Critical CareEmergency MedicineIntensive CareSMACCThe four phases of intravenous fluid therapy

The four phases of intravenous fluid therapy: Manu Malbrain

Manu Malbrain presents the four phases of intravenous fluid therapy.

He takes you through the big questions of fluids – What, when, why and how?

To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation


Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs.


As Paracelsus famously said “The dose makes the poison” This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement.


When do you start and stop? You must weigh up the benefit and risk of fluid administration. Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved.


Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia. Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!) We need to make good fluids better

So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.

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Manu Malbrain

CMO @azJanPalfijn Internist-intensivist, Professor Critical Care Research @OfLublin