The Four Phases of Intravenous (IV) Fluid Therapy: The ROSE Concept

IV Fluids are drugs

Although often perceived as such, IV fluids are not just harmless bags of water – they are medications with specific indications and contraindications, and the potential for patient complications and adverse effects.^1,2

• Like any other drug, dosing, selection, and timing should depend on the patient’s condition and treatment objectives¹
• Healthcare professionals often possess suboptimal knowledge regarding IV fluids and therefore they are frequently used irrationally³
• IV fluids are the most commonly prescribed drugs in healthcare⁴
• Personalising IV fluid therapy to the patient’s needs can ensure that it remains therapeutic rather than a risk factor⁵
• The choice of IV fluid can be foundational to patient recovery it can directly shape patient outcomes, from haemodynamic stability to long term recovery⁶

In this post, we explore the Four Phases of the ROSE concept (Resuscitation, Optimisation, Stabilisation, Evacuation) – a structured approach that can support clinicians in being more intentional with their IV fluid therapy choices.

The ROSE concept: A Structured Approach to Fluid Therapy

The guiding principles of ROSE offer a practical, stepwise strategy for the prescribing and administering of IV fluid therapy. Each distinct phase of the ROSE concept corresponds to a different clinical stage in a patient's journey, each with specific objectives to guide appropriate IV fluid and dosage selection to achieve the desired patient outcome at each stage. Understanding these objectives is crucial to ensure safe and effective fluid management:²

Resuscitation: Life-saving phase with focus on patient rescue

Optimisation: Focus on organ rescue and avoiding fluid overload

Stabilisation: Achieve maintenance homeostasis

Evacuation: Focus on organ recovery and resolving any fluid overload

Take a Moment to Stop and Think

Fluid therapy is not static but dynamic taking a moment to stop and think to consider which of the Four Phases your patient is in may lead to a more informed and effective IV fluid therapy choice.

Considering the 6Ds, in analogy with antibiotic therapy, can help at this stage:²

• Diagnosis: depending on underlying conditions, different types of fluids need to be administered
• Drug: approach an IV fluid the same way as any other drug selecting the most appropriate fluid type for the patient’s condition
• Dose: should be adjusted depending on the condition and indication
• Duration: stop IV fluids when they are no longer needed the best fluid may well be the one that was not used unnecessarily
• De escalation: taper fluids when oral intake has resumed and remove excess fluids in case of fluid overload with diuretics or ultrafiltration
• Discharge: when the patient is able to cover their daily fluid need
   

Fluid Stewardship -  A Call to Action

Considering guiding principles such as the ROSE Concept and the 6Ds can help you be more intentional with fluid prescribing and/or administering, however, a more comprehensive approach to fluid management is required to make real change in your organisation.

Fluid stewardship is a coordinated approach to IV fluid therapy. Key principles include:

• Promoting a culture of safety and accountability¹
• Continuous education on the importance of IV fluid management¹
• Multi disciplinary collaboration with a collective vision³
• Hospital-wide policies on IV fluid prescribing, storage and administration³
• Accountability, assessment and audit³
• Reducing healthcare costs without adversely impacting the quality of care⁴

By embedding fluid stewardship into practice, healthcare teams can transform IV fluid therapy into an intentional, high impact intervention improving patient outcomes, preventing complications and ensuring the rational use of fluids in clinical practice.¹

But how do you practically implement these changes in your daily clinical environment? Contact the Baxter Team.

References:
1. Malbrain M. (2025) Fluid prescribing and stewardship: strategies to achieve best practice. Hospital Pharmacy Europe. Available at: https://www.hospitalpharmacyeurope.com/wp-content/uploads/trackedfiles/1741945106-baxter-fluid-stewardship-online-book-lr.pdf (Accessed Mar 2025).
2. Malbrain M. et al (2023) The 4 indications of Fluid Therapy. Rational use of intravenous fluids in critically ill patients 10.1007/978 3 031 42205 8s
3. Wuyts S.  (2025) Defining fluid stewardship: a hospital pharmacy perspective. Hospital Pharmacy Europe. Available at: https:// www.hospitalpharmacyeurope.com/wp-content/uploads/trackedfiles/1741945106-baxter-fluid-stewardship-online-book-lr.pdf (Accessed Mar 2025).
4. Wong A. et al (2023) Introduction to Fluid Stewardship. Rational use of intravenous fluids in critically ill patients 10.1007/978 3 031 42205 8.
5. Malbrain, M. et al. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann. Intensive Care 10, 64 (2020). https://doi.org/10.1186/s13613-020-00679-3s.
6. Pedder, Andrew et al. Fluid management. Surgery Oxford International Edition, Volume 43, Issue 4, 181 – 189.