Choice of resuscitation fluids in critically ill adults: key messages from the European Society of Intensive Care Medicine 2024 clinical practice guidelines

The 2024 European Society of Intensive Care Medicine clinical practice guidelines provide clinicians with evidence‑based recommendations on intravenous fluids in critically ill adults across a range of common conditions. These guidelines aim to improve the practices of fluid therapy by adopting a global perspective that considers both clinical efficacy and resource utilization in diverse health care settings. The guidelines address 3 key areas: 1) albumin vs crystalloids, 2) balanced crystalloids vs isotonic saline, and 3) small‑volume hypertonic solutions vs isotonic crystalloids. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach, ensuring a rigorous and transparent evaluation of the evidence across critical outcomes. Albumin was generally not favored over crystalloids due to its lack of demonstrated mortality benefit, higher cost, and limited availability in resource‑limited settings. Balanced crystalloids were suggested over isotonic saline in most scenarios due to their potential to reduce mortality and mitigate harmful effects of hyperchloremia, although the certainty of evidence was low. Small‑volume hypertonic solutions were not shown to provide significant advantages over isotonic crystalloids, leading to a preference for the latter based on a very low certainty of evidence. This work provides an overview of the guideline development process and a detailed summary of their recommendations, highlighting key considerations for clinical practice. The guidelines also identify critical evidence gaps in fluid therapy research, underscoring the need for future studies to refine and optimize fluid management strategies in critically ill patients.