[Downloaded free from http://www.jnaccjournal.org on Tuesday, July 11, 2017, IP: 125.4.153.


Review Article

‘ROSE concept’ of fluid management: Relevance in
neuroanaesthesia and neurocritical care

Joseph N. Monteiro, Shwetal U. Goraksha

Fluid therapy in neurosurgical patients aims to restore intravascular volume, optimise haemodynamic parameters and
maintain tissue perfusion, integrity and function.The goal is to minimise the risk of inadequate cerebral perfusion pressure
and to maintain good neurosurgical conditions. However, fluid management in brain‑injured patients has several distinctive
features compared with non‑brain‑injured critically ill patients. The ROSE concept advocates the restriction of fluids,
which is consistent with the prevention of a ‘tight brain’ in neurosurgery. Whether this imbalance in fluid management
studies between different types of brain injuries is a reflection of differences in clinical relevance of fluid management is
not clear. Further randomised controlled trials in the future are essential in subarachnoid haemorrhage and traumatic
brain injury patients who are critical and need long‑term Intensive Care Unit stay to elucidate and define the role and
relevance of the ROSE concept in neuroanaesthesia and neurocritical care.
Key words: De‑resuscitation, fluid overload, resuscitation

INTRODUCTION in other critically ill patients is commonly guided
by haemodynamic monitoring, while sophisticated
Fluid therapy in neurosurgical patients aims to restore monitoring tools for CBF, and cerebral oxygenation
intravascular volume, optimise haemodynamic are generally less well implemented in clinical practice.
parameters and maintain tissue perfusion, integrity and Recent data suggest that the fluid administration may
function. The goal is to minimise the risk of inadequate have an impact on outcome.[2‑4]
cerebral perfusion pressure (CPP) and to maintain good
neurosurgical conditions. However, fluid management Positive fluid balance is associated with worse morbidity
in brain‑injured patients has several distinctive features and mortality in multiple studies which show worse
compared with non‑brain‑injured critically ill patients. overall mortality in critically ill patients,[5] and increased
Both the type of fluids used and the volume is very mortality in patients with acute kidney injury,[4] as
important. The use of hypotonic fluids can lead to tissue well as prolonged recovery in patients with acute lung
oedema, which results in oxygen diffusion and cerebral injury/acute respiratory distress syndrome (FACTT
blood flow  (CBF) impairments.[1] Fluid management trial). Increased mortality in septic shock patients (VAST
trial) and worse morbidity in colorectal surgery patients
Department of Anaesthesia, P D Hinduja Hospital and MRC, has been demonstrated. It is also associated with
Mumbai, Maharashtra, India intra‑abdominal hypertension.[5]

Address for correspondence: The ROSE concept has been advocated by Malbrain
Dr. Joseph N. Monteiro, D61, Nirvana Society, Bhagoji Keer Marg, et al.,[5] after reviewing the association between a positive
Mahim, Mumbai ‑ 400 016, Maharashtra, India.
E‑mail: monteiro04@gmail.com
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
Access this article online others to remix, tweak, and build upon the work non‑commercially, as long as the
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DOI: How to cite this article: Monteiro JN, Goraksha SU. 'ROSE
10.4103/2348-0548.197435 concept' of fluid management: Relevance in neuroanaesthesia and
neurocritical care. J Neuroanaesthesiol Crit Care 2017;4:10-6.

© 2017 Journal of Neuroanaesthesiology and Critical Care
10 | Published by Wolters Kluwer ‑ Medknow |

[6] CAPILLARIES AND THE BRAIN FLUID MOVEMENTS BETWEEN The brain and the spinal cord are isolated from VASCULATURE AND TISSUES the intravascular compartment by the blood‑brain barrier.org on Tuesday. Pc is the hydrostatic the patient’s baseline body weight and multiplying by pressure in the capillary membrane. 2017.g. Osmolarity is the primary determinant of water movement across the intact blood‑brain barrier. that Na+ and its anions Cl− and HCO−3. Cerebral autoregulation and the blood brain barrier are two protective mechanisms that usually preserve normal cerebral function. partial pressures of arterial oxygen and carbon Journal of Neuroanaesthesiology and Critical Care | Vol. The percentage of fluid accumulation can be defined Kf is the filtration coefficient for the membrane.[Downloaded free from http://www. Positive fluid balance is a state of equation. haematocrit. 4 • Issue 1 • Jan‑Apr 2017 | 11 . Fluid overload is Qf = Kf S ([Pc − Pt] – δ[πc − πt]) defined by ‘a cut off value of 10% of fluid accumulation Where Qf is the net amount of fluid that moves between as this is associated with worse outcomes’. which composed of endothelial cells that Ernest Starling described the forces that determine the form tight junctions severely limiting the diffusion of movement of water between vasculature and tissues. It is separated by the cell membrane with molecular weight plasma proteins.4. July 11.153. Normally. as follows: fluid overload resulting from fluid administration during resuscitation and subsequent therapies. the sum its active sodium pump. this plasma (extracellular fluid [ECF] = 20% of body weight) and the oncotic pressure is produced pre‑dominantly by intracellular fluid spaces  (ICF  =  40% of body weight) albumin. Cerebral autoregulation ensures that CBF and cerebral oxygen delivery is constant in spite of moderate changes in systemic blood pressure.[5] the capillaries and the surrounding extracellular space. CPP. Water comprises 60% of the total body weight of an In peripheral tissues only the plasma oncotic pressure adult. are the mainstay of the ECF osmolality.151] Monteiro and Goraksha: ROSE concept in neuroanaesthesia and neurocritical care fluid balance and fluid overload and the outcomes in which was formalised subsequently into Starling’s critically ill adults. The cell contains large anions an outward flux of fluids from the vessel into the such as protein and glycogen. the tissue pressure and the tissue oncotic pressure all act to draw fluid from the capillaries ANATOMY AND PHYSIOLOGY into the extracellular space of the tissue.. which ensures that sodium of the forces results in a Qf value slightly >0. blood Figure 1: Distribution of total body water viscosity. molecules between the intravascular space and the brain. indicating remains mainly in the ECF. This fluid is cleared from the therefore draw in K+ ions to maintain electrical neutrality tissue by the lymphatic system. IP: 125. immune globulins.[8] Conversely. and is divided functionally into the extracellular serves to maintain intravascular volume. CBF is determined by cerebral metabolic needs. the administration of hyperosmolar crystalloids (e.[5] pressure of the surrounding tissue. Pt is the hydrostatic 100%’. The capillary pressure.jnaccjournal. Either or both may be impaired in a patient with neurologic injury. mannitol) results in decrease in brain water content and ICP. thereby preventing the (Gibbs–Donnan equilibrium). and K+ has the corresponding FLUID MOVEMENTS BETWEEN THE function in the ICF. fibrinogen. [7] The administration of excess free water results in an increase in the intracranial pressure and an oedematous brain. and other high [Figure 1]. which cannot exit and tissue extracellular space. underlying normal physiological and pathophysiological mechanisms. These mechanisms ensure development of oedema. δ is the coefficient of reflection which can vary from 1 = no movement to These fluid management strategies can be used as 0 = free diffusion of the solute across the membrane. πc guidelines for neurosurgical patients but need to be is the oncotic pressure of the plasma and πt is the oncotic individualised and guided by an understanding of the pressure of the fluid in the extracellular space. S is ‘by dividing the cumulative fluid balance in litre by the surface area of the membrane.

151] Monteiro and Goraksha: ROSE concept in neuroanaesthesia and neurocritical care dioxide.4. haemorrhage and tissue large osmotic pressure gradient across the blood brain manipulation. 2017. advantage in acute resuscitation in that small Therefore. Surgical and traumatic losses in patients procedures and neurotrauma can be associated at risk for intracranial hypertension can be replaced with significant bleeding. and clinical studies have are associated with adverse outcomes as compared to shown that subarachnoid haemorrhage (SAH) and TBI crystalloids in traumatic brain injury (TBI) patients. If cerebral autoregulation fails. insensible losses (respiratory intracellular space to the intravascular space. decreases peripheral resistance and decreases are capable of markedly increased excretion or intracranial pressure. only to water. A daily from infectious risk. Its use is economical and free extreme conservation (<10 mEq excreted/day). Intravascular requirements of water and electrolytes.[14] the first 10 kg. with a beneficial effect on physiologic response to extracellular volume expansion intracranial pressure and decreasing brain oedema or an inability to conserve salt or water. 4 • Issue 1 • Jan‑Apr 2017 | . potassium. hence small molecules and ions produce magnesium. Fluid resuscitation Neurosurgical procedures and isolated head injury BLOOD TRANSFUSION are associated with minimal loss of ECF. brain.9 nm. lactated ringer oxygen delivery is compromised and is then dependent and some gelatin solutions increase brain volume and on CPP and viscosity.[8] Thus. The blood‑brain barrier is composed of brain endothelial More recent data suggest improved outcomes with cells with tight junctions creating an effective pore size balanced salt solutions. as compared to 0.. it has been shown to be effective for exceeding 1000 ml/day may represent an appropriate volume resuscitation. Its use has been associated requirement for potassium is 1 mEq/kg/day. Perioperative transfusion with 0.153. the daily maintenance requirements for water.jnaccjournal.e.[11] patients have a worse outcome with anaemia. It does not cause the hypotension requirement for sodium is 75 mEq (1. Hypertonic‑hyperoncotic fluids have the potential and 1 ml/kg/h for each additional kilogram after 20 kg.5 mEq/kg/day). and then hydrostatic pressure becomes important in determining brain water. intracranial pressure. The simplest formula provides in addition to maintenance In the normal brain changes in oncotic pressure do not fluids and replacement of estimated blood loss. Cerebral least 10 mEq/L of urine. It is permeable requires replacement of other electrolytes (i.9% saline versus 4% helps improve cerebral oxygen delivery. although associated injuries may necessitate aggressive fluid Many neurosurgical as well as non‑neurosurgical replacement.9% saline. Fresh Journal of Neuroanaesthesiology and Critical Care 12 | Vol. 2500 ml/day of a solution containing sodium 30 mEq/L Recommendations for the use of hypertonic saline are and potassium 25–30 mEq/L. Urinary output head trauma. The daily adult in uninjured areas. barrier and redistribute water to the intravascular space.[7] These tight junctions do not permit the Substantial or chronic loss of gastrointestinal fluids passage of even small molecules and ions. IP: 125. if the blood brain barrier is damaged 6 ml/kg/h for those involving moderate trauma and secondary to various types of trauma it becomes 8–15 ml/kg/h for those involving severe trauma. an additional 2 ml/kg/h for 11–20 kg. Transfusion albumin fluid evaluation’ study suggest that colloids thresholds are undefined. in Fluid maintenance resuscitation in patients in hypovolemic shock has Maintenance solutions are given to provide the daily been growing over the past decades.org on Tuesday. However. phosphate). To estimate maintenance water dehydration and central pontine myelinolysis due to requirements using body weight.9% saline. In healthy adults. the CBF and Hypoosmolar solutions such as albumin.13] of 0. July 11. Physiologic with increases in plasma osmolarity and sodium diuresis typically induces an obligate potassium loss of at and chloride levels and hypokalaemia.7–0. ROLE OF HYPERTONIC SALINE FLUID MANAGEMENT The use of hypertonic saline.[Downloaded free from http://www. even small increases in also must compensate for sequestration of interstitial the concentrations of plasma electrolytes can exert a fluid that accompanies trauma. seen when mannitol is used and increases cardiac Patients with a normal cardiac and renal reserve output.[10] close monitoring of serum sodium levels (<60 mEq/L) and serum osmolarity (<350 mosm/L). volumes are more effective than isotonic crystalloids sodium and potassium for a healthy 70 kg adult consist of in maintaining blood pressure and cardiac output. permeable to a variety of molecules. Replacement of fluid losses the osmotic gradient. significantly influence the osmotic pressures in the 4 ml/kg/h for procedures involving minimal trauma. an effective plasma volume expander with decreased oedemagenesis. administration of hypertonic saline creates an osmotic sufficient water is required to balance gastrointestinal gradient resulting in the transfer of fluid from the losses of 100–200 ml/day.[12. provide 4 ml/kg/h for rapid changes in serum sodium levels are possible. In and cutaneous) of 500–1000 ml/day. The findings of ‘0.

as proposed by Bagshaw and Bellomo. July 11. This compromises blood flow can guide fluid management in the critically ill. 2017. Therefore. viscosity. The fluid increasing non‑pulmonary organ failure. characterised sepsis. It is suggested that a haematocrit of 28%–33% strategies may necessitate a greater use of vasopressor provides an optimal balance between viscosity and therapy. some non‑responders stay in the Ebb Phase and progress cardiac index (CI) >2. It is characterised by low mean leakage.5 L/min/m2. (e. which impairs oxygen. albumin 20%) and early initiation of diuretics and Intravenous fluids are given during resuscitation to renal replacement therapy. pro‑inflammatory cytokines and stress Resuscitation phase (R) hormones after injury the Ebb Phase is initiated Occurs within minutes of severe body injury such as which represents a distributive shock. and impedes capillary blood flow information on lung water and tissue oedema. which have been OVERLOAD described below. Patients with higher invasive cardiac output monitors is recommended to severity of illness need more fluids. while the negative fluid balance is PHASES OF CRITICAL ILLNESS associated with improved organ function and survival. distorts the lungs. and and lymphatic drainage. Journal of Neuroanaesthesiology and Critical Care | Vol. shorter duration those patients that do not respond to the initial fluid of mechanical ventilation and intensive care stay without bolus. low CO. Fluids should be given at a rate of prevent the development of multiple organ dysfunction 1 mL/kg/h in combination with replacement fluids when syndrome.[15] It has four phases’ resuscitation (R). Restrictive fluid decrease. excess interstitial fluid and persistent high extravascular lung water index  (EVLWI). With decrease in haematocrit and viscosity. However. and the patient enters by arterial vasodilatation and transcapillary albumin the Ebb Phase of shock. Correct monitoring is essential before fluids potential renal dysfunction result in sodium and water administration. pancreatitis or trauma.[5] In response. with higher severity of illness and mortality. resuscitation with hyperoncotic solutions oxygen carrying capacity. variation (PPV) <12%. A high in encapsulated organs such as kidney and liver.[16] Subsequent • Salvage or rescue treatment with fluids administered haemodynamic stabilisation and restoration of plasma quickly as a bolus (4 mL/kg over 10–15 min) oncotic pressure sets off the Flow Phase with the • The goal is early adequate goal‑directed fluid resumption of diuresis and mobilisation of extravascular management. However. particularly in result in tissue oedema. and the stroke volume effects of fluid overload and interstitial oedema have returns to baseline. the ‘R’ or resuscitation within the ROSE concept. 4 • Issue 1 • Jan‑Apr 2017 | 13 . PATHOPHYSIOLOGY OF FLUID stabilisation (S) and evacuation (E). This phase corresponds of balance may be considered a biomarker of critical illness.4. burns. In this impairment leading to decreased tissue perfusion stage of shock. as well EVLWI indicates a state of capillary leakage. it is important to keep in mind monitoring including lung water measurements (late that the oxygen‑carrying capacity of the blood will also goal‑directed fluid removal  [LGFR]). fluid balance must be positive and the fluid resulting in negative fluid balances. increase venous return and stroke volume. suggested resuscitation targets are: MAP > 65 mmHg.[17] Studies show that a positive fluid balance is independently associated with impaired organ function and an MALBRAIN ET AL. coagulopathy and not as a volume expander. pulse pressure to global increased permeability syndrome (GIPS). Compensatory neuroendocrine reflexes and indicated. [15] responders following a fluid challenge. The adverse redistributes within 60 min. adequate fluid therapy is required to and oxygenation.’S ‘ROSE’ CONCEPT OF increased risk of death. Any further Patients managed with a conservative fluid strategy also fluid administration not only serves no purpose in seem to have improved lung function.[9] Excessive fluid at this stage can an impact on all end organ functions.g. associated increase intra‑abdominal pressure (IAP)..jnaccjournal. These patients require restrictive fluid strategies and the cerebrovascular resistance decreases and CBF even fluid removal guided by extended haemodynamic increases.151] Monteiro and Goraksha: ROSE concept in neuroanaesthesia and neurocritical care frozen plasma should be given only to correct any expressed as the ratio of C‑reactive protein over albumin).153. Secondary interstitial oedema leads to systemic arterial pressure (MAP). The use of non‑invasive or minimally retention and positive fluid balances. optimisation (O). and microcirculatory hypoperfusion and impaired tissue oxygenation. and therefore fluid assess fluid responsiveness. monitoring of EVLWI provides tissue architecture. resulting in positive on the correlation of haematocrit and whole blood fluid balances and progression to organ failure and death. but <50% There is literature to show that a negative fluid balance of haemodynamically unstable patients are fluid increases survival in patients with septic shock. but it may also be harmful them. no late conservative fluid The beneficial effects of haemodilution are based management (LCFM) achievement.org on Tuesday.[Downloaded free from http://www. IP: 125. left end‑diastolic area index characterised by high capillary leak index ([CLI] (LVEDAI) >8 cm/m2.

De‑resuscitation is characterised by the discontinuation Level 1 recommendation includes the use of the initial of invasive therapies leading to a negative fluid balance. albumin at 60 mg/h for 4 h.[19] RECOMMENDATIONS Monitoring may include invasive methods (e. IAP <15 mmHg. PPV) or volumetric measures of preload (e. fluid balance and organ function MONITORING • Targets: Neutral or negative fluid balance. July 11. American Stroke Association. GEDVI) may ‘Diuretics or renal replacement therapy (in combination be favoured over filling‑pressure measures such as with albumin) can be used to mobilise fluids in pulmonary artery occlusion pressure.[5] specifically to affect a meaningful clinical variable. Cordemans et al.5. IP: 125. 2017.[20] possible (Grade 2B)’. measurement has ever improved survival. EVLWI  <10−12  mL/kg PBW. colloid oncotic pressure (COP) value as long as it is accurate and reproducible. remain the essential indicators of successful • Need to avoid over‑enthusiastic fluid removal resuscitation.g. filling pressures and urine achieve negative fluid balance: output. They require LGFR (‘de‑resuscitation’) to heart rate.  2  ×  100  mL 20% which a biomarker of the severity of illness.. Further. then titrated to methods may be used to monitor preload and EVLWI. base deficit. followed by those who received initial maintenance and replacement of normal losses: adequate and LCFM. CI  >2. The albumin >30 g/L) – to pull fluid from the interstitium goal is to ensure adequate tissue perfusion with titration into the circulation of fluids to maintain a neutral fluid balance: • Frusemide  (‘Lasix’) infusion started 60  min after • Targets: MAP  >65 mmHg.org on Tuesday.[5] other dynamic haemodynamic measures (e. oesophageal Doppler). lactate level.151] Monteiro and Goraksha: ROSE concept in neuroanaesthesia and neurocritical care Optimisation phase (O) • High PEEP for 30  min  (at least equal to IAP)  –  to Occurs within hours and is the phase of ischaemia and drive fluid from the alveoli into the interstitium reperfusion. American resulting in hypovolaemia Heart Association and Neurocritical Care Society have • Diuretics or renal replacement therapy  (in given weak recommendations for monitoring in certain combination with albumin) can be used to mobilise situations such as aneurysmal SAH to maintain CBF fluids in haemodynamically stable patient. on the concept of goal‑directed therapy.. Preload optimised fluids can lead to hypovolemia. Positive fluid balance seen during this phase • Albumin administration  (e. and death.153. Evacuation phase (E) There may be some patients who do not transition from The traditional markers of the adequacy of fluid the ‘ebb’ phase of shock to the ‘flow’ phase after the ‘2nd hit’ resuscitation. Recent studies show that patients treated with Stabilisation phase (S) conservative initial and late fluid management had the This phase evolves over days and fluid is needed for best outcome.g. then titrated between PPV <14%. pulmonary vascular Monitoring though is essential in the operating room permeability index <2.[Downloaded free from http://www. hypotension and with global end‑diastolic volume index (GEDVI) hypoperfusion of tissues and should be monitored and 640–800 mL/m2..[21] haemodynamically stable patients with intra‑abdominal hypertension and a positive cumulative fluid balance The modern approach to fluid management is based after the acute resuscitation has been completed. keep the cumulative fluid balance on day 7 as low as fluid management based on fluid responsiveness. only a good protocol can do this.5  L/min/m2. avoided. refers to ‘LGFR’.[17] suggested the ‘PAL’ approach as a The reality is that fluids can be harmful. and the Intensive Care Unit (ICU). or gastric intramucosal pH to Furthermore. 4 • Issue 1 • Jan‑Apr 2017 | . transpulmonary thermodilution‑guided) or less ‘A goal of a 0 to negative fluid balance by day 3 and to invasive methods (e. and no >16−18 mmHg. and oxygenation. and CLI <60..[18] • Monitor daily body weight. LVEDAI 8 − 12/cm/m2. and should method of de‑resuscitation: only be given when they are expected to produce some Journal of Neuroanaesthesiology and Critical Care 14 | Vol. will only be of APP >55 mmHg. which involves ‘aggressive stratify patients with regard to the need for ongoing fluid and active fluid removal by means of diuretics and renal resuscitation and the risk of multiple organ dysfunctions replacement therapy with net ultrafiltration’. IAP (<15 mmHg) 5 and 20 mg/h to maintain > 100 mL/h urine output. Thermodilution albumin over 60 min on day 1.g. is monitored and abdominal perfusion pressure During this phase. blood pressure.g. an overzealous evacuation of (APP) (>55 mmHg) is calculated.4. in which it and the inciting issues/source control have been is believed that interventions should be performed addressed (Grade 2D)’.jnaccjournal.. including haemodynamic parameters like develop GIPS.g.

the goal is to prevent data indicate that positive fluid overloaded is detrimental secondary injury to the brain by preventing hypotension to neurosurgical and neurocritical patients as well as and maintaining cerebral perfusion between 50 and other critical patients. However. and therefore the evacuation and 70 mmHg. and Nil. intraoperatively such as 0. CONCLUSION which can increase cerebral oedema. Management of fluids such that stroke volume is adequate perfusion and oxygenation of the spinal optimised is an extremely well validated approach that cord as well as avoiding venous congestion that may has been shown repeatedly to reduce morbidity.[26] worsens the consequences of cerebral ischaemia[22] and hypo‑osmolality (target osmolality 290–320 osm/kg). Hetastarch and dextran solutions should be used cautiously as excess can REFERENCES lead to coagulopathy through interference with platelets and factor VIII. treat ischemic neurologic deficits due to vasospasm. 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Vincent JL. and restoring circulating blood volume achieve this. Whether this imbalance in fluid management studies between different types of brain The intravascular volume status has been found to be injuries is a reflection of differences in clinical relevance abnormally low in 36%–100% of patients with SAH of fluid management is not clear.19:137‑9. which in turn depends on intravascular volume and mean arterial blood pressure.jnaccjournal. occur with fluid overload.[1] and the level of hypovolemia correlates with the clinical grade.[25] 1. extensive INTRACRANIAL SURGERY instrumentation and repair may be associated with significant blood loss requiring large amounts of Normovolemia and normotension should be maintained asanguineous fluid as well as blood transfusions. Hyperglycaemia. 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