Overview of postoperative fluid therapy in adults
- Nicole Siparsky, MD, FACS
Nicole Siparsky, MD, FACS
- Assistant Professor of Surgery
- Rush Medical College
- Section Editors
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles
- Professor of Surgery
- SIU School of Medicine
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor of Medicine
- University of Rochester School of Medicine and Dentistry
The management of fluid in the postoperative surgical patient can vary from simple to complex.
Postoperative intravenous maintenance fluid therapy ensures adequate organ perfusion, prevents catabolism, ensures electrolyte- and pH-balance, and may be all that is required for patients who undergo surgical procedures that do not significantly alter the hemodynamic milieu. Typically, such procedures are associated with a small volume of blood loss (<250 mL), a short course of anesthesia (<3 hours), a small volume of intravenous fluid administration during surgery (<30 mL/kg), and little to no extravascular fluid shift in patients without significant organ dysfunction.
However, in many cases, postoperative patients with extensive traumatic or surgical tissue injury, burns, critical illness, or sepsis will require replacement fluid therapy in addition to maintenance therapy to compensate for preoperative and intraoperative losses, the stress response to surgery, the underlying disease state, ongoing gastrointestinal fluid loss, blood loss, and other bodily fluid loss. Such complex fluid management is often needed for patients who undergo surgical procedures that result in significant blood loss (>500 mL or 7 mL/kg) , hemodynamic instability, anesthesia time >3 hours, large-volume intravenous fluid administration (>30 mL/kg), fluid shifting out of the vascular space ("third-spacing"), and major organ dysfunction.
The prescription of maintenance and replacement fluids in postoperative surgical patients is reviewed here. The management of electrolyte abnormalities and nutritional support in the perioperative period are reviewed separately. (See "Overview of postoperative electrolyte abnormalities" and "Overview of perioperative nutritional support" and "Postoperative parenteral nutrition".)
PHYSIOLOGIC STRESS RESPONSE TO SURGERY
The stress response to traumatic or surgical tissue injury is a primal collection of biochemical pathways designed to facilitate survival following a major insult. The "fight or flight" response promotes expansion of the blood volume, glucose availability, perfusion of vital organs, and inflammation. This stress response is triggered by entry into a major body cavity (ie, chest, abdomen, joint, cranium), significant tissue disruption (eg, severe burn wounds, long bone fracture, penetrating gunshot wound, pancreatitis), significant blood loss (>500 mL or 7 mL/kg), and hemodynamic instability. Similarly, infection, such as abscess formation or sepsis, will also stimulate a stress response.
- Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005; 3:692.
- Kraft F, Schmidt C, Van Aken H, Zarbock A. Inflammatory response and extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:113.
- Markanday A. Acute Phase Reactants in Infections: Evidence-Based Review and a Guide for Clinicians. Open Forum Infect Dis 2015; 2:ofv098.
- Finnerty CC, Mabvuure NT, Ali A, et al. The surgically induced stress response. JPEN J Parenter Enteral Nutr 2013; 37:21S.
- Eng OS, Melstrom LG, Carpizo DR. The relationship of perioperative fluid administration to outcomes in colorectal and pancreatic surgery: a review of the literature. J Surg Oncol 2015; 111:472.
- Barmparas G, Liou D, Lee D, et al. Impact of positive fluid balance on critically ill surgical patients: a prospective observational study. J Crit Care 2014; 29:936.
- Elofson KA, Eiferman DS, Porter K, Murphy CV. Impact of late fluid balance on clinical outcomes in the critically ill surgical and trauma population. J Crit Care 2015; 30:1338.
- Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:801.
- Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth 2015; 62:158.
- Strunden MS, Heckel K, Goetz AE, Reuter DA. Perioperative fluid and volume management: physiological basis, tools and strategies. Ann Intensive Care 2011; 1:2.
- Hunsicker O, Fotopoulou C, Pietzner K, et al. Hemodynamic Consequences of Malignant Ascites in Epithelial Ovarian Cancer Surgery*: A Prospective Substudy of a Randomized Controlled Trial. Medicine (Baltimore) 2015; 94:e2108.
- Rizoli S. PlasmaLyte. J Trauma 2011; 70:S17.
- Lorenzo M, Davis JW, Negin S, et al. Can Ringer's lactate be used safely with blood transfusions? Am J Surg 1998; 175:308.
- Besen BA, Gobatto AL, Melro LM, et al. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116.
- Severs D, Hoorn EJ, Rookmaaker MB. A critical appraisal of intravenous fluids: from the physiological basis to clinical evidence. Nephrol Dial Transplant 2015; 30:178.
- Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308:1566.
- Annane D, Siami S, Jaber S, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 2013; 310:1809.
- Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med 2014; 370:1412.
- Schortgen F, Girou E, Deye N, et al. The risk associated with hyperoncotic colloids in patients with shock. Intensive Care Med 2008; 34:2157.
- Cooper DJ, Myburgh J, Heritier S, et al. Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality? J Neurotrauma 2013; 30:512.
- Bunn F, Trivedi D. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 2012; :CD001319.
- Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37:3124.
- Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015; 313:471.
- Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340:409.
- Theusinger OM, Spahn DR. Perioperative blood conservation strategies for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30:41.
- Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165.
- Clevenger B, Mallett SV, Klein AA, Richards T. Patient blood management to reduce surgical risk. Br J Surg 2015; 102:1325.
- Duus N, Shogilev DJ, Skibsted S, et al. The reliability and validity of passive leg raise and fluid bolus to assess fluid responsiveness in spontaneously breathing emergency department patients. J Crit Care 2015; 30:217.e1.
- Piper GL, Kaplan LJ. Fluid and electrolyte management for the surgical patient. Surg Clin North Am 2012; 92:189.
- Meyer ZC, Schreinemakers JM, Mulder PG, et al. Determining the clinical value of lactate in surgical patients on the intensive care unit. J Surg Res 2013; 183:814.
- Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med 2005; 45:524.
- 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.
- Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41:1774.
- Tisherman SA, Barie P, Bokhari F, et al. Clinical practice guideline: endpoints of resuscitation. J Trauma 2004; 57:898.
- Tseng GS, Wall MH. Endpoints of resuscitation: what are they anyway? Semin Cardiothorac Vasc Anesth 2014; 18:352.
- Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368.
- Charbonneau H, Riu B, Faron M, et al. Predicting preload responsiveness using simultaneous recordings of inferior and superior vena cavae diameters. Crit Care 2014; 18:473.
- Guarracino F, Ferro B, Forfori F, et al. Jugular vein distensibility predicts fluid responsiveness in septic patients. Crit Care 2014; 18:647.
- Barmparas G, Ko A, Harada MY, et al. Decreasing maintenance fluids in normotensive trauma patients may reduce intensive care unit stay and ventilator days. J Crit Care 2016; 31:201.
- Duncan AE. Hyperglycemia and perioperative glucose management. Curr Pharm Des 2012; 18:6195.
- PHYSIOLOGIC STRESS RESPONSE TO SURGERY
- Hormonal mediators
- FLUID LOSSES ASSOCIATED WITH SURGERY
- Insensible losses
- FLUID RESUSCITATION
- Estimate the fluid deficit
- Measure ongoing fluid losses
- Volume of replacement fluid
- Replacement fluids
- Fluid bolus administration
- Endpoints of fluid resuscitation
- MAINTENANCE FLUID THERAPY
- Daily fluid requirements
- Fluid selection and rate
- Monitoring and adjustments
- SUMMARY AND RECOMMENDATIONS