Advances in resuscitation and deresuscitation

Pantet, Oliviera; Ageron, François-Xavierb; Zingg, Tobiasc. Advances in resuscitation and deresuscitation. Current Opinion in Critical Care 31(3):p 277-284, June 2025. | DOI: 10.1097/MCC.0000000000001267

Summary

This review discusses significant recent developments in fluid resuscitation and deresuscitation practices within critical care, highlighting a paradigm shift toward conservative, personalized fluid management. Advances in fluid stewardship, goal-directed fluid therapy (GDFT), and innovative monitoring tools, including automated closed-loop systems and machine learning, support a precision medicine approach. The authors advocate for balanced resuscitation and proactive deresuscitation to mitigate fluid accumulation syndrome, thus optimizing clinical outcomes.

Key Points

1. Paradigm Shift in Resuscitation: Recent studies indicate that conservative fluid resuscitation strategies, emphasizing personalized and goal-directed approaches, reduce morbidity and mortality compared to traditional aggressive volume expansion.

2. Goal-Directed Fluid Therapy (GDFT): Modern fluid resuscitation prioritizes dynamic parameters such as pulse pressure variation (PPV) and stroke volume variation (SVV), moving away from less reliable static parameters like central venous pressure (CVP) to guide fluid administration decisions.

3. Fluid Stewardship and Personalization: Recognizing "fluid accumulation syndrome," characterized by harmful fluid overload, underscores the importance of fluid stewardship practices in ICUs, advocating for cautious fluid administration and early deresuscitation interventions.

4. Technological Innovations: Advances in noninvasive and automated closed-loop hemodynamic monitoring systems provide real-time, precision-driven fluid management, allowing more accurate adjustments of infusion rates to maintain optimal patient hemodynamics.

5. Balanced Fluid Resuscitation: Balanced crystalloids (e.g., Plasma-Lyte, Lactated Ringer’s) have shown superiority over saline (0.9% NaCl) by reducing risks of acute kidney injury and hyperchloremic metabolic acidosis, though their role in specific clinical scenarios, such as traumatic brain injury (TBI), remains nuanced.

6. Blood Product and Whole Blood Resuscitation: Whole blood, particularly low-titer group O whole blood (LTOWB), is increasingly favored for hemorrhagic shock due to simplified logistics, better coagulation profiles, reduced overall transfusion requirements, and potential mortality benefits.

7. Resuscitation Adjuncts: Despite its theoretical benefits, recent trials, such as the UK-REBOA study, question the efficacy and safety of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), indicating potential harm and increased mortality risks.

8. Pharmacological Adjuncts: Tranexamic acid (TXA) remains beneficial in hemorrhagic shock management, particularly postpartum hemorrhage and surgical bleeding. However, the role of adjuncts like cryoprecipitate and prothrombin complex concentrate (PCC) in trauma management remains uncertain following recent trials.

9. Deresuscitation Strategies: Active fluid removal through diuretics and kidney replacement therapy (KRT), coupled with proactive fluid minimization strategies, is recommended to prevent fluid accumulation syndrome. However, evidence for mortality benefits from deresuscitation remains mixed due to heterogeneous study designs and implementation challenges.

10. Emerging Fluid Management Concepts: The integration of artificial intelligence and machine learning into clinical workflows offers the potential for enhanced precision fluid management. Future developments in personalized fluid protocols, supported by omics technologies, are expected to further refine individualized patient care.

Conclusion

Recent advancements underscore the necessity of personalized, dynamic fluid management strategies encompassing both resuscitation and deresuscitation phases. Technological innovations, balanced fluid choices, comprehensive fluid stewardship, and precision medicine approaches promise improved patient outcomes by minimizing the risks associated with both fluid overload and inadequate resuscitation.

ACCESS FULL ARTICLE HERE

Discussion Questions

1. How can hospitals effectively implement fluid stewardship protocols to ensure adherence across diverse clinical teams in critical care?

2. Considering current evidence, what clinical indicators should trigger proactive deresuscitation, and how can this approach be standardized in ICU practice?

3. What role should artificial intelligence-driven closed-loop systems play in routine fluid management, and how might these technologies change the future landscape of resuscitation practices?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

Take Advantage of This Resource

I encourage you to explore this growing library of articles and leverage it to stay informed on the latest in critical care. Visit the collection today at: https://perfusfind.com/ic/

This is another step in making high-quality, evidence-based information easily accessible to the critical care community. As always, thank you for your continued support!

As always, don’t forget to like, share, and subscribe. See you on the other side!

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Upcoming events

Register Here!

REGISTER HERE!