PAEDIATRIC ANAESTHESIA AND CRITICAL CARE / ORIGINAL ARTICLE
The ROSE framework for fluid therapy in critically ill pediatric patients
1
Department of Pediatrics, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
2
Clinical Hospital, Federal University of Minas Gerais/EBSERH, Belo Horizonte, MG, Brazil
3
First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
4
International Fluid Academy, Lovendegem, Belgium
5
Medical Data Management, Medaman, Geel, Belgium
6
Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
Submission date: 2025-11-27
Final revision date: 2025-12-31
Acceptance date: 2026-02-03
Publication date: 2026-02-21
Corresponding author
Romina Aparecida dos Santos Gomes
Departamento de Pediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190, 30130-100, Belo Horizonte, Brazil
Departamento de Pediatria, Faculdade de Medicina da Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190, 30130-100, Belo Horizonte, Brazil
Anaesthesiol Intensive Ther 2026;58(1):20-29
KEYWORDS
childrenoptimizationfluid therapyresuscitationstabilizationcritically illevacuationfluid accumulationROSE
TOPICS
ABSTRACT
Introduction:
The study aimed to assess the applicability of the ROSE conceptual framework (Resuscitation, Optimization, Stabilization, Evacuation) for fluid therapy in critically ill pediatric patients, focusing on its distinct phases, prevention of fluid accumulation, and clinical outcomes.
Material and methods:
A quasi-experimental study was conducted including 122 (retrospective: n = 71; prospective: n = 51) mechanically ventilated and vasoactive-dependent children. A retrospective cohort was compared with a prospective cohort following structured training on ROSE-guided fluid management. Outcomes included fluid accumulation percentage (FA%), duration of mechanical ventilation, pediatric intensive care unit (PICU) length of stay, and need for renal replacement therapy (RRT). Adherence to phase-specific FA% targets was also assessed.
Results:
FA% was similar between cohorts (retrospective vs. prospective) on PICU days 1, 3, and 10 (median [IQR] 1.8% [0.2–4.3] vs. 1.9% [0.8–3.2], P = 0.934; 5.5% [1.7–10.3] vs. 6.1% [3.8–10.2], P = 0.565; 8.3% [0.8–24.8] vs. 7.2% [2.6–18.7], P = 0.848). By ROSE phase, FA% was comparable in Resuscitation (3.5% [2.0–6.0] vs. 4.7% [2.4–6.9], P = 0.244), Optimization (3.0% [0.1–6.7] vs. 4.2% [1.0–7.9], P = 0.261), and Evacuation (2.5% [−2.6–5.3] vs. 2.4% [−0.0–7.4], P = 0.256), but higher during Stabilization (2.5% [0.0–6.9] vs. 4.2% [2.0–8.9], P = 0.043). Mechanical ventilation, length of PICU stay, RRT, and fluid elimination were similar. No independent predictors emerged in logistic regression. FA% target adherence rose from 67.9% to 72.4% after ROSE.
Conclusions:
The ROSE framework in pediatric fluid management is feasible, provides benchmarking for FA% control, and shows promise for individualizing fluid management. Future validation in ROSE-naive centers is warranted.
The study aimed to assess the applicability of the ROSE conceptual framework (Resuscitation, Optimization, Stabilization, Evacuation) for fluid therapy in critically ill pediatric patients, focusing on its distinct phases, prevention of fluid accumulation, and clinical outcomes.
Material and methods:
A quasi-experimental study was conducted including 122 (retrospective: n = 71; prospective: n = 51) mechanically ventilated and vasoactive-dependent children. A retrospective cohort was compared with a prospective cohort following structured training on ROSE-guided fluid management. Outcomes included fluid accumulation percentage (FA%), duration of mechanical ventilation, pediatric intensive care unit (PICU) length of stay, and need for renal replacement therapy (RRT). Adherence to phase-specific FA% targets was also assessed.
Results:
FA% was similar between cohorts (retrospective vs. prospective) on PICU days 1, 3, and 10 (median [IQR] 1.8% [0.2–4.3] vs. 1.9% [0.8–3.2], P = 0.934; 5.5% [1.7–10.3] vs. 6.1% [3.8–10.2], P = 0.565; 8.3% [0.8–24.8] vs. 7.2% [2.6–18.7], P = 0.848). By ROSE phase, FA% was comparable in Resuscitation (3.5% [2.0–6.0] vs. 4.7% [2.4–6.9], P = 0.244), Optimization (3.0% [0.1–6.7] vs. 4.2% [1.0–7.9], P = 0.261), and Evacuation (2.5% [−2.6–5.3] vs. 2.4% [−0.0–7.4], P = 0.256), but higher during Stabilization (2.5% [0.0–6.9] vs. 4.2% [2.0–8.9], P = 0.043). Mechanical ventilation, length of PICU stay, RRT, and fluid elimination were similar. No independent predictors emerged in logistic regression. FA% target adherence rose from 67.9% to 72.4% after ROSE.
Conclusions:
The ROSE framework in pediatric fluid management is feasible, provides benchmarking for FA% control, and shows promise for individualizing fluid management. Future validation in ROSE-naive centers is warranted.
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