Hello, I'm Manu Malbrain, intensivist from Antwerp, Belgium. Today, I spoke about therapeutic conflicts in the ICU. Many critically ill patients develop therapeutic dilemmas—these are not static, but dynamic challenges that evolve over time. In addressing them, we must always prioritize support for the organ most at risk of causing a fatal outcome. To navigate these conflicts, we need clear answers to four essential questions: When should I start giving fluids? Not all patients require fluids. In some cases, the best fluid is the one never given. This phase is about understanding the benefits of fluid administration. When should I stop giving fluids? At some point, ongoing fluid resuscitation becomes harmful. A positive cumulative fluid balance is more than a cosmetic issue—meta-analyses confirm it is an independent predictor of morbidity and mortality. This question relates to the risks of fluid overload. When should I start removing fluids? Not all patients will transition spontaneously from the ebb to the flow phase of shock. Some require active intervention to promote de-resuscitation. This is about the benefits of fluid removal. When should I stop removing fluids? Excessive fluid removal can be just as dangerous. A dry patient can mean a dry liver—potentially leading to fatal consequences. This question centers on the risks of overzealous fluid removal. Ultimately, it's not just about choosing the right fluid for the right patient, but also delivering it in the right way and at the right time—using the appropriate monitoring tools tailored to the specific clinical situation. As we continue to push the boundaries of critical care, we must not lose sight of the microcirculation, which plays a crucial role in patient outcomes. That was the essence of my talk.

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