CLINICAL INVESTIGATION

Fluid Intake in Critically Ill Patients: The “Save

Useless Fluids For Intensive Resuscitation”
Multicenter Prospective Cohort Study
Frédérique Schortgen, MD1
OBJECTIVES: Patients at risk of adverse effects related to positive fluid balance Cécilia Tabra Osorio, RN1
could benefit from fluid intake optimization. Less attention is paid to nonresuscita- Dorothée Carpentier, MD2
tion fluids. We aim to evaluate the heterogeneity of fluid intake at the initial phase
Matthieu Henry, MD3
of resuscitation.
Pascal Beuret, MD4
DESIGN: Prospective multicenter cohort study. Guillaume Lacave, MD5
SETTING: Thirty ICUs across France and one in Spain. Georges Simon, MD6

PATIENTS: Patients requiring vasopressors and/or invasive mechanical Pierre-Yves Blanchard, RN7
ventilation. Tiphanie Gobe, RN8
Antoine Guillon, MD, PhD9
INTERVENTIONS: None.
Laurent Bitker, MD, PhD10,11,12
MEASUREMENTS AND MAIN RESULTS: All fluids administered by vascular
Guillaume Duhommet, RN13
or enteral lines were recorded over 24 hours following admission and were clas-
Jean-Pierre Quenot, MD, PhD14,15,16
sified in four main groups according to their predefined indication: fluids hav-
ing a well-documented homeostasis goal (resuscitation fluids, rehydration, blood Matthieu Le Meur, MD17

products, and nutrition), drug carriers, maintenance fluids, and fluids for technical Sébastien Jochmans, MD18
needs. Models of regression were constructed to determine fluid intake predicted Fabrice Dubouloz, RN19
by patient characteristics. Centers were classified according to tertiles of fluid Nolwenn Mainguy, RN20
intake. The cohort included 296 patients. The median total volume of fluids was Josselin Saletes, RN21
3546 mL (interquartile range, 2441–4955 mL), with fluids indisputably required Thibault Creutin, RN22
for body fluid homeostasis representing 36% of this total. Saline, glucose-con-
Pierre Nicolas, RN23
taining high chloride crystalloids, and balanced crystalloids represented 43%,
Julien Senay, RN24
27%, and 16% of total volume, respectively. Whatever the class of fluids, center
Anne-Lise Berthelot, RN25
of inclusion was the strongest factor associated with volumes. Compared with the
first tertile, the difference between the volume predicted by patient characteristics Delphine Rizk, RN26
and the volume given was +1.2 ± 2.0 L in tertile 2 and +3.0 ± 2.8 L in tertile 3. David Tran Van, MD27
Audrey Riviere, RN28
CONCLUSIONS: Fluids indisputably required for body fluid homeostasis repre-
sent the minority of fluid intake during the 24 hours after ICU admission. Center Sarah Beatrice Heili-Frades, MD, PhD29
effect is the strongest factor associated with the volume of fluids. Heterogeneity in Justine Nunes, RN30
practices suggests that optimal strategies for volume and goals of common fluids Nadine Robquin, RN31
administration need to be developed. Sylvie Lhotellier, RN32

KEYWORDS: fluid balance; fluid rescucitation, practices; shock Stanislas Ledochowski, MD33
Armelle Guénégou-Arnoux, MSc34

F
Adrien Constan, RN1
luid optimization is an important goal in the management of criti- Save Useless Fluids For Intensive
cally ill patients. Fluids must be chosen according to body fluid ho- Resuscitation (SUFFIR) Study Group,
Reseau European de Recherche en
meostasis, which depends on individual patient needs. While both
Ventilation Artificielle (REVA) Network
excess and insufficient amounts may impact outcomes, the first has been
much more evaluated than the second. Fluid overload has consistently be Copyright © 2023 by the Society of
associated with worsened outcome in critically ill patients (1). Comparative Critical Care Medicine and Wolters
studies performed in high-risk populations for fluid accumulation, that is, Kluwer Health, Inc. All Rights
patients receiving vasopressors and/or patients with acute respiratory distress Reserved.
syndrome (ARDS), show an increased number of ventilator-free days and DOI: 10.1097/CCM.0000000000006091

Critical Care Medicine www.ccmjournal.org     1

Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Schortgen et al
KEY POINTS
Question: This study aims to precisely identify
type and proportion for each vascular and enteral
fluid given to the ICU patient at the bedside during
the first 24 hours of the acute phase.
Findings: In this prospective multicenter cohort
study, median of total fluid intake was 3546 mL
(interquartile range, 2441–4955 mL) during the 24
hours study period. The volume of nonresuscita-
tion fluids represents the majority of fluid intake.
Fluid intake strongly varies between centers and
is not explained by patient characteristics alone.
Meanings: Heterogeneity in practices suggests
that optimal strategies for volume and goals of
common fluids administration need to be devel-
oped. Further studies are required to determine if
nonresuscitation fluids can be safely optimized.
a decreased length of ICU stay with restrictive fluid
management and/or de-escalation (2). However, a re-
cent randomized trial did not confirm these results
(3). Impressive efforts have been done by researchers
to optimize fluid resuscitation; however, little atten-
tion is paid to nonresuscitation fluids (4, 5). The pro-
portion of fluid resuscitation among total fluid intake
has consistently been shown to be small (3, 6–8). A
wide source of “other fluids” are inherently required
for resuscitation. These fluids are referred to as “hid-
den” or “creep” fluids because they are not usually ac-
knowledged by ICU teams. These “other fluids” need
to be identified and considered for restriction when
indicated. Consensus on fluid classification and ter-
minology does not exist in the literature (4). Only
one prospective study, specifically designed to iden-
tify the origins of fluid intake during the first few days
of septic shock resuscitation, has been performed in
eight ICUs (8). Nonresuscitation fluids represented
the largest source of fluids.
The aim of our study was to: 1) identify all possible
sources of fluids administered by intravascular or en-
teral lines during the acute phase of resuscitation in
patients at high risk of fluid accumulation; 2) describe
the proportion of resuscitation and nonresuscitation
fluids; and 3) assess the association between center
practices and fluid intake.
2     www.ccmjournal.org
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METHODS
Study Design
We conducted the Save Useless Fluids For Intensive
Resuscitation (SUFFIR) study, which was a prospec-
tive cohort in 30F and one Spanish adult ICU, 13
(43%) of which were in university hospitals. Centers
were invited to participate by the Reseau European de
Recherche en Ventilation Artificielle (REVA) network
(70 centers were active members of this network).
Enrollment was initially planned from February 2020
to May 2020. No sample size calculation was per-
formed. We estimated that 4 weeks of inclusion in 31
centers will allow recruiting around 300 patients. We
estimated that this number will be sufficient for a re-
gression analysis regarding the number of recorded
variables. Participating centers were free to select 4
consecutive weeks during this period to include be-
tween 10 and 20 consecutive patients. Because of the
first wave of the COVID-19 pandemic, the period of
inclusion was prolonged until October 2020. Nine cen-
ters started the study in March 2020 and had to sus-
pend enrollment until June 2020. Twenty-one centers
started enrollment after the first wave and one center
was unable to enroll patients.
A study committee including one intensivist and
one nurse from 11 participating centers was formed
to list all fluids likely to be administered to a critically
ill patient by either the intravascular or enteral route.
Our aim was to establish an exhaustive list. A con-
sensus terminology and definition of each type of fluid
was agreed by all participating centers to ensure uni-
form recording (eTable 1, http://links.lww.com/CCM/
H440). To validate the terminology used and the fea-
sibility of exhaustive recording, the case report form
(CRF) was constructed according to the classification
and was tested by nurses not involved in study devel-
opment. Data monitoring was performed by trained
research staff. The CRF included the details of fluids
preparation and duration of administration allowing
verification of aberrant volumes.
Inclusion criteria were patients requiring vasopres-
sors and/or invasive mechanical ventilation with a Fio2
greater than 50% and positive end-expiratory pressure
greater than 5 cm H2O. These criteria were chosen to
be easily identified by nurses at the bedside and to se-
lect a population exposed to the risks of fluid overload.
Patients were screened upon admission and had to be
XXX 2023 • Volume 51 • Number 00

included within 2 hours. Because exhaustive fluid re-
cording could not be feasible in emergency situations,
a second screening was done at the time of the first
input-output fluid balance calculation. Patients not
included upon admission could be included at the
second screening if inclusion criteria were still present.
In accordance with French national law on human
experimentation and with the Helsinki Declaration,
the “SUFFIR” study was approved by the ethics com-
mittee of the French Intensive Care Society on January
17, 2020 (CE SRLF 20-0). The Spanish center obtained
its authorization for participation according to local
regulation. All patients or close relatives were informed
that their medical personal data were included in the
SUFFIR anonymized database. Nonobjection confir-
mation for use of personal data was obtained from the
patient or their legal representative in accordance with
French local regulations. The study complied with the
Strengthening the Reporting of Observational Studies
in Epidemiology statement guidelines (http://www.
equator-network.org) (eTable 7, http://links.lww.com/
CCM/H440). The study was funded by a grant from
the French Intensive Care Society.
Data Collection
All fluids administered by intravascular and feed-
ing lines were recorded during the 24 hours follow-
ing inclusion. Indication, volume, and type of each
fluid administered were recorded. Sources of fluids
were divided in four classes: indisputably required
for body fluid homeostasis, diluent fluids for drugs,
maintenance fluids, and fluids for technical need. Ten
subclasses were also a priori defined and diluent flu-
ids were subdivided for each type of drugs (eTable 1,
http://links.lww.com/CCM/H440). Fluids indisputably
required for body fluid homeostasis were fluid boluses
for resuscitation, fluids for replacement of overt fluid
losses, blood products, and nutrition. Maintenance
fluids ordered for expected insensible fluid losses were
recorded in a specific class because their indications
are not well validated (4).
Fluids were specifically recorded for the study on a
specific paper sheet immediately filled after each ad-
ministration. Estimated volume was applied for un-
measurable fluids (see Supplement Online Material,
http://links.lww.com/CCM/H440, for details). We col-
lected precise data on the volume of reconstituted fluid
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Clinical Investigation
bags considering all electrolytes and drugs added for
the final preparation. Data were secondarily reported
by research personnel in an electronic CRF. Missing
data are indicated in eTable 2 (http://links.lww.com/
CCM/H440).
Statistical Analyses
Results are presented as median 25th–75th interquar-
tile range, mean ± sd, or number and percentage of
patients, as appropriate. A regression analysis was de-
veloped in the whole population to predict the volumes
of fluid intake adjusted to take into consideration the
patients’ characteristics. The characteristics of patients
expected to be associated with the volume of fluids
were a priori selected for adjustment (9). Variables
were successively entered in the model and the model
giving the best prediction was selected. Analysis of
variance was used to determine the association be-
tween center of inclusion and fluid intake. We arbi-
trarily chose the center of the principal investigator as
the reference center. Centers of inclusion were entered
in the model to estimate adjusted volume differences
compared with the reference center.
We also divided centers in tertiles according to the
median of fluid intake given three types of centers:
“low,” “moderate,” and “high” volumes. We compared
the characteristics of patients in the three tertiles using
a Student t test when quantitative variables were nor-
mally distributed or a Kruskal-Wallis, as appropriate.
The predictive model for fluid intake was applied in
patients included in the “low-volume” centers (tertile
1). Then, we assessed the difference between predicted
volume by the model and observed volume in the
second and third tertiles. The difference between pre-
dicted and observed volumes in the second and third
tertiles gave an estimation of the excess fluid intake.
We also performed a sensitivity analysis to limit as
much as possible the impact of patient effect on the dif-
ference of volumes given across centers. A more homo-
geneous subgroup of patients likely to be resuscitated
for severe infection was selected. Patients with invasive
mechanical ventilation, vasopressors, sedation, and
antibiotics were included in this subgroup analysis. The
difference between predicted and observed volume of
fluids was assessed in this subgroup according to the
center of inclusion. Statistical analyses were carried
out using R v4.0.3 (R Project for Statistical Computing,
www.ccmjournal.org     3
Schortgen et al

Vienna, Austria; https://www.R-project.org/). p values
of less than or equal to 0.05 were considered to be sta-
tistically significant.
RESULTS
Two hundred ninety-six patients were enrolled in 30
centers, 12 patients were not included in the anal-
ysis because of missing data. Two hundred eighty-
four patients were analyzed; 173 (61%) were included
at admission and 111 (39%) at the first fluid balance
assessment, 9 ± 5 hours after admission. Patients char-
acteristics are depicted in Table 1; 87% required vaso-
pressor and 32% had ARDS.
De cara já achei muito alto a media das primeiras 24h
em geral os trabalhos fora do brasil, são menores.
500 mL (0–1500 mL), that is, 14% of the total flu-
ids. The number of patients exposed to each type of
fluids with the corresponding volumes is reported
in eTable 3 (http://links.lww.com/CCM/H440).
Mean urine output at the end of study period was
1340 ± 1158 mL.
The characteristics of patients significantly associ-
ated with higher fluid intake were invasive mechanical
ventilation, use of antibiotics, and Simplified Acute
Physiology Score (SAPS) II score; ARDS was associ-
ated with a lower fluid intake (eTable 4, http://links.
lww.com/CCM/H440). After adjustment for patient
characteristics, SAPS II score (p = 0.01) and need for
antibiotics (p = 0.03) were significantly associated with
a higher volume of fluids for indisputable homeostasis

Volumes of Fluids goal (eTable 4, http://links.lww.com/CCM/H440).

Median fluid intake during the 24 hours study pe-
riod was 3546 mL (2441–4955 mL) corresponding
to 1279 mL (500–2406 mL) of fluids indisputably
required for homeostasis goal (38% of total flu-
ids), 1004 mL (500–1558 mL) of maintenance flu-
ids, 772 mL (535–1182 mL) for drug diluent, and
183 mL (98–381 mL) for technical needs (Table
2). The median volume of resuscitation fluid was
Interestingly, there was no association between vol-
umes and patients weight, even for resuscitation and
maintenance fluids which should be ordered in mL/kg
(eFig. 1, http://links.lww.com/CCM/H440).
Analysis of variance showed that the center of in-
clusion was the strongest factor associated with the
volume of total fluids (Table 3). Estimates of the dif-
ference in fluid intake, adjusted to take into considera-
tion the patient’s characteristics, are reported for each

TABLE 1.
Patient’s Characteristics at Inclusion
T1, Low-Volume T2, Moderate-Volume T3, High-Volume
Patient’s Characteristics All, n = 284 Centers, n = 92 Centers, n = 102 Centers, n = 90 pa

Age, yr 65 ± 14 65 ± 14 64 ± 14 66 ± 14 0.30
Simplified Acute Physiology 57 ± 19 58 ± 18 61 ± 19 52 ± 18 0.003
Score II score, points
Weight, kg 78 ± 20 79 ± 21 78 ± 17 77 ± 20 0.86
Invasive mechanical 219 (77) 78 (83) 77 (76) 64 (73) 0.24
ventilation, n (%)
Fio2, % 60 ± 26 62 ± 25 62 ± 26 57 ± 25 0.33
Positive end-expiratory 7±3 7±3 7±2 7±3 0.43
pressure, cm H2O
Acute respiratory distress 90 (32) 23 (24) 36 (36) 31 (35) 0.21
syndrome, n (%)
Serum creatinine, µmol/L 163 ± 197 179 ± 285 143 ± 111 168 ± 155 0.66
Vasopressors, n (%) 247 (87) 77 (82) 88 (88) 82 (92) 0.17
Dose, µg/kg/min 0.27 ± 0.78 0.27 ± 0.63 0.29 ± 1.1 0.25 ± 0.71 0.89
Received antibiotics, n (%) 242 (86) 82 (87) 82 (82) 78 (88) 0.23
ICU mortality, n (%) 75 (28) 24 (26) 22 (22) 29 (33) 0.42
a
Between tertiles comparison by Kruskal-Wallis test.

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 Clinical Investigation

TABLE 2.
Volumes of the Main Sources of Fluids
Volumes, mL

Fluid Type Mean ± sd Median (IQR, 25th–75th) Minimum–Maximum

Total fluid intake 4,049 ± 2,523 3,546 (2,441–4,955) 40–16,865

Total of fluids for indisputable homeostasis goal 1,757 ± 1,951 1,279 (500–2,406) 0–13,000
 Fluid boluses 1,140 ± 1,500 500 (0–1,500) 0–9,850
 Rehydration 201 ± 724 0 (0–86) 0–7,000
 Nutrition 248 ± 455 0 (0–269) 0–1,942
 Blood products 224 ± 889 0 (0–0) 0–7,992
Total carrier fluids for drugs 914 ± 552 772 (535–1,182) 0–3,365
 Vasopressors 109 ± 185 63 (18–144) 0–2,500
 Antibiotics 271 ± 295 176 (99–372.5) 0–1,978
 Sedation 132 ± 164 85 (0–200) 0–834
 Analgesics 97 ± 108 60 (20–35) 0–584
Total maintenance fluids 1,080 ± 794 1,004 (500–1,558) 0–5,000
Total of fluids for technical need 296 ± 344 183 (98–381) 0–3,586
 Vascular access management 90 ± 59 82 (49–121) 0–376
 Keep vein open 80 ± 180 0 (0–67) 0–1,250
 Vehicle 22 ± 43 0 (0–35) 0–240
 Renal replacement therapy 63 ± 344 0 (0–0) 0–3,510
IQR = interquartile range.

TABLE 3.
Association Between the Center of Inclusion and Total Fluid Intake Adjusted for Patient’s
Characteristics
Patient’s Characteristics Estimate (95% CI) p

Center of inclusion Not applicable < 0.00001

Age, per year –0.18 (–0.32 to –0.04) 0.0123
Weight, per kg 0.05 (–0.06 to 0.17) 0.3776
Simplified Acute Physiology Score II score, per point 0.22 (0.10–0.35) 0.0004
Acute respiratory distress syndrome, yes –3.92 (–9.01 to 1.16) 0.1299
Invasive mechanical ventilation, yes 7.96 (2.50–13.44) 0.0045
Creatinine, per µmol/L 0.01 (–0.00 to 0.02) 0.0904
Receiving antibiotics, yes 9.60 (3.42–15.79) 0.0025
Vasopressor dose, per 0.1 µg/kg/min 2.05 (–0.09 to 4.20) 0.0605

center in Figure 1. Compared with the reference center,
the difference varied from –176 mL to + 1062 mL.
The patients’ characteristics were similar between
the tertiles of centers, except for a lower SAPS II in the
“high-volume” tertile (Table 1). For the four classes
of fluids, the volume significantly increased from the
first to the third tertile (Fig. 2). The difference between
fluid intake predicted by the model and the observed
fluid intake was of 1.2 ± 2.0 L higher in “moderate-vol-
ume” centers (tertile 2) and 3.0 ± 2.8 L higher in “high-
volume” centers (tertile 3) (eTable 5, http://links.lww.
com/CCM/H440).

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Schortgen et al

the dilution of a same dose

of the same drug could
be ten-fold higher from
one center to another.
For instance, the volume
used to administer 4 g of
piperacillin/tazobactam
varied from 20 to 110 mL
and from 10 to 100 mL for
2 g of cefotaxime (eFigs.
3 and 4, http://links.
lww.com/CCM/H440).
Therefore, the volume
used for a 1-day treatment
of a standard dose is ex-
pected to vary from 80 to
Figure 1. Estimates of the difference in fluid intake in each center after adjustment for patients’ 440 mL for piperacillin/
characteristics.
tazobactam and from 30
to 300 mL for cefotaxime.
Volumes related to norep-
inephrine were also highly
variable depending on the
dilution used, from 0.1 to
2 mg/mL, and on vehicle
(i.e., crystalloids infused
at a constant flow up-
stream of the drug infu-
sion site) that was used in
19% of patients distributed
in 12 centers. For a patient
with a weight of 80 kg and
a dose of norepinephrine
of 1 µg/kg/min (i.e., the
mean dose observed in the
cohort), the daily volume
Figure 2. Mean volumes of fluids administered by tertile (T) of centers. related to norepineph-
rine may reach 532 mL if
using a concentration of
The sensitivity analysis performed in the subgroup 0.25 mg/mL and a vehicle at 3 mL/hr (i.e., the mean
of 156 patients with a more similar profile of severe in- rate observed in the cohort).
fection confirmed that the volume of the four classes of
fluids significantly increased from the first to the third
Types of Fluids
tertile (eFig. 2 and eTable 6, http://links.lww.com/
CCM/H440). Saline, glucose + sodium chloride (NaCl) greater
The main sources of fluids used for drug dilution than 6 g/L (i.e., excessive chloride load), and bal-
were related to antibiotics, sedation, vasopressors, and anced crystalloids represented 43%, 25%, and 16% of
analgesics (Table 2). A strong heterogeneity in drug the total volume, respectively (eFig. 5, http://links.
dilutions was observed. The volume administered for lww.com/CCM/H440). Balanced crystalloids were

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predominantly used for fluid resuscitation while saline
and glucose with high NaCl concentration were pre-
dominantly used for rehydration, maintenance fluids,
and drug carriers (eFig. 6, http://links.lww.com/CCM/
H440). Colloids were used in 6% of boluses. Seventy-
three percent of patients with maintenance fluids re-
ceived a hypotonic solution. Mean sodium intake was
14 g over the 24 hours of study period, with the main
source being resuscitation fluids (65%) (eFig. 7, http://
links.lww.com/CCM/H440).
DISCUSSION
This prospective multicenter cohort shows that, all to-
gether, drug carriers, maintenance fluids, and fluids for
technical needs, that is, not indisputably required for
body fluid homeostasis, represent the majority of fluid
intake.
The strongest factor associated with fluid intake cor-
responds to the center of inclusion.
Our study suggests that, when a restrictive fluid
management is indicated, all fluids must be consid-
ered. This finding is in accordance with a prospective
multicenter cohort of 200 ICU patients reporting that
nonresuscitation fluids represented half of total fluids
during the first day (8). After the acute phase of re-
suscitation, nonresuscitation fluids represent a larger
part of all fluids (6, 8, 9). While our study focused on
the first 24 hours, fluid boluses for resuscitation rep-
resented only 14% of total fluids administered. In two
cohort studies performed in a general population of
ICU patients, the proportion of fluid boluses for resus-
citation on day 1 was also limited at 20% (6) and 12%
(8) of the total fluid intake.
We observed that maintenance fluids accounted for
one quarter of fluid intake with heterogeneous prac-
tices probably not explained by patients’ variability
(eFig. 8, http://links.lww.com/CCM/H440). Delivery
of maintenance fluid remains debated and depends on
national and local practices (8, 10, 11). Defining main-
tenance fluids is difficult, particularly in retrospective
studies. A clear definition was used in our study to
make the difference between ordered fluid for expected
insensible fluid losses and fluids given for replacement
of apparent fluid losses. The volume of maintenance
fluid was similar to the sum of the volumes of fluids
administered for drug dilution and for technical need,
that is, 1 L (Table 2) which could provide sufficient
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Clinical Investigation
volume, electrolyte, and glucose to replace expected
daily needs (4).
The second source of fluids not dedicated to body
fluid homeostasis corresponded to drug dilution, with
mean volume of 900 mL. In previous observation, drug
carriers represented one-third to two-thirds of total
IV fluids (6, 8, 12). In our study, antibiotics, sedation,
and vasopressors represented the three main sources
of carriers, as similarly reported in previous observa-
tions (8). The heterogeneity of piperacillin/tazobactam
preparation is a telling example of the issue of accurate
volume for drug dilution. The minimal volume recom-
mended by manufacturers is 20 mL for the reconsti-
tution of 4 g. United States and European summaries
of product characteristics indicate that this solution
“must be” and “may be” further diluted in 50–150 mL,
respectively. Experts recommend a usual dilution of
4 g/50 mL (13). Observed wide ranges of norepineph-
rine dilution are probably also explained by the lack
of data supporting the best practice of vasopressor
infusion. When small doses are infused, dilution is
required to warrant a sufficient speed for constant in-
fusion. The use of vehicle is also advised to decrease
the lag in response time to the change in drug delivery
dose. This practice requires a rate of vehicle between
10 (14) and 350 mL/hr (15) which results in significant
volumes. In addition, the type of norepinephrine prep-
aration and norepinephrine dosage expressions may
impact volume intake (16).
Our results suggest that fluid management should
be more personalized to patient needs. Fluids resus-
citation and maintenance fluids volumes were sim-
ilar regardless of patient weight. Center of inclusion
was the strongest factor associated with fluid in-
take. In “moderate” and “high” volume centers, the
observed volumes were higher than predicted for all
classes of fluids. A post hoc analysis of the 6S study
(Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate
in Severe Sepsis) in septic shock patients also showed
that the country of inclusion and hospital characteris-
tics were significantly associated with total fluid input
(9). When comparing restrictive to standard strategies
of fluid management on outcome, practices already in
place in participating centers can influence the results.
In the CLASSIC study (randomized, parallel-group,
multicentre feasibilty trial on liberal vs restrictive fluid
therapy in septic shock) any advantage of restrictive
management was found in patients with septic shock
www.ccmjournal.org     7
Schortgen et al
(3). A volume difference of 2 L only between the two
arms on day 5 suggests that a restrictive strategy was
already applied in participating centers. In the land-
mark Fluid and Catheter Treatment Trial (FACTT)
showing a beneficial effect of fluid restriction in pa-
tient with ARDS, the between-arms difference in fluid
balance was 7 L (17).
A discrepant choice of crystalloids was observed
between indications (eFigs. 5 and 6, http://links.lww.
com/CCM/H440). While balanced crystalloids were
predominantly used for resuscitation, high-chloride
solutions corresponded to 68% of total volume. It is im-
probable that inconsistent choice of crystalloid accord-
ing to its indication was based on patient needs. This
suggests that physicians overlook crystalloids choice
for other indication than fluid boluses.
Our study has several strengths. The study com-
mittee identified all possible fluids administered to
ICU patients and we precisely defined the indication
of each of them. We provide a detailed fluid map-
ping that is mandatory for practice improvement.
Previous studies used computer software to collect
fluid inputs. Electronic health records do not allow
exhaustive and accurate volume tracing. Fluids for
technical needs are usually not recorded, for ex-
ample, line flushes. Drug dilutions configured by
default in electronic systems are not always used by
nurses and therefore the real volume infused may
not be adequately traced. Previous studies reporting
differences between centers in fluid intake did not
take into account patient characteristics (8). To bet-
ter control the variability related to practices we in-
cluded severe patients only, models were adjusted for
patient characteristics and a sensitive analysis was
performed.
Several limitations of our study must be dis-
cussed. Because of the COVID-19 pandemic in
2020, the minimal number of enrollments per
center was not strictly respected. The relatively
small sample size may limit the strength of our
findings, and therefore need to be validated in other
groups of patients. Despite adjustment and sensi-
tivity analysis, center-effect could be related to the
case mix of patients. More severe patients can need
more fluid resuscitation, more drugs, and more vas-
cular accesses. However, markers of severity and
mortality did not steady increase from the first to
the third tertile of centers. Fluids were recorded for
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1-day only. Because of the workload required for an
exhaustive recording we chose a short study period
to encourage precise recording. All patients were
followed during 24 hours; however, the amount of
resuscitation fluids and drugs could be underes-
timated in patients with delayed enrollment. Our
study was not designed to assess the impact of fluid
balance on outcome. Our study does not answer the
question of what the best practice of fluid manage-
ment is but rather raises questions on the justifica-
tion of observed practices.
CONCLUSIONS
Our study shows that many sources of fluids exist,
nonresuscitation fluids representing the majority of
intake. Alongside patient’s characteristics, center prac-
tices contribute to the difference in volumes infused.
Further studies are required to determine what are the
best practices, especially the possibility to safely banish
nonessential fluids for body homeostasis.
ACKNOWLEDGMENTS
We thank Marwa Touati from the clinical research
center of the Centre Hospitalier Intercommunal de
Créteil for the development of the electronic case re-
port form.
1 Réanimation et surveillance continue adulte, Centre hospit-
alier intercommunal, Créteil, France.
2 Department of Medical Intensive Care, Rouen University
Hospital, Rouen, France.
3 Médecine Intensive Réanimation, Centre hospitalier départe-
mental Vendée, La Roche-sur-Yon, France.
4 Réanimation et Soins continus, Centre Hospitalier, Roanne,
France.
5 Réanimation médico-chirurgicale, Centre Hospitalier de
Versailles, Le Chesnay, France.
6 Réanimation polyvalente, Centre hospitalier, Troyes, France.
7 Médecine Intensive et Réanimation, Groupe Hospitalier
Universitaire APHP-Sorbonne Université, Hôpital Tenon,
Paris, France.
8 Réanimation médicale, Centre Hospitalier Universitaire de
Rennes—Hôpital Pontchaillou, Rennes, France.
9 Intensive Care Unit, Tours University Hospital, Research
Center for Respiratory Diseases, INSERM U1100,
University of Tours, Tours, France.
10 Médecine Intensive—Réanimation, Hôpital de la Croix
Rousse, Hospices Civils de Lyon, Lyon, France.
11 Université Claude Bernard Lyon 1, Lyon, France.
XXX 2023 • Volume 51 • Number 00

12 Université Lyon, INSA-Lyon, Université Claude Bernard
Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294,
Villeurbanne, France.
13 Unité Réanimation Polyvalente, Centre Hospitalier Public du
Cotentin, Cherbourg-en-Cotentin, France.
14 Department of Intensive Care, Burgundy University Hospital,
Dijon, France.
15 Lipness Team, INSERM Research Center LNC-UMR1231
and LabEx LipSTIC, University of Burgundy, Dijon, France.
16 INSERM CIC 1432, Clinical Epidemiology, University of
Burgundy, Dijon, France.
17 Service de Réanimation, Groupe Hospitalier Nord Essonne,
Longjumeau, France.
18 Service de Médecine Intensive—Réanimation et Unité de
Recherche Clinique, Groupe Hospitalier Sud Ile-de-France,
Melun, France.
19 Réanimation des urgences, Hôpitaux universitaires de
Marseille Timone, Marseille, France.
20 Réanimation polyvalente, Centre hospitalier Bretagne
Atlantique, Vannes, France.
21 Service de Réanimation Médico-Chirurgicale et USC,
Centre hospitalier, Le Mans, France.
22 Service de médecine intensive-réanimation, Hôpitaux
Universitaires APHP-Paris-Saclay, Le Kremlin-Bicêtre,
France.
23 Médecine Intensive Réanimation, CHU Grenoble-Alpes, La
Tronche, France.
24 Service de réanimation polyvalente, Hôpital Foch, Suresnes,
France.
25 Service de réanimation polyvalente, Centre hospitalier,
Cholet, France.
26 Service de Médecine Intensive—Réanimation, Groupe
Hospitalier Pitié Salpêtrière APHP—Sorbonne Université,
Paris, France.
27 Réanimation polyvalente, Hôpital d’Instruction des Armées
Robert Picqué, Villenave d’Ornon, France.
28 Réanimation Polyvalente, CHU de La Réunion, Saint Pierre,
France.
29 Intermediate Respiratory Care Unit, University Hospital
Jiménez Díaz Quirón Health Foundation of Madrid, Madrid,
Spain.
30 Réanimation adultes, Centre Hospitalier Sud Francilien,
Corbeil-Essonnes, France.
31 Médecine Intensive Réanimation, Centre hospitalier inter-
communal, Villeneuve St Georges, France.
32 Réanimation—Hôpitaux universitaires, Strasbourg, France.
33 Réanimation polyvalente, Groupe hospitalier nord Dauphiné,
Bourgoin-Jallieu, France.
34 Université Paris Cité, AP-HP, Hôpital européen Georges
Pompidou, Unité de Recherche Clinique, Centre
d’Investigation Clinique 1418 Épidémiologie Clinique,
INSERM, Inria, HeKA, Paris, France.
The Save Useless Fluids For Intensive Resuscitation (SUFFIR)
Study Group members are: Pierre Asfar, Aurélia Papin,
Johann Auchabie, Anne-Lise Berthelot, Pierre-Yves Blanchard,
Critical Care Medicine
Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Clinical Investigation
Frédérique Schortgen, Adrien Constan, Marina Axus, Christophe
Guitton, Aurélie Lejeune, Matthieu Le Meur, Frédérique Partenet,
Jean-Christophe Richard, Laurent Bitker, Emmanuelle Meli, Jean
Dellamonica, Marine Corradi, Isabelle Runge, Aurore Guyat,
Georges Simon, Alexandra Lavalard, Olivier Nida, Guillaume
Lacave, Gwenaëlle Jacq.
The Reseau European de Recherche en Ventilation Artificielle
(REVA) Network is composed of 70 ICUs in France, Belgium,
and Spain (President Pr Alain Mercat).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/ccmjournal).
Mr. Constan, Dr. Schortgen, Ms. Tabra Osorio, Dr. Lacave, Dr.
Simon, Mr. Blanchard, Dr. Bitker, Dr. Le Meur, and Mr. Saletes
were involved in conceptualization. Dr. Schortgen and Ms.
Guénégou-Arnoux were involved in data curation. Ms. Guénégou-
Arnoux was involved in formal analysis. Mr. Constan was in-
volved in funding acquisition. Ms. Tabra Osorio, Dr. Carpentier,
Dr. Henry, Dr. Beuret, Dr. Lacave, Dr. Simon, Mr. Blanchard, Ms.
Gobe, Dr. Guillon, Dr. Bitker, Mr. Duhommet, Dr. Quenot, Dr. Le
Meur, Dr. Jochmans, Mr. Dubouloz, Ms. Mainguy, Mr. Saletes, Mr.
Creutin, Mr. Nicolas, Mr. Senay, Ms. Berthelot, Ms. Rizk, Dr. Tran
Van, Ms. Riviere, Dr. Heili-Frades, Ms. Nunes, Ms. Robquin, Ms.
Lhotellier, and Dr. Ledochowski were involved in investigation.
Ms. Guénégou-Arnoux and Dr. Schortgen were involved in meth-
odology. Mr. Constan was involved in project administration. Mr.
Constan, Dr. Schortgen, and Ms. Tabra Osorio were involved in
resources. Mr. Constan and Dr. Schortgen were involved in super-
vision. Mr. Constan, Dr. Schortgen, and Ms. Guénégou-Arnoux
were involved in validation. Mr. Constan and Dr. Schortgen were
involved in visualization. Mr. Constan and Dr. Schortgen were in-
volved in writing—original draft. Ms. Tabra Osorio, Dr. Carpentier,
Dr. Henry, Dr. Beuret, Dr. Lacave, Dr. Simon, Mr. Blanchard, Ms.
Gobe, Dr. Guillon, Dr. Bitker, Mr. Duhommet, Dr. Quenot, Dr. Le
Meur, Dr. Jochmans, Mr. Dubouloz, Ms. Mainguy, Mr. Saletes, Mr.
Creutin, Mr. Nicolas, Mr. Senay, Ms. Berthelot, Ms. Rizk, Dr. Tran
Van, Ms. Riviere, Dr. Heili-Frades, Ms. Nunes, Ms. Robquin, Ms.
Lhotellier, Dr. Ledochowski, and Ms. Guénégou-Arnoux were in-
volved in writing—review & editing.
Supported, in part, by grant from the French Intensive Care
Society.
Dr. Constan’s institution received funding from the French
Intensive Care Society/Société de Réanimation de Langue
Française. Dr. Senay disclosed work for hire. The remaining
authors have disclosed that they do not have any potential con-
flicts of interest.
For information regarding this article, E-mail: constan.adrien@
gmail.com
The datasets used and/or analyzed during the current study are
available from the corresponding author on reasonable request.
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