Current concepts of fluid management in enhanced recovery pathways

Abstract

Perioperative fluid management impacts outcomes and plays a pivotal role in enhanced recovery pathways (ERPs). There have been major advances in understanding the effects of fluid therapy and administration during the perioperative period. Improving fluid management during this period leads to a decrease in complications, decrease in length of stay (LOS), and enhanced patient outcomes. It is important to consider preoperative and postoperative fluid management to be just as critical as intraoperative management given multiple associated benefits to the patients. Preoperative hydration with (complex) carbohydrate drinks up until 2 h before surgery is safe and should be encouraged, as this helps improve metabolism, decrease insulin resistance, reduce anxiety, and reduce nausea and vomiting. During the intraoperative period, the goals of fluid management are to maintain euvolemia using an individualized plan for fluid and haemodynamic management, matching the needs for monitoring with patient and surgical risk through goal-directed therapy (GDT). By combining the use of fluids and inotropes, GDT uses measurements and indicators of cardiac output and stroke volume to improve blood flow intraoperatively, and ultimately reduce LOS and complications. In the postoperative period, an early transition to oral hydration helps to enhance the conditions for healing and recovery from surgery. I.V. fluid therapy should be kept at a minimum, and urine output should not be the driving force for fluid administration. The optimization of perioperative fluid management is critical to ERPs as it helps improve pulmonary function, tissue oxygenation, gastrointestinal motility, and wound healing.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery

“…The present study focused on IV fluid administration rather than urine output as a guidance parameter, since low urine output by itself is no longer considered harmful . Srinivasa et al .…”

“…The present study focused on IV fluid administration rather than urine output as a guidance parameter, since low urine output by itself is no longer considered harmful [25,26]. Srinivasa et al described no difference in urine output between patients monitored by goal-directed fluid therapy (GDFT) and patients with restrictive fluid management [27].…”

Accuracy of dynamic preload variables for predicting fluid responsiveness in patients with pediatric liver cirrhosis: A prospective study

“…Dynamic preload variables such as pulse pressure variation (PPV), stroke volume variation (SVV), and the plethysmographic variability index (PVI) are commonly used for predicting fluid responsiveness and are applied for intraoperative goal‐directed fluid therapy in high‐risk patients . We previously reported that the ability of dynamic preload variables to predict fluid responsiveness in adult patients with liver cirrhosis was reduced, which may be because liver cirrhosis induces low systemic vascular resistance; nevertheless, PPV, SVV, and PVI remain clinically applicable for adult patients with liver cirrhosis .…”

Is perioperative goal-directed therapy able to reduce surgical complications in different surgical settings? A meta-analytic study

“…Therefore, it can be argued that GDT allows the judicious use of fluid when it is needed. Moreover, it prevents unnecessary fluid loading when hemodynamic targets are already met (70). This personalized and prompt strategy can explain the reduction of postoperative complications in low-risk patients.…”