Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach?

Giorgio Della Rocca, Luigi Vetrugno, Gabriella Tripi, Cristian Deana, Federico Barbariol, Livia Pompei, Giorgio Della Rocca, Luigi Vetrugno, Gabriella Tripi, Cristian Deana, Federico Barbariol, Livia Pompei

Abstract

Background: Fluid management in the perioperative period has been extensively studied but, despite that, "the right amount" still remains uncertain. The purpose of this paper is to summarize the state of the art of intraoperative fluid approach today.

Discussion: In the current medical literature there are only heterogeneous viewpoints that gives the idea of how confusing the situation is. The approach to the intraoperative fluid management is complex and it should be based on human physiology and the current evidence.

Summary: An intraoperative restrictive fluid approach in major surgery may be beneficial while Goal-directed Therapy should be superior to the liberal fluid strategy. Finally, we propose a rational approach currently used at our institution.

Keywords: Colloid versus crystalloid; Fluid management; Intraoperative fluid; Liberal versus restricted.

Figures

Figure 1
Figure 1
Patient monitoring. Hemodynamic monitoring need to be considered on the basis of patient risk, surgical type and time.
Figure 2
Figure 2
Perioperative fluid therapy. Intraoperative fluid therapy must take into account patient risk and type of surgery.
Figure 3
Figure 3
Fluid flow-chart. The steps reported represent a rational approach to fluid management in ASA I-III patients.

References

    1. Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg. 2009;96:331–341.
    1. Lamke LO, Nilsson GE, Reithner HL. Water loss by evaporation from the abdominal cavity during surgery. Acta Chir Scand. 1977;143:279–284.
    1. Holte K, Kristensen BB, Valentiner L, Foss NB, Husted H, Kehlet H. Liberal vs restricted fluid management in knee arthroplasty: a randomized, double blind study. Anesth Analg. 2007;105:465–474.
    1. Holte K, Foss NB, Andersen J, Valentiner L, Lund C, Bie P, Kehlet H. Liberal or restricted fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth. 2007;99:500–508.
    1. Abraham-Nordling M, Hjern F, Pollack J, Prytz M, Borg T, Kressner U. Randomized clinical trial of fluid restriction in colorectal surgery. Br J Surg. 2012;99:186–191.
    1. Lobo SM, Ronchi LS, Oliveira NE, Brandão PG, Froes A, Cunrath GS, Nishiyama KG, Netinho JG, Lobo FR. Restrictive strategy of intraoperative fluid maintenance during optimization of oxygen delivery decreases major complications after high-risk surgery. Crit Care. 2011;15(5):R226.
    1. Bruegger D, Jacob M, Rehm M, Loetsch M, Welsch U, Conzen P, Becker BF. Atrial natriuretic peptide induces shedding of endothelial glycocalyx in coronary vascular bed of guinea pig hearts. Am J Physiol Heart Circ Physiol. 2005;289(5):H1933–H1939.
    1. Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology. 2008;109(4):723–740.
    1. Liu B, Finfer S. Intravenous fluids in adults undergoing surgery. Br Med J. 2009;339:3–4.
    1. Handy JM, Soni N. Physiological effects of hyperchloraemia and acidosis. Br J Anaesth. 2008;101(2):141–150.
    1. Guidet B, Soni N, Della Rocca G, Kozek S, Vallet B, Annane D, James M. A balanced view of balanced solutions. Crit Care. 2010;14(5):325.
    1. Soni N. British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) Anaesthesia. 2009;64(3):235–238.
    1. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, Glass P, Lipman J, Liu B, McArthur C, McGuinness S, Rajbhandari D, Taylor CB, Webb SA. Hydroxyethyl starch or saline for fluid resuscitation in intensive care (CHEST trial) N Engl J Med. 2012;367(20):1901–1911.
    1. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Aneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP. et al.Hydroxyethyl starch 130/0.42 versus ringer’s acetate in severe sepsis (6S trial) N Engl J Med. 2012;367(2):124–134.
    1. Guidet B, Martinet O, Boulain T, Philippart F, Poussel JF, Maizel J, Forceville X, Feissel M, Hasselmann M, Heininger A, Van Aken H. Assessment of hemodynamic efficacy and safety of 6% hydroxyethylstarch 130/0.4 vs 0.9% NaCl fluid replacement in patients with severe sepsis: the CRYSTMAS study. Crit Care. 2012;16(3):R94.
    1. Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declère AD, Preiser JC, Outin H, Troché G, Charpentier C, Trouillet JL, Kimmoun A, Forceville X, Darmon M, Lesur O, Reignier J, Abroug F, Berger P, Clec'h C, Cousson J, Thibault L, Chevret S. CRISTAL Investigators. Effects of fluid resuscitation with colloids vs. crystalloids onmortality in critically ill patients presenting with hypovolemic shock. The CRISTAL randomized trial. JAMA. 2013;310(17):1809–1817.
    1. Meybohm P, Aken HV, Gasperi AD, Hert SD, Rocca GD, Girbes AR, Gombotz H, Guidet B, Hasibeder W, Hollmann MW, Ince C, Jacob M, Kranke P, Kozek-Langenecker S, Loer SA, Martin C, Siegemund M, Wunder C, Zacharowski K. Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement. Crit Care. 2013;17(4):R166.
    1. Marechal X, Favory R, Joulin O, Montaigne D, Hassoun S, Decoster B, Zerimech F, Neviere R. Endothelial glycocalyx damage during endotoxiemia coincides with microcirculatory dysfunction and vascular oxidative stress. Shock. 2008;29:572–576.
    1. Steppan J, Hofer S, Funke B, Brenner T, Henrich M, Martin E, Weitz J, Hofmann U, Weigand MA. Sepsis and major abdominal surgery lead to flaking of the endothelial glycocalyx. J Surg Res. 2011;165(1):136–141.
    1. Bansch P, Nelson A, Ohlsson T, Bentzer P. Effect of charge on micorvascular permeability in early experimental sepsis in the rat. Microvasc Res. 2011;82(3):339–345.
    1. Singer M. Management of fluid balance: a European perspective. Curr Opin Anaesthesiol. 2012;25(1):96–101.
    1. Jungheinrich C, Neff TA. Pharmacokinetics of hydroxyethylstarch. Clin Pharmacokinet. 2005;44(7):681–699.
    1. Westphal M, James MF, Kozek-Langenecker S, Stocker R, Guidet B, Van Aken H. Hydroxyethyl starches: different products – different effects. Anesthesiology. 2009;111(1):187–202.
    1. Endo A, Uchino S, Iwai K, Saito K, Sanui M, Takinami M, Uezono S. Intraoperative hydroxyethyl starch 70/0.5 is not related to acute kidney injury in surgical patients: retrospective cohort study. Anesth Analg. 2012;115(6):1309–1314.
    1. Van DerLinden P, James M, Mythen M, Weiskopf RB. Safety of modern starches used during surgery. Anesth Analg. 2013;116:35–48.
    1. Corcoran T, Rhodes JE, Clarke S, Myles PS, Ho KM. Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesth Analg. 2012;114(3):640–651.
    1. Cecconi M, Fasano N, Langiano N, Divella M, Costa MG, Rhodes A, Della RG. Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Crit Care. 2011;15(3):R132.
    1. Polanczyk CA, Rohde LE, Goldman L, Cook EF, Thomas EJ, Marcantonio ER, Mangione CM, Lee TH. Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA. 2001;286(3):309–314.
    1. Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR, Hofer CK, Teboul JL, De Boode WP, Scolletta S, Vieillard-Baron A, De Backer D, Walley KR, Maggiorini M, Singer M. Clinical review: update on hemodynamic monitoring - a consensus of 16. Crit Care. 2011;15(4):229.
    1. Holte K. Pathophysiology and clinical implications of perioperative fluid management in elective surgery. Dan Med Bull. 2010;57(7):B4156.
    1. Assaad S, Popescu W, Perrino A. Fluid management in thoracic surgery. Curr Opin Anaesthesiol. 2013;26(1):31–39.
    1. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9329)):1812–1818.
    1. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH, Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F. Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641–648.
    1. McArdle GT, McAuley DF, McKinley A, Blair P, Hoper M, Harkin DW. Preliminary results of a prospective randomized trial of restrictive versus standard fluid regime in elective open abdominal aortic aneurysm repair. Ann Surg. 2009;250(1):28–34.
    1. 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(6):1392–1402.
    1. Della Rocca G, Pompei L. Goal-directed therapy in anesthesia: any clinical impact or just a fashion? Minerva Anestesiol. 2011;77(5):545–553.
    1. Doherty M, Buggy DJ. Intraoperative fluids: how much is too much? Br J Anaesth. 2012;109:69–79.
    1. 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;77:110–114.
    1. Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey JG. Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg. 2005;100(3):675–682.
    1. Moretti EW, Robertson KM, El-Moalem H, Gan TJ. Intraoperative colloid administration reduces postoperative nausea and vomiting and improves postoperative outcomes compared with crystalloid administration. Anesth Analg. 2003;96(2):611–617.
    1. Vallet B, Blanloeil Y, Cholley B, Orliaguet G, Pierre S, Tavernier B. Guidelines for perioperative haemodynamic optimization. Ann Fr Anesth Reanim. 2013;32(10):e151–e158.
    1. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N. Haemodynamic goal-directed therapy and postoperative infections: earlier is better: a systematic review and meta-analysis. Crit Care. 2011;15:R154.
    1. Mythen MG, Swart M, Acheson N, Crawford R, Jones K, Kuper M, McGrath JS, Horgan A. Perioperative fluid management: consensus statement from the enhanced recovery partnership. Perioper Med (Lond) 2012;1:2.
    1. Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M, Lewington AJ, Pearse RM, Mythen M. British consensus guidelines on intravenous fluid therapy for adult surgical patients – GIFTASUP. 2008. Available from: . (Accessed 12 June 2014)
    1. Vallet B, Blanloeil Y, Cholley B, Orliaguest G, Pierre S, Tavernier B. Guidelines for perioperative haemodynamic optimization. Ann Fr Anesth Reanim. 2013;32:454–462.
    1. Gustafsson UO, Scott MJ, Schwenk W, Demartine N, Roulin D, Francis N, McNaught CE, Macfie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Lijungqvist O. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS) society. World J Surg. 2013;37:259–284.
    1. McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329(7460):258.
    1. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423–429.
    1. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Br Med J. 1997;315:909–912.
    1. Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65–71.
    1. 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;93:1069–1076.
    1. Gan TJ, Soppitt A, Maroof M, El-Moalem H, Robertson KM, Moretti E, Dwane P, Glass PS. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826.
    1. Conway DH, Mayall R, Abdul-Latif MS, Gilligan S, Tackaberry C. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia. 2002;57:845–849.
    1. Wakeling HG, McFall MR, Jenkins CS, Woods WG, Miles WF, Barclay GR, Flaming SC. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642.
    1. Agency for Healthcare Research and Quality. Esophageal Doppler ultrasound-based cardiac output monitoring for real-time therapeutic management of hospitalized patients: a review. 2014. (accessed 12 June 2014)
    1. National Institute for Health and Clinical Excellence. CardioQ-ODM oesophageal Doppler monitor. Medical Technology Guide 3. 2011. (accessed 12 June 2014)
    1. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M. A randomized, controller trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;48(3):5–14.
    1. Wesseling KH, Jansen JRC, Settels JJ, Schreuder JJ. Computation of aortic flow from pressure in humans using a nonlinear, three-element model. J Appl Physiol. 1993;74:2566–2573.
    1. Jonas MM, Tanser SJ. Lithium dilution measurement of cardiac output and arterial pulse waveform analysis: an indicator dilution calibrated beat-by-beat system for continuous estimation of cardiac output. Curr Opin Crit Care. 2002;8:257–261.
    1. Sander M, Spies CD, Grubitzsch H, Foer A, Müller M, Von Heymann C. Comparison of uncalibrated arterial waveform analysis in cardiac surgery patients with thermodilution cardiac output measurements. Crit Care. 2006;10:R164.
    1. Østergaard M, Nielsen J, Nygaard E. Pulse contour cardiac output: an evaluation of the FloTrac method. Eur J Anaesthesiol. 2009;26:484–489.
    1. Vetrugno L, Costa MG, Spagnesi L, Pompei L, Chiarandini P, Gimillaro I, Della RG. Uncalibrated arterial pulse cardiac output measurement in patients with moderately abnormal left ventricular function. J Cardiothorac Vasc Anesth. 2011;25(1):53–58.
    1. Hofer CK, Senn A, Weibel L, Zollinger A. Assessment of stoke volume variation for prediction of fluid responsiveness using the modified FlowTrac and PiCCO plus system. Crit Care. 2008;12:R82.
    1. Salzwedel C, Puig J, Carstens A, Bein B, Molnar Z, Kiss K, Hussain A, Belda J, Kirov MY, Sakka SG, Reuter DA. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Crit Care. 2013;17:R191.
    1. Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, Grocott MPW, Ahern A, Griggs K, Scott R, Hinds C, Rowan K. for the OPTIMISE Study Group. 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(21):2181–2190.
    1. Pearse R, Dawson D, Fawcett J, Rhodes A, Ground RM, Bennet ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445] Crit Care. 2005;9:R687–R693.
    1. Brandstrup B, Svendsen PE, Rasmussen M, Belhage B, Rodt SÅ, Hansen B, Møller DR, Lundbech LB, Andersen N, Berg V, Thomassen N, Andersen ST, Simonsen L. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: nearmaximal stroke volume or zero fluid balance? Br J Anaesth. 2012;109:191–199.
    1. Morris C. Oesophageal Doppler monitoring, doubt and equipoise: evidence based medicine means change. Anaesthesia. 2013;68:677–683.
    1. Hood JA, Wilson RJT. Pleth variabilità index to predict fluid responsiveness in colorectal surgery. Anesth Analg. 2011;113:1058–1063.
    1. Monnet X, Guérin L, Jozwiak M, Bataille A, Julien F, Richard C, Teboul JL. Pleth variabilità index is a weak predictor of fluid responsiveness in patients receiving norepinephrine. Br J Anaesth. 2013;110:207–213.
    1. Srinivasa S, Kahokehr A, Soop M, Taylor M, Hill AG. Goal-directed fluid therapy- a survey of anaesthetists in the UK, USA, Australia and New Zealand. BMC Anesthesiol. 2013;13:5.
    1. Miller TE, Roche AM, Gan TJ. Poor adoption of hemodynamic optimization during major surgery: are we practicing substandard care? Anesth Analg. 2011;112(6):1274–1276.
    1. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94(6):1176–1186.
    1. Morgan TJ. High-risk non-cardiac surgery - is supranormal oxygen delivery the answer? Crit Care Resusc. 2000;2:150–155.
    1. Arulkumaran N, Corredor C, Hamilton MA, Ball J, Grounds RM, Rhodes A, Cecconi M. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth. 2014;112(4):648–659.
    1. Wenkui Y, Ning L, Jianfeng G, Weiqin L, Shaoqiu T, Zhihui T, Tao G, Juanjuan Z, Fengchang X, Hui S, Weiming Z, Jie-Shou L. Restricted perioperative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Surgery. 2010;147:542–552.
    1. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intrabdominal surgery. Anesth. 2005;103:25–32.
    1. Holte K, Kehlet H. Fluid therapy and surgical outcomes in elective surgery: a need for reassessment in fast-track surgery. J Am Coll Surg. 2006;202(6):971–989.

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