There are only four major indications for fluid administration in the critically ill: resuscitation, maintenance, replacement and nutrition (enteral or parenteral). In this review, a conceptual framework is presented looking at fluids as drugs by taking into account the four D’s (drug selection, dose, duration and de-escalation) and the four phases of fluid therapy within the ROSE concept (resuscitation, optimization, stabilization and evacuation). The four hits model is presented herein. This will provide answers to the four basic questions surrounding fluid therapy: When to start IV fluids? When to stop fluid administration? When to start fluid removal and finally When to stop fluid removal? In analogy to the way we deal with antibiotics in critically ill patients, it is time for fluid stewardship.

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