Inflammatory Stewardship-A Perspective for Active Management of Acute Inflammation

Major surgery and traumatic injury are potent triggers of systemic inflammation. While appropriately regulated inflammation supports host defense and tissue repair, dysregulated and time-dependent inflammatory trajectories contribute to postoperative and post-traumatic complications, organ dysfunction, prolonged disability, and mortality. Translation of mechanistic insight into effective bedside strategies has been limited by marked inter-individual heterogeneity, rapid phase shifts in the inflammatory response, and the absence of operational workflows that measure inflammation with sufficient biological and temporal resolution to guide patient-specific decisions. This perspective introduces 'inflammatory stewardship' as a precision-medicine paradigm for proactive management of acute inflammation in perioperative and critical care settings. Inflammatory stewardship integrates two core components: inflammatory staging and biomarker-guided immunomodulation. Inflammatory staging uses serial, multidimensional monitoring to characterize trajectories and to determine whether a patient's current inflammatory status lies within an individualized target range. Monitoring may combine routinely available clinical parameters with more specific immune phenotyping, functional assays, and molecular signatures, provided that assays are standardized, clinically interpretable, and available within actionable turnaround times. Biomarker-guided immunomodulation then links off-target trajectories to patient-specific escalation or de-escalation strategies, supported by predefined safety criteria and interdisciplinary governance. This perspective outlines key implementation requirements and a research agenda to establish reference trajectories, validate actionable endotypes, and embed biomarkers into adaptive interventional study designs. Inflammatory stewardship offers a testable roadmap to operationalize personalized inflammation management after surgery and trauma, aiming to enable earlier detection of maladaptive trajectories and more effective, patient-tailored immunomodulatory care in intensive care.