European Society of Intensive Care Medicine Clinical Practice Guideline on fluid therapy in adult critically ill patients: Part 3-fluid removal at de-escalation phase.

Purpose: This is the third of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on fluid management in adult critically ill patients. This part addresses fluid removal in the de-escalation phase of shock management.

Methods: This guideline was formulated by an international panel of clinical experts, methodologists, and patient representatives. A literature search was conducted to identify relevant randomized controlled trials (RCTs) in adults published up to February 2025. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.

Results: Based on data from 13 RCTs, the panel issued three conditional recommendations. The panel suggested de-escalation of fluid therapy over no de-escalation in critically ill adults after the acute phase of fluid resuscitation (low certainty evidence). They suggested protocolized fluid removal by diuretics over usual care in critically ill patients after the acute phase of fluid resuscitation (moderate certainty evidence). A conditional recommendation was issued against the routine use of ultrafiltration or extracorporeal fluid removal in critically ill adults after the acute phase of fluid resuscitation, without other indication for RRT (low certainty evidence). There was limited evidence to comment on fluid removal in specific patient cohorts.

Conclusions: This ESICM guideline provides three recommendations to inform clinicians on fluid removal during the de-escalation phase in critically ill patients with shock who no longer need fluid resuscitation.