Restricted, optimized or liberal fluid strategy in thoracic surgery

Abstract

Perioperative fluid balance has a major impact on clinical and functional outcome, regardless of the type of interventions. In thoracic surgery, patients are more vulnerable to intravenous fluid overload and to develop acute respiratory distress syndrome and other complications. New insight has been gained on the mechanisms causing pulmonary complications and the role of the endothelial glycocalix layer to control fluid transfer from the intravascular to the interstitial spaces and to promote tissue blood flow. With the implementation of standardized processes of care, the preoperative fasting period has become shorter, surgical approaches are less invasive and patients are allowed to resume oral intake shortly after surgery. Intraoperatively, body fluid homeostasis and adequate tissue oxygen delivery can be achieved using a normovolemic therapy targeting a “near-zero fluid balance” or a goal-directed hemodynamic therapy to maximize stroke volume and oxygen delivery according to the Franck–Starling relationship. In both fluid strategies, the use of cardiovascular drugs is advocated to counteract the anesthetic-induced vasorelaxation and maintain arterial pressure whereas fluid intake is limited to avoid cumulative fluid balance exceeding 1 liter and body weight gain (~1-1.5 kg). Modern hemodynamic monitors provide valuable physiological parameters to assess patient volume responsiveness and circulatory flow while guiding fluid administration and cardiovascular drug therapy. Given the lack of randomized clinical trials, controversial debate still surrounds the issues of the optimal fluid strategy and the type of fluids (crystalloids versus colloids). To avoid the risk of lung hydrostatic or inflammatory edema and to enhance the postoperative recovery process, fluid administration should be prescribed as any drug, adapted to the patient's requirement and the context of thoracic intervention.

Anesthesia management of patients undergoing off-pump coronary artery bypass grafting: A retrospective study of single center

“…The debate of the perioperative fluid infusion strategy in cardiac surgery still exists. All of the available surveys and real-life studies on fluid management show great variability among centers, and even among physicians at the same center ( 15 – 17 ). A liberal infusion strategy can reduce the incidence of tissue hypoperfusion resulting from inadequate fluid resuscitation but increase the risks of pulmonary edema and congestive heart failure ( 18 , 19 ).…”

Modern fluid management in thoracic surgery

“…Or rather, we should accept that the anesthetic and surgical techniques involved in lung resection inevitably cause patient harm and that inappropriate fluid management can exacerbate this. This is also the basis of the multiple hit model of acute lung injury whereby intraoperative ventilatory-driven lung injury is fueled by other factors including the overzealous use of intravenous fluids [22 ▪▪ ].…”

“…At the time of lung resection surgery and one-lung ventilation, patients are vulnerable to the development of interstitial and alveolar edema. The detrimental effects of preexisting pulmonary diseases, previous chemoradiotherapy, lung manipulation and tissue trauma by the surgeon, and ischemia-reperfusion can all harm the endothelial glycocalyx layer and the underlying endothelial cells [22 ▪▪ ,23]. This ultimately causes impaired tissue blood flow and interstitial edema.…”

“…This ultimately causes impaired tissue blood flow and interstitial edema. When combined with a liberal fluid regimen, lung injury and postoperative pulmonary complications (PPCs) are more likely [4,22 ▪▪ ,24,25 ▪ ]. The dogmatic practice of maintaining a dry lung with a volume-restrictive fluid regime of 1-2 ml/kg/hour was traditionally recommended in order to minimize the detrimental effects of fluid administration.…”

The effects of hydroxyethyl starch and gelatine on lung tissue and coagulation during the resuscitation of rats with traumatic haemorrhagic shock

“…The effects of shock are reversible in the early stages, but they can lead to multiple organ failure and death if not treated early [2]. performed and which fluid type might be advantageous in patients with lung injuries requiring thoracic surgery [5]. Trauma-related coagulopathy is a condition in which complex haemostatic and immunoinflammatory responses cause abnormal clot formation and activation of anticoagulant pathways rather than procoagulants [6].…”