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Fluid therapy for the surgical patient

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Abstract

Perioperative fluid therapy is the subject of much controversy, and the results of the clinical trials investigating the effect of fluid therapy on outcome of surgery seem contradictory.The aim of this chapter is to review the evidence behind current standard fluid therapy, and to critically analyse the trials examining the effect of fluid therapy on outcome of surgery. The following conclusions are reached: current standard fluid therapy is not at all evidence-based; the evaporative loss from the abdominal cavity is highly overestimated; the non-anatomical third space loss is based on flawed methodology and most probably does not exist; the fluid volume accumulated in traumatized tissue is very small; and volume preloading of neuroaxial blockade is not effective and may cause postoperative fluid overload. The trials of ‘goal-directed fluid therapy’ aiming at maximal stroke volume and the trials of ‘restricted intravenous fluid therapy’ are also critically evaluated. The difference in results may be caused by a lax attitude towards ‘standard fluid therapy’ in the trials of goal-directed fluid therapy, resulting in the testing of various ‘standard fluid regimens’ versus ‘even more fluid’. Without evidence of the existence of a non-anatomical third space loss and ineffectiveness of preloading of neuroaxial blockade, ‘restricted intravenous fluid therapy’ is not ‘restricted’, but rather avoids fluid overload by replacing only the fluid actually lost during surgery. The trials of different fluid volumes administered during outpatient surgery confirm that replacement of fluid lost improves outcome. Based on current evidence, the principles of ‘restricted intravenous fluid therapy’ are recommended: fluid lost should be replaced and fluid overload should be avoided.

Section snippets

Current fluid therapy in major surgery: evidence and implications

Standard fluid therapy includes replacement of fluid lost (by basal fluid requirements, perspiration through the surgical wound, loss to the third space, and blood loss and exudation through the surgical wound) and maintenance of physiological functions (‘preloading’ of neuroaxial blockade).

It is generally agreed that fluid lost by the basal fluid requirements, perspiration through the surgical wound, blood loss, and exudation should be replaced. Any disagreement regarding these losses is about

Trials of goal-directed fluid regimens (standard fluid versus extra fluid)

The trials of goal-directed therapy fall into two categories: trials of fluid loading alone, and trials investigating the effect of fluid therapy in addition to different medications.

Six trials were found examining the effect of fluid therapy alone.105, 106, 107, 108, 109, 110 The trials of good methodological quality (see below) are shown in Table 1. The goal of the fluid therapy was to obtain a maximal stroke volume (SV) output determined by oesophageal Doppler or a target CVP, from the

Trials of an optimization programme with fluid and additional drugs

Eleven trials were found which tested ‘standard fluid therapy’ versus ‘extra fluid, inotropic, and other-drug therapy’.113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123 Even though fluid therapy was the first treatment of choice, the fluid volume administered is described in only four trials.113, 115, 116, 122

In the trial by Wilson and colleagues122, 138 patients undergoing major abdominal surgery were randomised into three groups. The two intervention groups received preoperative

Trials on restricted intravenous fluid therapy

As discussed above, current standard fluid therapy is not at all evidence-based; the existence of a non-anatomical third space loss is not convincing, and no effect of the preloading of the neuroaxial blockade has been shown. The postoperative weight gain of 3–7 kg in patients undergoing major elective surgery therefore seems to represent a genuine fluid overload. For a thorough review of the physiological (adverse) effects of fluid overload see Holte et al.125

We therefore designed a clinical

Trials of outpatient surgery

Nine randomised trials were found testing different intravenous fluid volumes on outcome of outpatient surgery (see Table 2).31, 32, 127, 128, 129, 130, 131, 132, 133 The outcome assessed included thirst, dizziness, drowsiness, well-being, and for some of the trials nausea, vomiting and overnight stay in hospital. Intravenous fluid was found to improve self-reported drowsiness and dizziness in seven of the trials31, 127, 128, 129, 130, 131, 133, and in three of the trials postoperative nausea

Recommendations

With no evidence of the existence of a non-anatomical third space loss and no effect of fluid preloading of neuroaxial blockade, the ‘restricted intravenous fluid therapy’ is not at all ‘restricted’, but based on current evidence. The principle is that loss should be replaced, but fluid overload (recognized as a postoperative body weight gain) should be avoided.

This principle should be continued postoperatively (in the recovery room and in the surgical ward), with replacement of the daily

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