Part 3—fluid removal at de-escalation phase

The European Society of Intensive Care Medicine has published the third and final part of its Clinical Practice Guideline on fluid management in adult critically ill patients, focusing on fluid removal during the de-escalation phase of shock management.

Developed by an international panel of experts, methodologists, and patient representatives, the guideline is based on evidence from 13 randomised controlled trials (RCTs). The panel applied the GRADE methodology to evaluate the certainty of evidence and formulate recommendations.

Key recommendations include:

• Suggesting de-escalation of fluid therapy over no de-escalation in critically ill adults after the acute phase of fluid resuscitation (low certainty evidence).
• Suggesting protocolized fluid removal by diuretics over usual care in critically ill patients after the acute phase (moderate certainty evidence).
• Recommending against routine ultrafiltration or extracorporeal fluid removal in critically ill adults after the acute phase, unless another indication for RRT exists (low certainty evidence).

The guideline highlights the importance of individualised management and acknowledges the limited evidence for specific patient subgroups.

This publication offers clinicians practical recommendations to support informed decision-making in fluid removal during the de-escalation phase of critical illness.

This is the third and final part of the ESICM Guideline on Fluid Therapy, following parts on:
1. Choice of resuscitation fluids
2. Volume of resuscitation fluids