Fluid Management Protocol

Adult Critically Ill Patient — ICU / Emergency DepartmentPOCUS-guided · ROSD Framework

Based on: Oh's ICM Manual · Washington Manual of Critical Care · FCCS · Marino's ICU Book

🏆 ICU Golden Rule

1. Give fluids until perfusion improves.

2. Stop fluids before congestion develops.

3. Remove fluids once shock resolves.

1Recognise Shock

Shock is present if one or more of the following:

2Immediate Resuscitation

Examples of Severe Shock:

Septic shock · Haemorrhagic shock · Severe dehydration · Anaphylaxis

1Administer high-flow oxygen

2Secure two large-bore IV lines (≥16G)

3Draw bloods: FBC, U&E, LFT, lactate, cultures, coagulation

4Send cultures before antibiotics if sepsis suspected

5Perform bedside POCUS (heart, lungs, IVC)

6Start balanced crystalloid (Ringer's Lactate or Plasma-Lyte)

Initial Bolus

500 mL RL / Plasma-Lyte

Over 10–15 minutes. Reassess after every bolus.

❌ Never prescribe "3 L stat" — reassess after every 500 mL

3Fluid Responsiveness Assessment

Before additional fluid, ask: "Will fluid increase cardiac output?"

A — PREFERREDPassive Leg Raise (PLR)

Elevate legs to 45° for 60–90 seconds while monitoring:

✓VTI increase > 10%

✓Stroke volume increase > 10%

✓MAP increase > 10%

✅ Positive
→ Fluid responsive

❌ Negative
→ Stop fluids

B — POCUSUltrasound Assessment

Heart

•Hyperdynamic LV (likely hypovolaemia)

•Normal LV function

•Poor LV function (cardiogenic)

•RV dilation

Lungs

•A-lines only → dry

•Few B-lines → mild

•Multiple diffuse B-lines → wet (STOP fluids)

⚠ Do NOT use IVC alone to guide fluid decisions

4Fluid Decision

✅ IF FLUID RESPONSIVE

250–500 mL

balanced crystalloid over 10–15 min

Repeat only if ALL of:

Improved MAP

Improved VTI on echo

Improved capillary refill

Improving lactate trend

NO signs of congestion

❌ IF NOT FLUID RESPONSIVE

STOP FLUIDS

Consider instead:

Norepinephrine (vasodilatory/septic shock)

Dobutamine (cardiogenic, poor LV)

Vasopressin (refractory vasodilatory)

5Congestion Screen (After Every Bolus)

Clinical

Lung Ultrasound

Echo

If ANY congestion sign present → STOP FLUIDS

6Vasopressor Threshold

Start Norepinephrine if MAP < 65 despite:

OR20–30 mL/kg fluids already given

ORNot fluid responsive on assessment

ORPulmonary oedema developing

Standard Target

≥ 65

mmHg MAP

Chronic Hypertension

70–75

mmHg MAP

Neurocritical Care

Individual

per team plan