Introduction And Pathophysiological Rationale
- The ROSE Concept (Resuscitation–Optimization–Stabilization–Evacuation) represents a major paradigm shift in dynamic fluid stewardship for critically ill children.
- Traditional liberal fluid resuscitation frequently leads to Fluid Overload (FO), characterized by a cumulative fluid accumulation exceeding 10–15% of body weight.
- Severe FO triggers Global Increased Permeability Syndrome (GIPS), causing profound organ and peripheral edema, which directly correlates with prolonged mechanical ventilation, progression of Acute Kidney Injury (AKI), and increased mortality in pediatric sepsis and Pediatric Acute Respiratory Distress Syndrome (PARDS).
- Pediatric patients are particularly vulnerable to FO due to a higher percentage of total body water, immature renal function, and profound sepsis-driven capillary leak.
The Four Dynamic Phases Of ROSE
| Phase | Timeframe | Clinical Strategy And Interventions |
|---|---|---|
| Resuscitation | Minutes to Hours | Rapid administration of 10–20 mL/kg balanced crystalloids to restore perfusion, strictly guided by fluid responsiveness. |
| Optimization | Hours | Continuous reassessment of fluid responsiveness utilizing Point-Of-Care Ultrasound (POCUS), passive leg raises, and stroke volume variation to actively titrate fluids and prevent excess accumulation. |
| Stabilization | Hours to Days | Strict restriction of maintenance intravenous fluids and prioritization of enteral nutrition support to halt ongoing fluid accumulation. |
| Evacuation | Days to Weeks | Active de-resuscitation triggered once the child is hemodynamically stable. Achieved via pharmacological diuresis or hybrid Renal Replacement Therapy (e.g., Sustained Low-Efficiency Diafiltration [SLED]) to achieve a negative fluid balance. |
Clinical Evidence And Prognostic Impact
- The 2026 prospective study by dos Santos Gomes et al. validated the ROSE framework in pediatric critical care, proving it successfully controlled fluid accumulation percentage in 80–85% of cases.
- Adherence to the ROSE protocol directly correlates with significantly reduced organ dysfunction, shorter Pediatric Intensive Care Unit (PICU) length of stay, and improved oxygenation in PARDS registries.
- Real-world cohorts in low- and middle-income countries utilizing bedside POCUS and lactate trends demonstrated a 20–30% lower incidence of FO compared to legacy liberal fluid strategies.
Guideline Integration And Indian Implementation
- Surviving Sepsis Campaign (SSC) 2026: Explicitly integrates the phased ROSE approach into fluid therapy recommendations for Phoenix-defined sepsis and septic shock, issuing conditional recommendations for balanced crystalloids and early de-resuscitation.
- PALICC-2 Guidelines: Indirectly supports the ROSE framework by emphasizing strict fluid restriction in PARDS to minimize pulmonary edema.
- Indian Academy Of Pediatrics (IAP): Endorses the ROSE framework within Indian pediatric modules, actively promoting resource-limited setting adaptations such as utilizing clinical signs and bedside POCUS when advanced hemodynamic monitors are unavailable.
- MoHFW And ICMR STWs (2025): The Indian Council of Medical Research Standard Treatment Workflows incorporate ROSE principles into standardized pediatric sepsis and AKI bundles, advocating for SLED during the evacuation phase to manage severe FO in public PICUs.