J 41:543–603. https://​doi.​org/​10.​1093/​eurhe​artj/​ehz405 99. Bellani G, Laffey JG, Pham T et al (2016) Epidemiology, patterns of care,
80. Millington SJ, Aissaoui N, Bowcock E et al (2024) High and intermediate and mortality for patients with acute respiratory distress syndrome in
risk pulmonary embolism in the ICU. Intensive Care Med 50:195–208. intensive care units in 50 countries. JAMA 315:788–800. https://​doi.​org/​
https://​doi.​org/​10.​1007/​s00134-​023-​07275-6 10.​1001/​jama.​2016.​0291
81. Belenkie I, Dani R, Smith ER, Tyberg JV (1989) Effects of volume load‑ 100. Thompson BT, Chambers RC, Liu KD (2017) Acute respiratory distress
ing during experimental acute pulmonary embolism. Circulation syndrome. N Engl J Med 377:562–572. https://​doi.​org/​10.​1056/​NEJMr​
80:178–188. https://​doi.​org/​10.​1161/​01.​cir.​80.1.​178 a1608​077
82. Molloy WD, Lee KY, Girling L et al (1984) Treatment of shock in a canine 101. Kuebler WM, Ying X, Singh B et al (1999) Pressure is proinflammatory in
model of pulmonary embolism. Am Rev Respir Dis 130:870–874. lung venular capillaries. J Clin Invest 104:495–502. https://​doi.​org/​10.​
https://​doi.​org/​10.​1164/​arrd.​1984.​130.5.​870 1172/​JCI68​72
83. Ferrari E, Sartre B, Labbaoui M et al (2022) Diuretics versus volume 102. Van Mourik N, Metske HA, Hofstra JJ et al (2019) Cumulative fluid bal‑
expansion in the initial management of acute intermediate high-risk ance predicts mortality and increases time on mechanical ventilation in
pulmonary embolism. Lung 200:179–185. https://​doi.​org/​10.​1007/​ ARDS patients: an observational cohort study. PLoS One 14:e0224563.
s00408-​022-​00530-5 https://​doi.​org/​10.​1371/​JOURN​AL.​PONE.​02245​63
84. Lim P, Delmas C, Sanchez O et al (2022) Diuretic vs. placebo in interme‑ 103. Sakr Y, Vincent J-L, Reinhart K et al (2005) High tidal volume and positive
diate-risk acute pulmonary embolism: a randomized clinical trial. Eur fluid balance are associated with worse outcome in acute lung injury.
Heart J Acute Cardiovasc Care 11:2–9. https://​doi.​org/​10.​1093/​ehjacc/​ Chest 128:3098–3108. https://​doi.​org/​10.​1378/​chest.​128.5.​3098
zuab0​82 104. Rosenberg AL, Dechert RE, Park PK, Bartlett RH (2009) Review of a large
85. Ghignone M, Girling L, Prewitt RM (1984) Volume expansion versus clinical series: association of cumulative fluid balance on outcome in
norepinephrine in treatment of a low cardiac output complicating an acute lung injury: a retrospective review of the ARDSnet tidal volume
acute increase in right ventricular afterload in dogs. Anesthesiology study cohort. J Intensive Care Med 24:35–46. https://​doi.​org/​10.​1177/​
60:132–135. https://​doi.​org/​10.​1097/​00000​542-​19840​2000-​00009 08850​66608​329850
86. Mortensen CS, Kramer A, Schultz J et al (2020) Impact of preload on 105. Vignon P, Evrard B, Asfar P et al (2020) Fluid administration and monitor‑
right ventricular hemodynamics in acute pulmonary embolism. Crit ing in ARDS: which management? Intensive Care Med 46:2252–2264
Care Med 48:e1306–e1312. https://​doi.​org/​10.​1097/​CCM.​00000​00000​ 106. MendesPelosi RSP, Schultz MJ et al (2020) Fluids in ARDS: more pros
004643 than cons. Intensive Care Med Exp 8:32. https://​doi.​org/​10.​1186/​
87. Schouver ED, Chiche O, Bouvier P et al (2017) Diuretics versus volume S40635-​020-​00319-X
expansion in acute submassive pulmonary embolism. Arch Cardiovasc 107. Silversides JA, Major E, Ferguson AJ et al (2017) Conservative fluid man‑
Dis 110:616–625. https://​doi.​org/​10.​1016/j.​acvd.​2017.​01.​016 agement or deresuscitation for patients with sepsis or acute respiratory
88. Ternacle J, Gallet R, Mekontso-Dessap A et al (2013) Diuretics in normo‑ distress syndrome following the resuscitation phase of critical illness: a
tensive patients with acute pulmonary embolism and right ventricular systematic review and meta-analysis. Intensive Care Med 43:155–170.
dilatation. Circ J Off J Jpn Circ Soc 77:2612–2618. https://​doi.​org/​10.​ https://​doi.​org/​10.​1007/​s00134-​016-​4573-3
1253/​circj.​cj-​13-​0404 108. National Heart Lung and Blood Institute Acute Respiratory Distress
89. Bodson L, Bouferrache K, Vieillard-Baron A (2011) Cardiac tamponade. Syndrome (ARDS) Clinical Trials Network (2006) Comparison of two
Curr Opin Crit Care 17:416–424. https://​doi.​org/​10.​1097/​MCC.​0b013​ fluid-management strategies in acute lung injury. N Engl J Med
e3283​491f27 354:2564–2575. https://​doi.​org/​10.​1056/​NEJMo​a0622​00
90. Adler Y, Charron P, Imazio M et al (2015) 2015 ESC Guidelines for the 109. Martin GS, Mangialardi RJ, Wheeler AP et al (2002) Albumin and furo‑
diagnosis and management of pericardial diseases: the Task Force for semide therapy in hypoproteinemic patients with acute lung injury.
the Diagnosis and Management of Pericardial Diseases of the European Crit Care Med 30:2175–2182. https://​doi.​org/​10.​1097/​00003​246-​20021​
Society of Cardiology (ESC)Endorsed by: The European Association for 0000-​00001
Cardio-Thoracic Surgery (EACTS). Eur Heart J 36:2921–2964. https://​doi.​ 110. Martin GS, Moss M, Wheeler AP et al (2005) A randomized, controlled
org/​10.​1093/​eurhe​artj/​ehv318 trial of furosemide with or without albumin in hypoproteinemic
91. Kerber RE, Gascho JA, Litchfield R et al (1982) Hemodynamic effects of patients with acute lung injury. Crit Care Med 33:1681–1687. https://​
volume expansion and nitroprusside compared with pericardiocentesis doi.​org/​10.​1097/​01.​CCM.​00001​71539.​47006.​02
in patients with acute cardiac tamponade. N Engl J Med 307:929–931. 111. Mitchell JP, Schuller D, Calandrino FS, Schuster DP (1992) Improved
https://​doi.​org/​10.​1056/​NEJM1​98210​07307​1506 outcome based on fluid management in critically ill patients requiring
92. Sagristà-Sauleda J, Angel J, Sambola A, Permanyer-Miralda G (2008) pulmonary artery catheterization. Am Rev Respir Dis 145:990–998.
Hemodynamic effects of volume expansion in patients with cardiac https://​doi.​org/​10.​1164/​AJRCCM/​145.5.​990
tamponade. Circulation 117:1545–1549. https://​doi.​org/​10.​1161/​CIRCU​ 112. Hu W, Lin CW, Liu BW et al (2014) Extravascular lung water and pulmo‑
LATIO​NAHA.​107.​737841 nary arterial wedge pressure for fluid management in patients with
93. Singh V, Dwivedi SK, Chandra S et al (2014) Optimal fluid amount acute respiratory distress syndrome. Multidiscip Respir Med 9:3. https://​
for haemodynamic benefit in cardiac tamponade. Eur Heart J Acute doi.​org/​10.​1186/​2049-​6958-9-3
Cardiovasc Care 3:158–164. https://​doi.​org/​10.​1177/​20488​72613​516017 113. Zhang Z, Ni H, Qian Z (2015) Effectiveness of treatment based on PiCCO
parameters in critically ill patients with septic shock and/or acute
 respiratory distress syndrome: a randomized controlled trial. Intensive 116. Calfee CS, Delucchi K, Parsons PE et al (2014) Subphenotypes in acute
Care Med 41:444–451. https://​doi.​org/​10.​1007/​S00134-​014-​3638-4 respiratory distress syndrome: latent class analysis of data from two
114. Wang L, Long X, Lv M (2014) Effect of different liquid management randomised controlled trials. Lancet Respir Med 2:611–620. https://​doi.​
strategies on the prognosis of acute respiratory distress syndrome. J org/​10.​1016/​S2213-​2600(14)​70097-9
Dalian Med Univ 36:140–143. https://​doi.​org/​10.​11724/​jdmu.​2014.​02.​09 117. Famous KR, Delucchi K, Ware LB et al (2017) Acute respiratory distress
115. Mikkelsen ME, Christie JD, Lanken PN et al (2012) The adult respiratory syndrome subphenotypes respond differently to randomized fluid
distress syndrome cognitive outcomes study: long-term neuropsycho‑ management strategy. Am J Respir Crit Care Med 195:331–338. https://​
logical function in survivors of acute lung injury. Am J Respir Crit Care doi.​org/​10.​1164/​rccm.​201603-​0645OC
Med 185:1307–1315. https://​doi.​org/​10.​1164/​RCCM.​201111-​2025OC