Fluid Therapy in Mechanically Ventilated Critically Ill Adult Patients

Importance: Fluid therapy is ubiquitous in the intensive care unit (ICU) but carries risks, especially in mechanically ventilated patients. Contemporary global practice across dose, indication, and type is unknown. Objective: To characterize ICU fluid practices in mechanically ventilated adults. Design, Setting, and Participants: International prospective observational cohort study between April 2024 and July 2025, across 206 ICUs in 41 countries on 6 continents. Consecutive adult patients receiving invasive mechanical ventilation within 3 days of ICU admission and ventilated 24 hours or more. Exclusion criteria were age younger than 16 years and transfer under mechanical ventilation from another ICU. Exposures: Fluid volume, indication, and type after intubation. Main Outcomes and Measures: Key measures included (1) total infused volume and daily fluid balance over 7 days after intubation; (2) the indication for fluid therapy over the first 3 days after intubation; (3) the proportion of total administered fluid volume attributable to each fluid type over the first 3 days after intubation. Results: Among 2454 patients analyzed (median age, 63 years [IQR, 49-73 years]; 63.6% [1560] male), median daily fluid input peaked on day 1 at 3.0 L (IQR, 2.2-4.0 L) and declined to 2.6 L (IQR, 1.8-3.5 L) through day 6. Daily fluid balance (median, 0.9 L; IQR, 0.1-1.9 L on day 1) decreased to less than 0.3 L (IQR, -0.5 to 1.2 L) by day 3 and remained near-neutral through day 6. Maintenance and replacement fluids (to meet daily requirements and to correct ongoing losses; 31.9%) and creep fluids (to deliver medications and maintain catheter patency; 30.9%) were the primary indications, whereas resuscitation (to restore circulating blood volume; 16.0%) accounted for a smaller proportion. Isotonic balanced crystalloids (48.9%) and isotonic saline (0.9% sodium chloride) (27.0%) were common; colloids were rare (1.3%). Substantial between-site variation persisted after adjustment for case-mix. Conclusions and Relevance: In this prospective international cohort study, fluid therapy varied widely among mechanically ventilated critically ill patients, with maintenance and creep fluids-rather than resuscitation fluids-accounting for most total volume.

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Journal
JAMA
Published
2026-10-14
DOI
https://doi.org/10.1001/jama.2026.21291
Primary Topic
Respiratory Support and Mechanisms
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article
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article

Fluid Therapy in Mechanically Ventilated Critically Ill Adult Patients

Nodreen Christine Ayupo, Frank M.P. van Haren, Betsy Kirui, Swagata Tripathy et al.
JAMA
Respiratory Support and Mechanisms
article

Fluid Therapy in Mechanically Ventilated Critically Ill Adult Patients

Nodreen Christine Ayupo, Frank M.P. van Haren, Betsy Kirui, Swagata Tripathy, Frederique Paulus, Dalim Kumar Baidya, Marcus Josephus Schultz, Soumya Sarkar, Luigi Pisani, Sadik Mohammed, Melkamu Tilahun, Sheila Nainan Myatra, Pragyan Kumar Routray, Arthur Kwizera, Arnaldo Dubín, Andrew Kintu, 孟庆华, Siebe G. Blok, Rabiul Alam Md Erfan Uddin, Sunitha Binu Varghese, Niels Van Regenmortel, Manu L. N. G. Malbrain, Arjen M. Dondorp, Ziyokov Joshi, Aggrey Lubikire, Nura Nasser, Ranjan Nath, Pieter Roel Tuinman, Louise Rose, Suma Rabab Ahmad, Harm‐Jan de Grooth, Urvi Bhooshan Shukla, Naomi E. Hammond, Xavier Monnet, Chinmayee Bhise, Saurabh Karmakar, Jonathan A. Silversides, Henry Sserwadda, Bharath Kumar Pamulapati, Selina Mutuku, Kenneth Nyeko, Salim Chowdhury, Feng Zhang, Rekha Das, Abdul Majid Rahimi, Rajdeep Biswas, Guangzhi Shi, Ruth Nasozi, Roya Afzali, Noorullah Ahmadzai, Shoaib Mirzada, Mithun Shil, Hajara Nakayiza, Betty Khainza, Mohammad Jahidul Alam, Peter Oduor, Zhonghua Shi, Edrisa Ssemwanga, Ary Serpa Neto, Nurita Dian Kestriani Saragih Sitio, Michelle Chew, Joya Devi, Zhonghui Duan, Noor Hafidz, Dita Aditianingsih, PRoFLUID Investigators, Ian Buyonje, Jianshe Shi, Jafar Khan Sulimankhil, Esther Kitooleko, Shivanjali Kadam, Rezaul Hoque Tipu, Innocent Rubangakene, Bruce Bwamiki, Yumei Wang, Kanmathareddy Amulya Reddy, Fazlulhaq Ehsan, Mehernegar Haqyar Mohammadi, Eid Mohammad Saidi, Shamim Nabaggala, Lameck Ssemwogerere, Deepak Anand, Xiaohui Li, Kenneth Tashobya, Arthur Kisakye, Mohammad Dawood Safi, Yaorong Zhang, Rosephil Koremo, Carmen Barbas, Michel Vinent Ondwordo, Mayurdhwaja Rath, Michael Mutuma, Prajakta Dahitule, Madhava Devireddy, Patricia Mwathi, Yugan Dylan Naicker, Dominic Ogwal, Frozan Mohibzada, Rajesh Kumar, Fan Wu
article en

Abstract

Importance: Fluid therapy is ubiquitous in the intensive care unit (ICU) but carries risks, especially in mechanically ventilated patients. Contemporary global practice across dose, indication, and type is unknown. Objective: To characterize ICU fluid practices in mechanically ventilated adults. Design, Setting, and Participants: International prospective observational cohort study between April 2024 and July 2025, across 206 ICUs in 41 countries on 6 continents. Consecutive adult patients receiving invasive mechanical ventilation within 3 days of ICU admission and ventilated 24 hours or more. Exclusion criteria were age younger than 16 years and transfer under mechanical ventilation from another ICU. Exposures: Fluid volume, indication, and type after intubation. Main Outcomes and Measures: Key measures included (1) total infused volume and daily fluid balance over 7 days after intubation; (2) the indication for fluid therapy over the first 3 days after intubation; (3) the proportion of total administered fluid volume attributable to each fluid type over the first 3 days after intubation. Results: Among 2454 patients analyzed (median age, 63 years [IQR, 49-73 years]; 63.6% [1560] male), median daily fluid input peaked on day 1 at 3.0 L (IQR, 2.2-4.0 L) and declined to 2.6 L (IQR, 1.8-3.5 L) through day 6. Daily fluid balance (median, 0.9 L; IQR, 0.1-1.9 L on day 1) decreased to less than 0.3 L (IQR, -0.5 to 1.2 L) by day 3 and remained near-neutral through day 6. Maintenance and replacement fluids (to meet daily requirements and to correct ongoing losses; 31.9%) and creep fluids (to deliver medications and maintain catheter patency; 30.9%) were the primary indications, whereas resuscitation (to restore circulating blood volume; 16.0%) accounted for a smaller proportion. Isotonic balanced crystalloids (48.9%) and isotonic saline (0.9% sodium chloride) (27.0%) were common; colloids were rare (1.3%). Substantial between-site variation persisted after adjustment for case-mix. Conclusions and Relevance: In this prospective international cohort study, fluid therapy varied widely among mechanically ventilated critically ill patients, with maintenance and creep fluids-rather than resuscitation fluids-accounting for most total volume.

JAMA
Australian National University (AU), Medical University of Lublin (PL), Uppsala University (SE), Queen's University Belfast (GB), Belfast Health and Social Care Trust (GB), Capital Medical University (CN), King's College London (GB), Guy's and St Thomas' NHS Foundation Trust (GB), University of St.Gallen (CH), Mahidol University (TH), Université Paris-Saclay (FR), Tata Memorial Hospital (IN), Hospital Israelita Albert Einstein (BR), Vienna General Hospital (AT), University Medical Center Utrecht (NL), UNSW Sydney (AU), University of Oxford (GB), Australian and New Zealand Intensive Care Society (AU), Beijing Sanbo Brain Hospital (CN), The George Institute for Global Health (AU), All India Institute of Medical Sciences Bhubaneswar (IN), Monash Health (AU), St George Hospital (AU), Mahidol Oxford Tropical Medicine Research Unit (TH), Sanatorio Otamendi y Miroli (AR), Ziekenhuisnetwerk Antwerpen Stuivenberg (BE), Amsterdam University Medical Centers (NL), Bicêtre Hospital (FR), Monash University (AU), All India Institute of Medical Sciences (IN), Makerere University (UG), Medical University of Vienna (AT)
Good health and well-being
Openalex Percentile: Top 13%
Respiratory Support and Mechanisms
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