Individualized fluid optimization and de-escalation in critically ill patients with septic shock.

Abstract

Purpose of review: To provide an updated and practical overview of individualized fluid optimization and de-escalation strategies in critically ill patients with septic shock, integrating the most recent evidence and recommendations on fluid responsiveness and fluid stewardship.

Recent findings: Emerging evidence reinforces the importance of dynamic, patient-tailored fluid management strategies over standardized protocols. Trials such as ANDROMEDA, CLASSIC, have highlighted the need for fluid responsiveness assessment, restricted fluid strategies, and early vasopressor use. The concept of fluid stewardship, structured across four phases - resuscitation, optimization, stabilization, and de-escalation - has gained recognition as a rational approach to avoid fluid overload and improve outcomes. Recent ESICM guidelines also stress the use of balanced crystalloids and individualized volume targets.

Summary: Septic shock fluid therapy is evolving from a one-size-fits-all model toward individualized, phase-based management. By incorporating hemodynamic monitoring, dynamic reassessment, and structured clinical phases, fluid administration can be better tailored to each patient's evolving condition. This review emphasizes the critical role of personalized approaches in each phase of fluid therapy and highlights how fluid stewardship may enhance recovery and reduce complications associated with fluid overload.