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Background <p>Intravenous fluid therapy is a foundational intervention in emergency medicine and critical care, particularly in shock and sepsis. While early practice emphasized rapid volume expansion to restore perfusion, accumulating evidence over the past two decades has revealed that both insufficient and excessive fluid administration may contribute to organ dysfunction. Consequently, fluid therapy has evolved from empiric volume-based resuscitation toward a more nuanced, phase- and phenotype-specific approach.</p> Purpose of Review <p>To synthesise landmark clinical trials that have shaped contemporary fluid management, clarify how evidence has refined the earlier resuscitation paradigms, and outline emerging concepts of precision fluid stewardship across the emergency–critical care continuum.</p> Discussion <p>Early protocolized resuscitation, exemplified by early goal-directed therapy (EGDT), initially demonstrated benefit in septic shock; however, subsequent multicentre trials (ProCESS, ARISE, ProMISe) showed that contemporary usual care achieves equivalent outcomes with similar fluid volumes but less invasive monitoring and treatment intensity. Large randomised trials established crystalloids as first-line resuscitation fluids, demonstrated no survival benefit of albumin in sepsis and harm in traumatic brain injury, and contraindicated hydroxyethyl starch due to renal toxicity. Studies comparing saline with balanced crystalloids revealed modest renal advantages with balanced solutions in some populations, while others showed clinical equivalence. Importantly, trials such as FACTT, CLASSIC, and CLOVERS clarified that restrictive or conservative strategies after initial resuscitation are safe but not universally superior, underscoring the importance of illness phase. The ROSE framework (Resuscitation, Optimisation, Stabilisation, Evacuation) contextualises fluid therapy as a dynamic intervention requiring escalation, reassessment, and timely de-escalation. Emerging tools including dynamic haemodynamic assessment, point-of-care ultrasound, and data-driven decision support systems further support a shift toward individualized fluid prescription.</p> Conclusion <p>Contemporary evidence supports viewing intravenous fluids as pharmacologic agents requiring indication-specific dosing, careful titration, and active withdrawal. Rather than abandoning early fluid resuscitation, modern practice emphasises precision-guided administration tailored to disease state, physiological response, and phase of illness. The future of fluid management lies in stewardship strategies that maximise benefit while minimising harm across the emergency and critical care continuum.</p>

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Fluid Therapy Along the Emergency Medicine–Critical Care Continuum: From Resuscitation to Precision Stewardship

  • 期刊论文

  • 发表日期：

    2026年2月20日

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  • Vignesh Jayaprakash,
  • Robin Chowdhary,
  • Aayushi Sharma

摘要

Background

Intravenous fluid therapy is a foundational intervention in emergency medicine and critical care, particularly in shock and sepsis. While early practice emphasized rapid volume expansion to restore perfusion, accumulating evidence over the past two decades has revealed that both insufficient and excessive fluid administration may contribute to organ dysfunction. Consequently, fluid therapy has evolved from empiric volume-based resuscitation toward a more nuanced, phase- and phenotype-specific approach.

Purpose of Review

To synthesise landmark clinical trials that have shaped contemporary fluid management, clarify how evidence has refined the earlier resuscitation paradigms, and outline emerging concepts of precision fluid stewardship across the emergency–critical care continuum.

Discussion

Early protocolized resuscitation, exemplified by early goal-directed therapy (EGDT), initially demonstrated benefit in septic shock; however, subsequent multicentre trials (ProCESS, ARISE, ProMISe) showed that contemporary usual care achieves equivalent outcomes with similar fluid volumes but less invasive monitoring and treatment intensity. Large randomised trials established crystalloids as first-line resuscitation fluids, demonstrated no survival benefit of albumin in sepsis and harm in traumatic brain injury, and contraindicated hydroxyethyl starch due to renal toxicity. Studies comparing saline with balanced crystalloids revealed modest renal advantages with balanced solutions in some populations, while others showed clinical equivalence. Importantly, trials such as FACTT, CLASSIC, and CLOVERS clarified that restrictive or conservative strategies after initial resuscitation are safe but not universally superior, underscoring the importance of illness phase. The ROSE framework (Resuscitation, Optimisation, Stabilisation, Evacuation) contextualises fluid therapy as a dynamic intervention requiring escalation, reassessment, and timely de-escalation. Emerging tools including dynamic haemodynamic assessment, point-of-care ultrasound, and data-driven decision support systems further support a shift toward individualized fluid prescription.

Conclusion

Contemporary evidence supports viewing intravenous fluids as pharmacologic agents requiring indication-specific dosing, careful titration, and active withdrawal. Rather than abandoning early fluid resuscitation, modern practice emphasises precision-guided administration tailored to disease state, physiological response, and phase of illness. The future of fluid management lies in stewardship strategies that maximise benefit while minimising harm across the emergency and critical care continuum.