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State-of-the-art fluid management in the operating room

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The underlying principles guiding fluid management in any setting are very simple: maintain central euvolemia, and avoid salt and water excess. However, these principles are frequently easier to state than to achieve. Evidence from recent literature suggests that avoidance of fluid excess is important, with excessive crystalloid use leading to perioperative weight gain and an increase in complications. A zero-balance approach aimed at avoiding fluid excess is recommended for all patients. For major surgery, there is a sizeable body of evidence that an individualized goal-directed fluid therapy (GDFT) improves outcomes. However, within an Enhanced Recovery program only a few studies have been published, yet so far GDFT has not achieved the same benefit. Balanced crystalloids are recommended for most patients. The use of colloids remains controversial; however, current evidence suggests they can be beneficial in intraoperative patients with objective evidence of hypovolemia.

Section snippets

Zero-balance approach to fluid therapy

A number of studies in the literature have examined whether a “restrictive” fluid regimen is associated with fewer complications then a “liberal” fluid regimen. However, the terminology is confusing with widespread variation between studies in fluid regimens making interpretation difficult [11]. The term “restriction” is commonly interpreted to imply hypovolemia, whereas it may simply represent avoidance of the fluid excess seen in the “liberal” group.

One of the most well-known and frequently

Individualized GDFT

Goal-directed therapy (GDT) is a term that has been used for nearly 30 years to describe methods of optimizing fluid and hemodynamic status to improve outcome for high-risk surgical patients. However, the terminology used in the literature is inconsistent and confusing [16]. The term was first used to describe early oxygen-targeted GDT in the 1980s and the 1990s that used the pulmonary artery catheter (PAC) to augment oxygen delivery to supranormal levels in high-risk surgical patients. More

Does GDFT improve outcomes?

There are a number of technologies that can be used for GDFT. The most widely studied is the esophageal Doppler monitor (EDM, Deltex Medical, Chichester, UK). The Doppler probe is placed in the esophagus and focused at the descending thoracic aorta, where it uses the Doppler principle to measure blood flow velocity and produce a waveform for velocity versus time. This velocity–time integral (area under the velocity vs. time curve) is then converted to SV using a nomogram of height, weight, and

Recent studies of GDFT within an Enhanced Recovery program

In the past few years, a number of studies have examined the use of the GDFT with the EDM within Enhanced Recovery After Surgery (ERAS) programs. ERAS programs comprise a range of therapeutic options designed to minimize the stress response to surgery and improve recovery (Table 2).

ERAS programs are becoming the standard of care for colorectal surgery, and are increasingly being applied to other surgeries. A meta-analysis has showed that ERAS programs reduced LOS for colorectal surgery by 2.5

Which fluid should one use?

An electrolyte-balanced crystalloid such as Lactated Ringers (LR), Plasma-Lyte™, or Normosol™ should be used to meet maintenance requirements. The recommended rate for a background infusion to replace insensible losses and urine output is in the range 1–3 ml/kg/h based on lean body weight [14]. However, 0.9% NS is still the most commonly used crystalloid in the world [53]. NS is not “normal” as it contains supraphysiologic levels of sodium and chloride (NS contains 154 mmol/l of chloride, which

What about minor surgery?

In patients undergoing minor or ambulatory surgery, a relatively generous crystalloid regimen has been shown to improve outcomes such as pain, nausea, and dizziness, and facilitate earlier discharge [74], [75], [76]. Although these studies were performed in the era when prolonged fasting was still the norm, there may be limited harm in infusing 1.5–2 l of balanced crystalloid in most of these patients and possible benefit. Most patients undergoing ambulatory surgery will not have a

Conclusion

Perioperative fluid management is important. There is an increasing body of literature suggesting that both hypovolemia and fluid excess are associated with harm. All patients should therefore have an individualized plan for fluid management and appropriate hemodynamic monitoring. GDFT should be considered based on surgical complexity and patient risk factors.

Practice points

  • •

    Every patient undergoing surgery should have an individualized fluid management plan.

  • •

    A zero-balance approach aimed at

Conflict of interest statement

Miller: Honoraria – Edwards Lifesciences.

Raghunathan: Research Support – Baxter.

Gan: Honoraria – Baxter, Edwards Lifesciences, Hospira, Merck. Research support – Covidien, Fresenius, Merck, Pacira, and Premier.

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