UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Intraoperative fluid management

Author
Girish P Joshi, MB, BS, MD, FFARCSI
Section Editor
Michael Avidan, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA

INTRODUCTION

Maintenance of intravascular volume is important to achieve optimal perioperative outcomes [1-3]. There are controversies surrounding intraoperative fluid management, with variable recommendations for the composition and volume of fluid administered [4,5]. A probable reason for such variability is that evidence regarding best fluid management with respect to clinically important outcomes is limited and of low quality.

Factors that alter intravascular volume perioperatively, measurement of fluid status in the operating room, and strategies to choose the composition and volume of fluid in the context of surgical losses associated with elective surgical procedures (not trauma or emergent surgery) will be reviewed here.

General issues pertaining to maintenance and replacement fluid and non-operative fluid management are discussed elsewhere. (See "Maintenance and replacement fluid therapy in adults" and "Treatment of severe hypovolemia or hypovolemic shock in adults".)

INTRAOPERATIVE CHANGES IN VOLUME AND TISSUE PERFUSION

Patients undergoing surgery are at risk for either a reduction or an increase in fluid volume, and for a reduction in tissue perfusion. The definitions of these terms will be briefly reviewed in this section, while the clinical determination of volume status is discussed in the following section.

Definitions — There are three terms that need be understood when discussing intraoperative fluid management:

                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Tue Sep 20 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg 2005; 101:601.
  2. Chappell D, Jacob M, Hofmann-Kiefer K, et al. A rational approach to perioperative fluid management. Anesthesiology 2008; 109:723.
  3. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP). London: NHS National Library of Health. http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/british_consensus_guidelines_on_intravenous_fluid_therapy_for_adult_surgical_patients__giftasup__2008 (Accessed on September 18, 2009).
  4. Chawla G, Drummond GB. Textbook coverage of a common topic: fluid management of patients after surgery. Med Educ 2008; 42:613.
  5. Soni N. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP): Cassandra's view. Anaesthesia 2009; 64:235.
  6. Brandstrup B. Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol 2006; 20:265.
  7. Kheterpal S, Tremper KK, Englesbe MJ, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 2007; 107:892.
  8. Chieveley-Williams S, Hamilton-Davies C. The role of the gut in major surgical postoperative morbidity. Int Anesthesiol Clin 1999; 37:81.
  9. Lowell JA, Schifferdecker C, Driscoll DF, et al. Postoperative fluid overload: not a benign problem. Crit Care Med 1990; 18:728.
  10. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89:622.
  11. Arieff AI. Fatal postoperative pulmonary edema: pathogenesis and literature review. Chest 1999; 115:1371.
  12. Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103:25.
  13. Mayberry JC, Welker KJ, Goldman RK, Mullins RJ. Mechanism of acute ascites formation after trauma resuscitation. Arch Surg 2003; 138:773.
  14. Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg 2003; 138:637.
  15. Jacob M, Chappell D, Conzen P, et al. Blood volume is normal after pre-operative overnight fasting. Acta Anaesthesiol Scand 2008; 52:522.
  16. Brauer KI, Svensén C, Hahn RG, et al. Volume kinetic analysis of the distribution of 0.9% saline in conscious versus isoflurane-anesthetized sheep. Anesthesiology 2002; 96:442.
  17. Connolly CM, Kramer GC, Hahn RG, et al. Isoflurane but not mechanical ventilation promotes extravascular fluid accumulation during crystalloid volume loading. Anesthesiology 2003; 98:670.
  18. Jacob M, Chappell D, Rehm M. The 'third space'--fact or fiction? Best Pract Res Clin Anaesthesiol 2009; 23:145.
  19. Lamke LO, Nilsson GE, Reithner HL. Water loss by evaporation from the abdominal cavity during surgery. Acta Chir Scand 1977; 143:279.
  20. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134:172.
  21. Magder S. Fluid status and fluid responsiveness. Curr Opin Crit Care 2010; 16:289.
  22. Cecconi M, Aya HD. Central venous pressure cannot predict fluid-responsiveness. Evid Based Med 2014; 19:63.
  23. Gelman S. Venous function and central venous pressure: a physiologic story. Anesthesiology 2008; 108:735.
  24. Alpert RA, Roizen MF, Hamilton WK, et al. Intraoperative urinary output does not predict postoperative renal function in patients undergoing abdominal aortic revascularization. Surgery 1984; 95:707.
  25. Egal M, Erler NS, de Geus HR, et al. Targeting Oliguria Reversal in Goal-Directed Hemodynamic Management Does Not Reduce Renal Dysfunction in Perioperative and Critically Ill Patients: A Systematic Review and Meta-Analysis. Anesth Analg 2016; 122:173.
  26. Renner J, Scholz J, Bein B. Monitoring fluid therapy. Best Pract Res Clin Anaesthesiol 2009; 23:159.
  27. Knotzer H, Hasibeder WR. Microcirculatory function monitoring at the bedside--a view from the intensive care. Physiol Meas 2007; 28:R65.
  28. Funk DJ, Moretti EW, Gan TJ. Minimally invasive cardiac output monitoring in the perioperative setting. Anesth Analg 2009; 108:887.
  29. Desebbe O, Cannesson M. Using ventilation-induced plethysmographic variations to optimize patient fluid status. Curr Opin Anaesthesiol 2008; 21:772.
  30. Cecconi M, Parsons AK, Rhodes A. What is a fluid challenge? Curr Opin Crit Care 2011; 17:290.
  31. Ansari BM, Zochios V, Falter F, Klein AA. Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review. Anaesthesia 2016; 71:94.
  32. Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2015; 62:169.
  33. Swenson JD, Harkin C, Pace NL, et al. Transesophageal echocardiography: an objective tool in defining maximum ventricular response to intravenous fluid therapy. Anesth Analg 1996; 83:1149.
  34. Renner J, Gruenewald M, Brand P, et al. Global end-diastolic volume as a variable of fluid responsiveness during acute changing loading conditions. J Cardiothorac Vasc Anesth 2007; 21:650.
  35. Tousignant CP, Walsh F, Mazer CD. The use of transesophageal echocardiography for preload assessment in critically ill patients. Anesth Analg 2000; 90:351.
  36. Gutierrez MC, Moore PG, Liu H. Goal-directed therapy in intraoperative fluid and hemodynamic management. J Biomed Res 2013; 27:357.
  37. Reeves ST, Finley AC, Skubas NJ, et al. Special article: basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2013; 117:543.
  38. Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008; 63:44.
  39. Phan TD, Ismail H, Heriot AG, Ho KM. Improving perioperative outcomes: fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. J Am Coll Surg 2008; 207:935.
  40. Bisgaard J, Gilsaa T, Rønholm E, Toft P. Optimising stroke volume and oxygen delivery in abdominal aortic surgery: a randomised controlled trial. Acta Anaesthesiol Scand 2013; 57:178.
  41. Yin JY, Ho KM. Use of plethysmographic variability index derived from the Massimo(®) pulse oximeter to predict fluid or preload responsiveness: a systematic review and meta-analysis. Anaesthesia 2012; 67:777.
  42. Doherty M, Buggy DJ. Intraoperative fluids: how much is too much? Br J Anaesth 2012; 109:69.
  43. Thiele RH, Colquhoun DA, Blum FE, Durieux ME. The ability of anesthesia providers to visually estimate systolic pressure variability using the "eyeball" technique. Anesth Analg 2012; 115:176.
  44. Cannesson M, Le Manach Y, Hofer CK, et al. Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a "gray zone" approach. Anesthesiology 2011; 115:231.
  45. Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 2009; 37:2642.
  46. Yang SY, Shim JK, Song Y, et al. Validation of pulse pressure variation and corrected flow time as predictors of fluid responsiveness in patients in the prone position. Br J Anaesth 2013; 110:713.
  47. Biais M, Bernard O, Ha JC, et al. Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery. Br J Anaesth 2010; 104:407.
  48. Michard F, Biais M. Rational fluid management: dissecting facts from fiction. Br J Anaesth 2012; 108:369.
  49. Lansdorp B, Lemson J, van Putten MJ, et al. Dynamic indices do not predict volume responsiveness in routine clinical practice. Br J Anaesth 2012; 108:395.
  50. Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2015; 28:40.
  51. Cheung AT, Savino JS, Weiss SJ, et al. Echocardiographic and hemodynamic indexes of left ventricular preload in patients with normal and abnormal ventricular function. Anesthesiology 1994; 81:376.
  52. Thys DM, Hillel Z, Goldman ME, et al. A comparison of hemodynamic indices derived by invasive monitoring and two-dimensional echocardiography. Anesthesiology 1987; 67:630.
  53. Ertmer C, Rehberg S, Van Aken H, Westphal M. Relevance of non-albumin colloids in intensive care medicine. Best Pract Res Clin Anaesthesiol 2009; 23:193.
  54. Hahn RG. Volume kinetics for infusion fluids. Anesthesiology 2010; 113:470.
  55. Hiltebrand LB, Kimberger O, Arnberger M, et al. Crystalloids versus colloids for goal-directed fluid therapy in major surgery. Crit Care 2009; 13:R40.
  56. McIlroy DR, Kharasch ED. Acute intravascular volume expansion with rapidly administered crystalloid or colloid in the setting of moderate hypovolemia. Anesth Analg 2003; 96:1572.
  57. Shaw AD, Bagshaw SM, Goldstein SL, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg 2012; 255:821.
  58. Scheingraber S, Rehm M, Sehmisch C, Finsterer U. Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery. Anesthesiology 1999; 90:1265.
  59. Wilkes NJ, Woolf R, Mutch M, et al. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid-base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg 2001; 93:811.
  60. Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 2012; 256:18.
  61. Schäfer M, Von Ungern-Sternberg BS, Wight E, Schneider MC. Isotonic fluid absorption during hysteroscopy resulting in severe hyperchloremic acidosis. Anesthesiology 2005; 103:203.
  62. Gheorghe C, Dadu R, Blot C, et al. Hyperchloremic metabolic acidosis following resuscitation of shock. Chest 2010; 138:1521.
  63. Burdett E, Dushianthan A, Bennett-Guerrero E, et al. Perioperative buffered versus non-buffered fluid administration for surgery in adults. Cochrane Database Syst Rev 2012; 12:CD004089.
  64. Westphal M, James MF, Kozek-Langenecker S, et al. Hydroxyethyl starches: different products--different effects. Anesthesiology 2009; 111:187.
  65. Van Der Linden P, James M, Mythen M, Weiskopf RB. Safety of modern starches used during surgery. Anesth Analg 2013; 116:35.
  66. Gillies MA, Habicher M, Jhanji S, et al. Incidence of postoperative death and acute kidney injury associated with i.v. 6% hydroxyethyl starch use: systematic review and meta-analysis. Br J Anaesth 2014; 112:25.
  67. Dart AB, Mutter TC, Ruth CA, Taback SP. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev 2010; :CD007594.
  68. Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012; 367:1901.
  69. Kozek-Langenecker SA. Effects of hydroxyethyl starch solutions on hemostasis. Anesthesiology 2005; 103:654.
  70. Kozek-Langenecker SA, Jungheinrich C, Sauermann W, Van der Linden P. The effects of hydroxyethyl starch 130/0.4 (6%) on blood loss and use of blood products in major surgery: a pooled analysis of randomized clinical trials. Anesth Analg 2008; 107:382.
  71. Opperer M, Poeran J, Rasul R, et al. Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis. BMJ 2015; 350:h1567.
  72. Thomas-Rueddel DO, Vlasakov V, Reinhart K, et al. Safety of gelatin for volume resuscitation--a systematic review and meta-analysis. Intensive Care Med 2012; 38:1134.
  73. Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 2007; 51:331.
  74. Bundgaard-Nielsen M, Secher NH, Kehlet H. 'Liberal' vs. 'restrictive' perioperative fluid therapy--a critical assessment of the evidence. Acta Anaesthesiol Scand 2009; 53:843.
  75. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011; 112:1392.
  76. Lassen K. Intravenous fluid therapy. Br J Surg 2009; 96:123.
  77. Lobo DN. Fluid overload and surgical outcome: another piece in the jigsaw. Ann Surg 2009; 249:186.
  78. Bellomo R. Noradrenaline: friend or foe? Heart Lung Circ 2003; 12 Suppl 2:S42.
  79. Sear JW. Kidney dysfunction in the postoperative period. Br J Anaesth 2005; 95:20.
  80. Rahbari NN, Zimmermann JB, Schmidt T, et al. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg 2009; 96:331.
  81. Lobo SM, Ronchi LS, Oliveira NE, et al. Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery. Crit Care 2011; 15:R226.
  82. Abraham-Nordling M, Hjern F, Pollack J, et al. Randomized clinical trial of fluid restriction in colorectal surgery. Br J Surg 2012; 99:186.
  83. Corcoran T, Rhodes JE, Clarke S, et al. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg 2012; 114:640.
  84. Wuethrich PY, Burkhard FC, Thalmann GN, et al. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial. Anesthesiology 2014; 120:365.
  85. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2009; 103:637.
  86. Grocott MP, Dushianthan A, Hamilton MA, et al. Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database Syst Rev 2012; 11:CD004082.
  87. Pearse RM, Harrison DA, MacDonald N, et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 2014; 311:2181.
  88. Brandstrup B, Svendsen PE, Rasmussen M, et al. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 2012; 109:191.
  89. Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006; 93:1069.
  90. Yates DR, Davies SJ, Milner HE, Wilson RJ. Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery. Br J Anaesth 2014; 112:281.
  91. Kuper M, Gold SJ, Callow C, et al. Intraoperative fluid management guided by oesophageal Doppler monitoring. BMJ 2011; 342:d3016.
  92. Gurgel ST, do Nascimento P Jr. Maintaining tissue perfusion in high-risk surgical patients: a systematic review of randomized clinical trials. Anesth Analg 2011; 112:1384.
  93. Hartog CS, Kohl M, Reinhart K. A systematic review of third-generation hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed. Anesth Analg 2011; 112:635.
  94. Lambert KG, Wakim JH, Lambert NE. Preoperative fluid bolus and reduction of postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery. AANA J 2009; 77:110.
  95. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85.