ROSE Concept

Introduction And Pathophysiological Rationale

The ROSE Concept (Resuscitation–Optimization–Stabilization–Evacuation) represents a major paradigm shift in dynamic fluid stewardship for critically ill children.
Traditional liberal fluid resuscitation frequently leads to Fluid Overload (FO), characterized by a cumulative fluid accumulation exceeding 10–15% of body weight.
Severe FO triggers Global Increased Permeability Syndrome (GIPS), causing profound organ and peripheral edema, which directly correlates with prolonged mechanical ventilation, progression of Acute Kidney Injury (AKI), and increased mortality in pediatric sepsis and Pediatric Acute Respiratory Distress Syndrome (PARDS).
Pediatric patients are particularly vulnerable to FO due to a higher percentage of total body water, immature renal function, and profound sepsis-driven capillary leak.

Phase	Timeframe	Clinical Strategy And Interventions
Resuscitation	Minutes to Hours	Rapid administration of 10–20 mL/kg balanced crystalloids to restore perfusion, strictly guided by fluid responsiveness.
Optimization	Hours	Continuous reassessment of fluid responsiveness utilizing Point-Of-Care Ultrasound (POCUS), passive leg raises, and stroke volume variation to actively titrate fluids and prevent excess accumulation.
Stabilization	Hours to Days	Strict restriction of maintenance intravenous fluids and prioritization of enteral nutrition support to halt ongoing fluid accumulation.
Evacuation	Days to Weeks	Active de-resuscitation triggered once the child is hemodynamically stable. Achieved via pharmacological diuresis or hybrid Renal Replacement Therapy (e.g., Sustained Low-Efficiency Diafiltration [SLED]) to achieve a negative fluid balance.

The 2026 prospective study by dos Santos Gomes et al. validated the ROSE framework in pediatric critical care, proving it successfully controlled fluid accumulation percentage in 80–85% of cases.
Adherence to the ROSE protocol directly correlates with significantly reduced organ dysfunction, shorter Pediatric Intensive Care Unit (PICU) length of stay, and improved oxygenation in PARDS registries.
Real-world cohorts in low- and middle-income countries utilizing bedside POCUS and lactate trends demonstrated a 20–30% lower incidence of FO compared to legacy liberal fluid strategies.

Surviving Sepsis Campaign (SSC) 2026: Explicitly integrates the phased ROSE approach into fluid therapy recommendations for Phoenix-defined sepsis and septic shock, issuing conditional recommendations for balanced crystalloids and early de-resuscitation.
PALICC-2 Guidelines: Indirectly supports the ROSE framework by emphasizing strict fluid restriction in PARDS to minimize pulmonary edema.
Indian Academy Of Pediatrics (IAP): Endorses the ROSE framework within Indian pediatric modules, actively promoting resource-limited setting adaptations such as utilizing clinical signs and bedside POCUS when advanced hemodynamic monitors are unavailable.
MoHFW And ICMR STWs (2025): The Indian Council of Medical Research Standard Treatment Workflows incorporate ROSE principles into standardized pediatric sepsis and AKI bundles, advocating for SLED during the evacuation phase to manage severe FO in public PICUs.