Perioperative fluid management: From physiology to improving clinical outcomes

Abstract

Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.

Adequate Dosage of Norepinephrine Infusion Combined with Goal-Directed Fluid Therapy During General Anesthesia May Improve Elderly Patients’ Postoperative Outcome Undergoing Lumbar Spinal Fusion

“…This makes norepinephrine a possible choice for elderly patients with relative contraindications of phenylephrine, such as low baseline HR or poor cardiac function. We did not include such patients because of the monitoring indicators-PPV, which was not suitable for patients with arrhythmias [3]. Currently, studies are exploring the optimum single dose for use as a continuous infusion rate during other surgeries in elderly patients.…”

“…Reportedly, prolonged surgery, intraoperative blood loss and volume of crystalloid uid resuscitation increased are harmful to the early rapid recovery of patients [2]. The goals of intraoperative uid management are to maintain central euvolemia and minimize excessive salt and water infusion [3]. Excessive uid loading in elderly patients will disrupt glycocalyx, which is a carbohydrate-rich layer lining the endothelium that plays a crucial role in maintaining endothelial integrity.…”

Impact of surgical indication on patient outcomes and compliance with enhanced recovery program for colorectal surgery: A Francophone multicenter retrospective analysis

“…Another major component of the ERP is fluid management monitoring, which is known to be associated with less anastomotic complications, less postoperative ileus, less acute urinary retention and reduce hospital stay. It also decreases medical complications such as cardiac insufficiency, respiratory failure or acute kidney injury 25‐27 . Patients with cancer were more likely to benefit from fluid management monitoring but the proportion of patients concerned was less than 60%.…”

Efficacy of Goal-Directed Fluid Therapy Monitored by Pulse-Pressure Variation Using a C ontinuous Non-Invasive Arterial Pressure Monitoring System (the CNAPTM System) During Parathyroidectomy in Patients with End-Stage Renal Failure - A randomized trial

“…Salmasi et al [38] found that MAP below the absolute value of 65 mmHg or a decrease of >20% of baseline can increase the risk of postoperative myocardial damage. The main goal of perioperative fluid management is optimal microcirculatory perfusion, which can be achieved with well-controlled blood pressure and adequate volume expansion [39]. Some authors suggest that the right amount of fluid can be input during parathyroidectomy, but the absolute amount of liquid should not be fixed [38].…”