Article

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

Conference Reports and Expert Panel

Intensive Care Med 2025; 51: 461-477

Published: 31 March 2025

Abstract

Objective

This European Society of Intensive Care Medicine (ESICM) guideline provides evidence-based recommendations 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 hemorrhagic 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 heart congestion in acute pulmonary embolism (ungraded best practice). No recommendation could be made for circulatory failure associated with acute respiratory distress syndrome.

A. Sepsis

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 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 (conditional recommendation, very low certainty of evidence).

Question 2

Should a liberal vs. restrictive strategy be used in 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 need fluid resuscitation for circulatory failure, we cannot recommend for or against systematic restrictive or liberal fluid administration (no recommendation; moderate level of evidence for no effect).

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 for circulatory failure, we suggest using an individualized approach compared with a non-individualized approach during the optimization phase (conditional recommendation, very low certainty of evidence).

Hemorrhagic shock

Question 4

Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory failure in critically ill patients with hemorrhagic shock following penetrating trauma?

Recommendation

In adults with hemorrhagic shock after penetrating trauma, we 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 (conditional recommendation, moderate certainty of evidence).

Question 5

Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory failure in critically ill patients with hemorrhagic shock following blunt trauma?

Recommendation

In adults with hemorrhagic shock following blunt trauma, we suggest a restrictive fluid resuscitation strategy (as part of a permissive hypotensive approach) compared with a liberal fluid resuscitation strategy before definitive hemorrhage control (conditional recommendation, for; low certainty of evidence).

Question 6

Should a restrictive or liberal strategy be used for fluid resuscitation of circulatory failure in critically ill patients with hemorrhagic shock of non-traumatic origin?

Recommendation

The panel recommends (ungraded best practice statement) that in adults with hemorrhagic shock of non-traumatic origin, fluid administration should be guided by hemodynamic and biochemical parameters in the context of the primary disease state prior to definitive hemorrhage control.

Obstructive shock

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 circulatory failure due to acute pulmonary embolism, clinicians should be cautious about administering fluids and should base their decision on 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 circulatory failure due to cardiac tamponade, fluid should be given cautiously as a temporary measure until definitive management can be undertaken.

Left-sided cardiogenic shock

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 (ungraded best practice statement) that fluid resuscitation should not be the primary treatment. If fluids are administered, the patient should be monitored closely, especially for pulmonary edema.

Acute respiratory distress syndrome

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 are unable to make a recommendation about the volume of fluid administration (no recommendation; very low certainty of evidence).

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.