Perioperative Fluid Management

Sophie E. Noblett, MD, FRCS, and Alan F. Horgan, MD, FRCS

With the introduction of enhanced surgical recovery programs there has been a rekindled
interest over recent years in the optimal surgical fluid regimen. The historical debate
between liberal vs restrictive fluid regimens has been re-evaluated and the idea of individualized goal-directed therapy has been introduced and subjected to a number of randomized controlled trials. While untreated hypovolemia can be detrimental to patients, fluid
overload can be just as (if not more) hazardous. By tailoring fluid administration to an
individual patients needs using a treatment algorithm based on closely monitored flow
variables, postoperative recovery can be improved with reduced morbidity, less gastrointestinal dysfunction, and reduced hospital stay.
Semin Colon Rectal Surg 21:160-164 Crown Copyright 2010 Published by Elsevier Inc.
All rights reserved.

History of Perioperative
Fluid Management

he bodys fluid and electrolyte balance is kept within a

tightly defined range mainly by the action of antidiuretic
hormone and the renin-angiotensin-aldosterone axis. In the
perioperative period preoperative fasting, bleeding, and insensible losses reduce extracellular volume. Activation of the
inflammatory cascade increases capillary permeability, depleting intravascular volume, with the resulting increased
tissue oncotic pressure further exacerbating the fluid loss.
These reductions in intravascular volume trigger a number of
physiologic responses. Moore described the net effect of the
metabolic-endocrine response to trauma as conservation of
sodium and water, thus implying fluid delivery should be
restricted.1 In contrast, Shires et al in the 1960s2 focused on
the effects of fluid redistribution, with third space losses
depleting intravascular volume. Despite conflicting studies
on the exact alterations in extracellular fluid volume in response to trauma,3 this work led to the dogma that intravenous fluid and sodium administration in excess of normal
maintenance requirements were necessary in the perioperative period to maintain tissue perfusion and oxygenation.
Shoemaker et al were the first to show that critically ill
patients fared better when their cardiac output and oxygen
delivery were increased above normal values and this work
was then continued to include high-risk surgical patients.4,5
Department of Colorectal Surgery, Freeman Hospital, Newcastle Upon
Tyne, Tyne and Wear, UK.
Address reprint requests to Alan F. Horgan, MD, Department of Colorectal
Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK.
E-mail: Alan.Horgan@nuth.nhs.uk

160

This prompted several trials using combinations of fluids and

inotropes to study the effects of improving tissue oxygen
delivery in surgical patients.6-8 These studies found that patients in the intervention groups who had received more fluid
exhibited reduced mortality and morbidity when compared
with the control patients. However, it remains unclear
whether the benefits seen were due to the inotropes, or the
extra fluid received by the intervention patients. Similarly the
controlled study environment, often involving admission to a
critical care facility, complex monitoring, and differing targets, add to the complex interaction of factors that may have
influenced the resultant outcomes.
Over the past decade, the evolution of enhanced surgical
recovery programs has prompted a re-evaluation of surgical
fluid management. These programs employ a multimodal
approach to perioperative care aiming to modify the homeostatic response to surgical trauma, and while the beneficial
effects (wound healing and resolution of inflammation)
should be preserved, the more undesirable effects are attenuated. Hemorrhage and intravascular hypovolemia are initiators of the stress response by the stimulation of volume and
pressure receptors, which activate the central nervous system. The response tends to be proportionate to the amount of
shock; both the degree and the duration of blood volume
deficit, therefore, are important determinants of the degree of
physiological response to injury. Also, since hemorrhage and
hypovolemia decrease cardiac output, tissue ischemia may
result. This is another important activator of physiologic responses to injury, not only because it may potentiate activation of the centrally mediated stress responses, but also because it leads to initiation of local responses, mediator
release, and cell activation.
It is clear therefore that optimizing hemodynamic status in

1043-1489/$-see front matter Crown Copyright 2010 Published by Elsevier Inc. All rights reserved.
doi:10.1053/j.scrs.2010.05.007

Perioperative fluid management

the perioperative period may have profound effects on surgical outcome by direct maintenance of organ perfusion and
by modulation of the inflammatory response to injury. However the problems of fluid overload and its related complications should not be underestimated.

Hazards of a
Liberal Fluid Regimen
Increased aldosterone and antidiuretic hormone release following surgery led to conservation of water and sodium as an
integral component of the stress response.1 With liberal intravenous fluid administration in addition to this natural
stress response, patients can be at risk from overhydration.
Administration of excess fluid may contribute to significant
postoperative morbidity with affects on several organ systems: cardiac function, respiration, the coagulatory system,
and the gastrointestinal tract.9-11 The sequelae of fluid overload are often the result of fluid shifts, with accumulation of
fluid in potential spaces, particularly those of the bowel wall,
peritoneum, and pleural cavities. These third space losses are
a particular problem after major abdominal surgery and have
been shown to increase with intravenous fluid therapy.12
Holte et al13 illustrated the potential detrimental effects of
excess fluid by subjecting healthy volunteers to 1 of 2 fluid
administration regimens. They found significant weight gain
and worsened spirometry readings in the group given liberal
fluids. In a study assessing deaths from pulmonary edema in
major inpatient surgery, 7.6% of patients developed pulmonary edema with an associated mortality of 11.9%. Net fluid
retention of 67 ml/kg/d was found to be a predisposing
factor in those patients affected.14 Similarly, weight gain of
20% over baseline has been correlated with increased postoperative morbidity.10 Certainly, in thoracic surgery there is a
trend toward a dry regimen, with evidence to suggest this
reduces postoperative pulmonary complications.15
Excess fluid volume may increase cardiac work and myocardial oxygen demands. The Starling myocardial performance curve shows that until a certain point intravascular
volume expansion increases cardiac output due to increased
end-diastolic filling. Beyond that point, further fluid administration will lead to reduced ventricular function. In a large
observational study of patients undergoing major noncardiac
surgery, those patients who underwent pulmonary artery
catheterization and increased fluid administration had a
marked increase in cardiac morbidity. Compared with the
control group, it is unclear, however, how much of the postoperative outcome could be attributed to the fluid administration alone.16
Excretion of administered intravenous fluid relies on adequate renal function; thus, in overhydration, excess demands
are placed on the kidney. A study of overhydrated burn patients showed that only 50% of patients had excreted the
excess volume at 1 week.17 Even in healthy volunteers, excretion of an acute saline bolus (22 ml/kg) takes several
days.18 While functional demand on the kidney may be in-

161
creased, there is no clear evidence of the role of fluid excess
on postoperative renal morbidity in isolation.
Tissue edema in the gut wall impairs bowel motility, impairs gastric emptying, and predisposes to postoperative ileus, prolonging hospital stay.9 Indeed, gastrointestinal disturbance is 1 of the commonest morbidities recorded after
major abdominal surgery with local effects of prolonged nausea and vomiting with enteric nutritional intolerance. More
globally, however, the gut mucosal edema and prolonged
ileus may allow translocation of bacteria and endotoxin, further driving the systemic inflammatory response and contributing to multiple organ dysfunction and sepsis. Largevolume fluid sequestration in the peritoneal cavity together
with bowel wall and luminal fluid associated with ileus, can
in extreme cases result in abdominal compartment syndrome, with concomitant effects on respiratory and renal
function.

Evolution of Fluid Restriction

The increasing interest in strategies to improve postoperative outcome on the back of enhanced surgical recovery
programs called for the traditional aggressive approach to
perioperative fluid administration to be re-evaluated. Taking the lead from thoracic surgical practice, Kehlet and colleagues introduced the concept of fluid restriction in his fast
track surgical regimens with intraoperative fluid standardized to 2 L (1500 mL isotonic saline 500 mL 6% hydroxyethyl starch).19
A large multicenter study comparing standard and restrictive fluid regimens in patients undergoing colorectal surgery
found a marked reduction in morbidity rate of 21% versus
40% in the restricted group.20 In contrast, however, a large
study of 80 patients under going colorectal surgery randomized to either a restricted or a standard regimen found day of
surgery intravenous fluid to be 2 vs 2.75 L in the restricted
and standard groups, respectively.21 This study failed to
show any significant improvement in outcome with a more
restrictive regimen; however, it did provide evidence that
there were no adverse effects to patients subjected to fluid
restriction. The standard group in the Brandstrup study,
however, received a median of 5388 mL intravenous fluid on
the day of surgery with a range of 2700-11,083 mL. It is
possible that more patients in this group experienced complications from overhydration, in what was clearly a rather
wet standard regimen.20 Certainly, animal studies have
shown that excess crystalloid administration has a significant
impact on functional and structural intestinal anastomotic
stability.22
There are now numerous studies in colorectal surgery and
other surgical specialties showing patients fared better when
fluids are administered in a restricted manner.23-25 Even salt
and water administration within an accepted normal range
has been linked with increased morbidity, with a study of
patients undergoing colorectal resection showing fewer complications following mean daily sodium doses of 115 mmol
compared with 149 mmol.26 So should we conclude that
fluid restriction in elective surgery is beneficial?

162

Figure 1 Curve A represents the hypothesized line of risk relationship between volume load and morbidity. Broken line B represents
a division between patient groups in a wet vs dry regimen. Broken
line C represents a division between patients and groups in a goaldirected vs nonoptimized study. The nidus of the curve is the
optimization zone.45 Reprinted with permission from Oxford University Press. (Color version of figure is available online.)

Current
Perspective: Individualized
Goal-Directed Therapy
The great fluid debate of whether patients should be treated
with a restricted or liberal fluid regimen has now been expanded to include a third option goal-directed therapy.
This theory accepts that there are clear benefits to giving
intravenous fluid, allowing maintenance of tissue perfusion
indexes and oxygenation (agreeing with the liberal fluid argument); however, it also accepts there are definite risks and
adverse events associated with overhydration (agreeing with
the restrictive regimen promoters). Figure 1 suggests how
both these arguments may interact. If the relationship between volume load (x-axis) and morbidity (y-axis) is plotted
as a U-shaped curve, we can see that too little fluid with
tissue hypoxia would be related to increased morbidity as
would too much fluid; the nadir of this curve represents the
zone of optimization. The key here is that both the restrictive
and the liberal studies to date have still followed generic
recipe approaches to fluid administration using planned
volume per kilogram per hour of crystalloid through the
duration of surgery. Patient perioperative monitoring in most
work consists of pulse, mean arterial pressure, central venous
pressure, and urine output being used to assess volume status. There is, however, no evidence that static measurements
of pressure are adequate detectors of tissue hypoperfusion;
certainly it is well-established that hypovolemia may be
present despite normal systemic and filling pressures.27,28
Fluid management strategies based on targeted flow variables

S.E. Noblett and A.F. Horgan

rather than targets of simple filling pressures are more successful.29,30
This realization has led to a new body of evidence using
protocolized fluid algorithms based on flow parameters to
guide fluid therapy on an individual patient basis. Many
studies have been carried out assessing the role of goal-directed therapy and have employed a variety of monitoring
techniques. Early studies used pulmonary artery catheters
and targeted cardiac index and/or oxygen delivery in the preor intraoperative period.6,8,31,32 These studies have demonstrated potential benefits from goal-directed fluid administration. Boyd et al6 increased oxygen delivery using dopexamine
infusion and found a reduction in 60-day mortality and morbidity in a group of high-risk surgical patients. Wilson et al8
found similar results using combinations of fluids and inotropes; however, on further study they found similar results
could be obtained from fluids alone. Lobo et al32 randomized
19 patients undergoing major surgery to receive fluids and
dobutamine to achieve supranormal cardiovascular values.
They found a reduced mortality, fewer complications, and a
trend toward less organ dysfunction in the intervention patients. With the inherent risks of pulmonary artery catheterization, and patients requiring critical care admission for
their use, practically, this type of monitoring is not feasible
for routine use in elective surgical patients. Further studies
have therefore looked at intraoperative optimization using
more minimally invasive techniques, such as esophageal
Doppler monitoring. In 1995, Mythen and Webb33 randomized patients undergoing cardiac bypass surgery to receive
perioperative plasma volume expansion using colloid and
found a reduction in gut mucosal hypoperfusion and improved outcome in the intervention group. Studies in other
patient groups have confirmed potential benefits in terms of
morbidity and hospital stay following perioperative optimization.34-36 Studies on patients undergoing major colorectal
resections have shown a significantly increased cardiac output, reduced critical care admission, with reduced morbidity,
improved recovery of gastrointestinal function, and reduced
hospital stay following goal-directed fluid administration.37-39 Additionally, significantly reduced serum interleukin-6 (as a marker of the systemic inflammatory response to
surgical trauma) was found in a group of colorectal patients
who had undergone a fluid optimization regimen compared with standard care.39 Studies of general surgical patients (mean age 55-60 years) had a reduced stay of 2 days;
cardiac surgical patients (mean age 65 years) had a reduced
stay of 4 days, and fractured neck of femur patients (mean age
75-85 years) had a reduced stay by 4-8 days.33-36 In patients
of increasing age and comorbidity, the importance of accurate perioperative fluid management is even greater, with
potentially increased benefits of a goal-directed regimen.
Goal-directed or fluid optimization regimens in patients undergoing major abdominal surgery have now been
subjected to systematic review and meta-analysis, confirming
that goal-directed, flow-guided optimization results in improved hemodynamic control, reduced morbidity, reduced
ileus, and shorter hospital stays.40,41

Perioperative fluid management

The Future of
Perioperative Fluid Management
Intravenous fluids are medications. As such, they are probably the most widely prescribed drug in hospital medicine yet
the rationale behind what fluid, how much, and when continues to be debated in surgical practice. Fluid prescription
and administration is often carried out by a recipe-book
approach to a given operation or clinical situation with little
regard to the individual patient and physiologic response. It
needs to be stressed to doctors and all involved in patient care
that intravenous fluids, while often not considered as drugs,
are not benign medications. Indeed, in the UK the report of
the National Confidential Enquiry into Perioperative Death
highlighted overhydration as a major contributory factor in
the evolution of postoperative complications causing death.42
A large US study found over 8000 postoperative deaths per
year were attributed to pulmonary edema in the absence of
any other cause except excess intravenous fluid therapy.43 In
response to this and with the increasing evidence to support
goal-directed therapy, the British Consensus Guidelines on
intravenous fluid therapy for adult surgical patients now state
that, for patients undergoing some forms of orthopedic and
abdominal surgery, intraoperative fluids should be administered to monitored and targeted optimal stroke volume to
reduce morbidity.44
Surgical fluid management aims to avoid tissue hypoperfusion, activation of the systemic inflammatory response, and
multiple organ failure yet at the same time prevent fluid
overload. Judicious perioperative fluid therapy can improve
outcome after major surgery; however, accurate fluid optimization requires careful cardiovascular monitoring. Ideal intraoperative fluid management is tailored to the individual
patient and involves monitoring of flow-based parameters by
a minimally invasive technique with little risk. Simply using
extra monitoring, however, is not enough. A proactive approach to goal-directed therapy following a treatment algorithm will allow most patients to achieve their individual
optimized hydration state, allowing maximum tissue perfusion and oxygenation while protecting them from the risks
of volume overload. Goal-directed fluid management has
been shown to reduce morbidity and improve outcome in
many surgical disciplines and is an important component of
enhanced recovery after surgery programs.

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