Resuscitation is only a slice of ICU fluid: maintenance and fluid creep make up most of what goes in
In a 41-country cohort of 2,454 ventilated adults, resuscitation made up about one liter in six of the fluid given in the first three days after intubation. Maintenance and the carrier fluid for drugs and line flushes made up about a third each.
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The question
Last week's ARISE FLUIDS trial asked whether to give more resuscitation fluid or start a pressor early in septic shock. But resuscitation is only the fluid we decide to give to support the circulation. How much fluid do ventilated ICU patients actually receive in total, and why? PRoFLUID, a prospective observational cohort, tracked every infusion in 2,454 adults in 206 ICUs across 41 countries (April 2024 to July 2025), recording the reason for each fluid over the first three days after intubation.
What they found
- Share of total fluid volume in the first three days: maintenance and replacement 31.9%, creep fluid (the carrier fluid for intravenous drugs and the flushes that keep lines open) 30.9%, and resuscitation only 16.0%. Enteral feeding, blood products and oral fluids made up most of the rest.
- Daily input peaked at a median of 3.0 liters on the first day, and daily fluid balance was near neutral from day 3.
- Practice varied widely. For a typical patient, more restrictive ICUs gave about 2.1 liters a day and more liberal ICUs about 3.9 liters, after adjusting for case mix.
- Balanced crystalloids were the most common fluid (48.9% of prescribed intravenous fluid), followed by saline (27.0%); synthetic colloids were rare.
Why it matters
The authors call for fluid stewardship that extends beyond resuscitation to maintenance and creep. Our take: creep fluid usually isn't ordered as fluid at all; it comes in with the drugs and line care. When we argue about fluids or pressors, we're arguing about a small slice of what goes in. More fluid goes into the patient than we pay attention to. When you're asked to take fluid off a patient in the ICU, look at the maintenance bag, the drips and the flushes first. The study didn't test whether trimming them improves outcomes.
Caveats
This is an observational study: it describes practice and tests no intervention. Fluid given before intubation, including in the emergency department, was not counted. Participating ICUs may be more interested in fluids than most, and only about one patient in twenty was from North America.
Funding and ties: funded by Amsterdam UMC. Several authors report fees or grants from companies including Baxter, Becton Dickinson, Getinge and Vantive, mostly outside the submitted work; one author reports non-financial support from Becton Dickinson and Baxter during the study. Full disclosures are in the paper.
The source: Blok SG, de Grooth HJ, Pisani L, et al., for the PRoFLUID Investigators. Fluid Therapy in Mechanically Ventilated Critically Ill Adult Patients. JAMA. Published online October 14, 2026. doi:10.1001/jama.2026.21291 Read the original
🎧 Listen: Weekly · Oct 20, from 08:00.
Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our disclaimer and disclosures. Spotted an error? Tell us.
