4Fluid therapy for the surgical patient
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
References (132)
- et al.
Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial
Lancet
(2002) Fatal postoperative pulmonary edema. Pathogenesis and literature review
Chest
(1999)- et al.
Preoperative oral carbohydrates and postoperative insulinresistance
Clin Nutr
(1999) Effect of bowel exposure on body temperature during surgical operations
Am J Surg
(1971)- et al.
Blood volume and body fluid compartment changes soon after closed and open intracardiac surgery
Thorac Cardiovasc Surg
(1966) - et al.
The effects of haemorrhage and hormones on the partition of body water II. The effects of acute single and multiple haemorrhage and adrenal corticosteroids in the dog
J Surg Res
(1963) - et al.
Volume preloading is not essential to prevent spinal-induced hypotension at Caesarean section
Br J Anaesth
(1995) - et al.
Randomized study of intravenous fluid preload before epidural analgesia during labour
Br J Anaesth
(2000) - et al.
Rapid saline infusion produces hyperchloraemic acidosis in patients undergoing gynaecologic surgery
Anesthesiology
(1999) - et al.
Cause of metabolic acidosis in prolonged surgery
Crit Care Med
(1999)
Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline
Anesthesiology
Some aspects of pulmonary function after rapid saline infusion in healthy subjects
Clin Sci Mol Med
Physiologic effects of intravenous fluid administration in healthy volunteers
Anesth Analg
Effect of intraoperative fluid management on outcome after intra-abdominal surgery
Anesthesiology
Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery
Anesth Analg
Pulmonary edema in the operative and postoperative period: a review of 40 cases
Ann Surg
Pulmonary edema during volume infusion
Circulation
The danish study group on perioperative fluid therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens. A randomized assessor blinded multi centre trial
Ann Surg
The clinical syndrome
J Trauma
Post resuscitative blood volumes in combat casualties
Surg Gynecol Obstet
Pulmonary edema during fluid infusion in the absence of heart failure
J Am Med Assoc
Preoperative and intraoperative predictors of postoperative morbidity, poor graft function, and early rejection in 190 patients undergoing liver transplantation
Arch Surg
Pulmonary risk factors of elective abdominal aortic surgery
J Vasc Surg
Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance
Eur J Anaesth
Elective pneumonectomy: factors associated with morbidity and operative mortality
Ann Thorac Surg
Postoperative fluid overload: not a benign problem
Crit Care Med
Electric impedance for evaluation of body fluid balance in cardiac surgical patients
J Cardiothorac Vasc Anesth
Physiologic variables and fluid resuscitation in the postoperative intensive care unit patient
Crit Care Med
Perioperativ væskebehandling en kvalitetsundersøgelse
Ugeskr Laeger
Insensible perspiration during anaesthesia and surgery
Acta Anaesthesiol Scand
Glucose infusion in stead of preoperative fasting reduces postoperative insulin resistance
J Am Coll Surg
Perioperative oral carbohydrate improve well being after elektive colorectal surgery
Clin Nutr
Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery
Acta Anaesthesiol Scand
Intravenous fluid load and recovery. A double-blind comparison in gynaecological patients who had day-case laparoscopy
Anaesthesia
Intravenous fluid loading with or without supplementary dextrose does not prevent nausea, vomiting and pain after laparoscopy
Can J Anaesth
Intraoperative urinary output does not predict postoperative renal function in patients undergoing abdominal aortic revascularization
Surgery
Intravenous fluid administration and urine output during radical neck surgery
Head Neck
Water loss by evaporation from the abdominal cavity during surgery
Acta Chir Scand
Fluid resuscitation following injury: rationale for the use of balanced salt solutions
Crit Care Med
Extracellular fluid volume expansion and third space sequestration at the site of small bowel anastomosis
Br J Surg
Fluid and electrolyte physiology
Distributional changes in extra cellular fluid during acute hemorrhagic shock
Surg Forum
Acute changes in extracellular fluids associated with major surgical procedures
Ann Surg
Salt administration during surgery
Surg Forum
Effects of temporary cardiopulmonary bypass on extracellular fluid volume and total body water in man
Circulation
Extracellular fluid volume changes following major surgery
Br J Surg
The effect of trauma on extracellular water volume
Arch Surg
Changes of the apparent 3HOH, 82Br, 125I human albumin and 51Cr red blood cell dilution volumes before, during and after operation in human subjects
Ann Surg
Cited by (177)
Eliminating the need for preoperative intravenous hyperhydration: Sodium thiosulfate as nephrotoxicity prevention in HIPEC-treated patients – A retrospective analysis
2024, European Journal of Surgical OncologyPerioperative Fluid Management
2023, Anesthesiology ClinicsPerioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)
2022, Journal of Gynecology Obstetrics and Human ReproductionAssociation between perioperative fluid management and patient outcomes: a multicentre retrospective study
2021, British Journal of AnaesthesiaCitation Excerpt :Furthermore, with the evolution of noncardiac surgical and fluid management protocols over time, our study provides insights into the latest practices by analysing data from recent years. Both hypervolaemia and hypovolaemia are detrimental to patients' health.7–10 The optimal fluid volumes required to reduce fluid-related complications have remained elusive.
Multimodal rehabilitation: Pre- and intraoperative optimization in CRC surgery
2021, Foundations of Colorectal Cancer