JAMA Study Highlights Wide Variation in Fluid Therapy Among Critically Ill Patients

A new study published in the Journal of American Medical Association showed that fluid therapy in mechanically ventilated critically ill patients provided significant variation, with a majority of the total volume attributed to maintenance and creep fluids instead of resuscitation fluids.

An international observational study was conducted from April 2024 to July 2025 in 206 ICUs spanning 41 countries across 6 continents, to describe how fluid therapy is used in mechanically ventilated adult patients in the ICU. The study focused on adult patients who received invasive mechanical ventilation within 3 days of ICU admission and were ventilated for 24 hours or more. Patients under 16 years old and those transferred under mechanical ventilation from another ICU were excluded from the study.

The key aspects evaluated were 1. the total volume of fluids administered and daily fluid balance during the first 7 days after intubation, 2. the reasons for fluid therapy during the initial 3 days after intubation, 3. the percentage of each fluid type in the total volume of fluids administered during the first 3 days after intubation.

In a study of 2454 patients (with a median age of 63 years [range, 49-73 years] and 63.6% [1560] being male), the median daily intake of fluids reached its highest point on the first day at 3.0 liters (range, 2.2-4.0 liters) and decreased to 2.6 liters (range, 1.8-3.5 liters) by the sixth day. The daily balance of fluids (with a median of 0.9 liters; range, 0.1-1.9 liters on day 1) dropped to below 0.3 liters (range, -0.5 to 1.2 liters) by day 3 and stayed close to neutral until day 6.

The main reasons for fluid administration were maintenance and replacement fluids (to fulfill daily needs and correct ongoing losses; 31.9%) and creep fluids (for administering medications and keeping catheters clear; 30.9%), while resuscitation (to replenish blood volume; 16.0%) made up a smaller part.

Common fluid choices were isotonic balanced crystalloids (48.9%) and isotonic saline (0.9% sodium chloride) (27.0%), while colloids were infrequently used (1.3%). Considerable differences between sites continued even after accounting for patient characteristics.

Overall, this study illuminate the potential for establishing uniform protocols in fluid administration and expanding fluid conservation efforts to encompass not only resuscitation fluids but also maintenance and insensible loss fluids.

Source:

Blok, S. G., de Grooth, H.-J., Pisani, L., Barbas, C., Chew, M., Dubin, A., Hammond, N., Kwizera, A., Malbrain, M. L. N. G., Monnet, X., Myatra, S. N., Rose, L., Neto, A. S., Shi, Z., Silversides, J., Tripathy, S., van Haren, F., Dondorp, A., Schultz, M. J., … PRoFLUID Investigators. (2026). Fluid therapy in mechanically ventilated critically ill adult patients. The Journal of the American Medical Association. https://doi.org/10.1001/jama.2026.21291