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; Quality and Safety
- 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.
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- 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