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PRACTICE POINTER

Perioperative fluid therapy


Intravenous fluid therapy is an important aspect of perioperative care, but doctors often prescribe
fluid with limited knowledge of its benefits and risks. This article provides an evidence based summary
of current best practice in the prescription of fluid for patients undergoing major non-cardiac surgery.
Rupert M Pearse clinical reader
1
, Gareth L Ackland clinician scientist, honorary consultant
2
1
Barts and The London School of Medicine and Dentistry, Queen Marys University of London, London EC1M 6BQ, UK;
2
University College
London/University College Hospitals NHS Trust, Wolfson Institute for Biomedical Research, London WC1E 6BT
Patient outcomes after major non-cardiac surgery can be
improved considerably through more effective perioperative
care.
1
Factors such as advancing age, comorbidity, and complex
surgical procedures can result in postoperative morbidity and
mortality rates similar to those found with common acute
medical emergencies.
1-3
Patients who survive postoperative
complications experience functional limitation and reduced long
term survival.
1-3
Doctors often prescribe intravenous fluid with
limited knowledge of the benefits and risks of this treatment.
Doctors in training commonly express frustration at the lack of
clear guidance on the optimal approach to fluid therapy. The
debate that followed recent UKguidelines aimed at standardising
best practice highlights the uncertainty in this area, even among
experienced practitioners.
4 5
We review the evidence from clinical studies, systematic
reviews, and practice guidelines to provide a summary of current
best practice in the prescription of fluid for patients undergoing
major non-cardiac surgery.
What are the principles behind fluid
therapy?
In health, 60% of total body mass consists of water. Most water
resides within the intracellular compartment, separated from
extracellular water, which comprises the interstitial and plasma
volumes. The neuroendocrine response to surgery results in
retention of sodium and water with a reduction in maintenance
requirements. Conversely, absolute hypovolaemia (blood loss)
and relative hypovolaemia (such as epidural or inflammation
mediated vasodilatation) commonly result in a fluid deficit. For
most patients fluid losses are replaced during surgery and oral
intake of fluid is rapidly resumed after surgery. However, for
some procedures (such as gastrointestinal surgery, proximal
femoral fracture repair), the preoperative deficit and losses
during surgery vary widely and may not be adequately replaced.
Inadequate fluid replacement leads to reduced cardiac output
and oxygen delivery to injured tissues, which is associated with
an excess of postoperative complications. Excessive fluid
administration may also have adverse effects, including acidosis,
coagulation defects, and oedema of both lungs and peripheral
tissues (fig 1).
6
It is also worth noting that postoperative
adverse events may be attributed to fluid prescribing when
associated factors are to blame. The tissue injury of surgery
results in a systemic inflammatory response associated with
both tissue oedema and hypovolaemia. Negative fluid balance
after surgery is associated with reduced mortality (odds ratio
0.50 (95%confidence interval 0.28 to 0.89)),
7
although this may
reflect the degree of inflammatory response as well as excessive
fluid administration.
8
Fluid restriction and diuresis may decrease
oedema in patients with poor ventricular function but also
increase the incidence of acute kidney injury.
How should we select the dose of
intravenous fluid?
Perioperative maintenance fluid
The normal daily dietary requirements for water and electrolytes
are listed in table 1. However, retention of sodium and water
after surgery reduces their requirements. Additional amounts
should be given only to correct deficit or continuing losses.
Monitoring should include clinical examination, fluid balance
charts, regular weighing, and biochemical analyses (urea,
electrolytes, creatinine, bicarbonate).
It is often helpful to calculate the quantity of water, sodium,
and potassium prescribed in a given fluid regimen (table 2).
The optimal daily dose of water and electrolytes cannot be
provided by a single crystalloid solution, and a suitable daily
prescription for maintenance fluid will normally include more
than one formulation. Many fluid solutions contain large
quantities of sodium and chloride, which may result in nausea
Correspondence to: R Pearse Adult Critical Care Unit, Royal London Hospital, London E1 1BB r.pearse@qmul.ac.uk
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BMJ 2012;344:e2865 doi: 10.1136/bmj.e2865 (Published 26 April 2012) Page 1 of 6
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PRACTICE
Methods
We searched various databases, including Clinical Evidence and the Cochrane Collaboration, for articles which would define clinical practice
by using the search terms: surgery; fluid, intra-venous; perioperative; blood transfusion. We also consulted several UK and international
experts in formulating the contents of this review and sought comments on the final version.
We recognise the considerable variation in clinical practice in this area. The article focuses on key aspects of the topic affecting the majority
of patients who would benefit from a standardised and individual approach to fluid prescribing. Our aim is to provide simple guidance for the
less experienced or less expert clinician who prescribes fluid on a regular basis. We stress the importance of recognising that fluids are
drugs and accordingly require expert guidance in their use.
and vomiting, metabolic acidosis,
9
and impaired renal blood
flow.
10
However, although hypotonic solutions are important
sources of water, they may cause severe hyponatraemia and
neurological impairment when used as replacement fluids.
Analysis of 38 randomised trials involving 1589 patients
undergoing major abdominal aortic surgery failed to identify
specific superior fluid regimens.
11
Although crystalloid solutions
that contain bicarbonate may limit the deleterious effects of
chloride, the clinical and metabolic consequences of limiting
chloride-rich fluids remain unclear.
9
Replacement of perioperative fluid deficit
The most important information required to assess intravascular
volume is provided by the clinical scenario; is it likely that the
patient is hypovolaemic? Estimates of fluid deficit based on
traditional physiological parameters such as heart rate, blood
pressure, and central venous pressure are not reliable. A
systematic review of 24 studies showed that central venous
pressure is a poor measure of fluid deficit (pooled correlation
between central venous pressure and change in cardiac output
0.11 (95% confidence interval 0.02 to 0.21)).
12
Assessing the dynamic response of physiological variables to
a fluid challenge is a more instructive approach. The response
to the rapid administration of a fluid bolus (in our practice, 250
ml colloid solution) may be evaluated during surgery by
monitoring cardiac output and is best guided by an algorithm
for perioperative fluid and inotropic therapy (fig 2). This
treatment approach is associated with a mortality reduction of
37%and a two or three day reduction in length of hospital stay.
13
The National Institute for Health and Clinical Excellence (NICE)
has endorsed the use of perioperative cardiac output monitoring
while acknowledging the need for further research.
14
For most patients, resumption of oral fluid and light diet can
begin shortly after surgery. Patients undergoing major gut or
vascular surgery require individualised prescription of
intravenous fluid, and the clinical team should communicate to
ensure optimal fluid administration during and after surgery.
These patients should be reassessed on a regular basis by
suitably trained staff.
After major surgery, a substantial proportion of patients will
become critically ill. In this scenario decisions regarding fluid
and inotropic therapy should be guided by senior medical advice.
This is best determined by objective, dynamic assessment of
cardiovascular performance in response to a fluid challenge and
may also be guided by a basic transthoracic echocardiogram to
assess left ventricular function. Lactate and central venous
saturation measured from a blood sample drawn from a central
venous catheter may also indicate hypovolaemia. This approach
is currently being evaluated in clinical trials. Initial care of
patients who become critically ill on a standard surgical ward
can be improved by input from critical care outreach staff.
However, this resource cannot replace prompt admission to a
critical care unit.
2 3
What are the differences between
crystalloid and colloid solutions?
Intravenous fluids should be considered as conventional drugs,
with both beneficial and adverse effects. Differences in the
chemical structure of colloid and crystalloid solutions may
explain their diverse metabolic effects (table 2). There is no
evidence that resuscitation with colloids (including albumin)
reduces the risk of death or morbidity compared with
resuscitation with crystalloids (pooled relative risk 1.00 (0.91
to 1.09)).
15
Safety concerns have emerged from several studies
regarding a potential increase in the risk of bleeding and acute
kidney injury with different colloids. However, systematic
review of these data is limited by the lack of statistical power
and inconsistent definitions of kidney injury.
16
There are several
ongoing clinical trials comparing the effects of crystalloid and
colloid solutions. Until these studies are complete, wide
international variations in fluid prescribing practice are unlikely
to change.
17
When should we transfuse blood to a
surgical patient?
Increased mortality among patients undergoing non-cardiac
surgery is associated with both preoperative anaemia (odds ratio
142 (131 to 154)) and perioperative haemorrhage.
18 19
However, the benefits of blood transfusion are uncertain, and
further research is required in this area.
20
The adverse effects
associated with transfusion are well described,
21
and, for surgical
patients, include increased risks of postoperative infection and
increased recurrence after cancer surgery.
22 23
Current guidelines
recommend transfusion when haemoglobin values fall below
70 g/L during the perioperative period but do not recommend
transfusion to achieve values >100 g/L.
24
A recent large
randomised trial in patients undergoing proximal femoral
fracture repair, which randomised patients to transfusion triggers
of 100 g/L versus 80 g/L, did not show any differences in
functional outcome (odds ratio 1.01 (0.84 to 1.22)).
25
Consideration should also be given to the use of techniques
which reduce transfusion requirements, including iron and
erythropoietin, antifibrinolytic therapy, and red cell salvage
devices.
23
Systematic reviews indicate that use of autologous
transfusion of the patients own blood (donated before surgery)
is not associated with benefit and may increase transfusion
rates.
26
How should we optimise perioperative
nutrition?
Surgical patients should be screened for nutritional deficit and
managed according to published guidelines for perioperative
nutritional support.
27
In the small proportion of patients who
present for surgery with a severe nutritional deficit, caution
should be taken with re-feeding after surgery either by enteral
or parenteral routes. The advice of a specialist dietician should
be sought. Most patients without disorders of gastric emptying
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BMJ 2012;344:e2865 doi: 10.1136/bmj.e2865 (Published 26 April 2012) Page 2 of 6
PRACTICE
who are undergoing elective surgery should be fasted for six
hours for solids (including milk), but clear non-particulate oral
fluids should not be withheld for more than two hours before
induction of anaesthesia.
28
Preoperative administration of
carbohydrate-rich drinks two to three hours before induction of
anaesthesia may enhance recovery from surgery.
29
These
approaches should be considered for most patients in the
preparation for elective surgery. Meanwhile, routine use of
preoperative mechanical bowel preparation is not beneficial and
should be avoided, unless indicated surgically.
29 30
Most patients
do not require intravenous fluid once surgery is complete and
can rapidly resume oral fluids and light diet.
Conclusions
Perioperative fluid therapy may have important beneficial effects
on outcome after surgery. Inappropriate fluid management is
likely to harmpatients, but fluid prescribing practice still varies
widely. Forthcoming guidelines from NICE will encourage a
standardised approach to fluid prescription and management.
Such initiatives are welcome and should be widely implemented
to ensure the highest standards of patient care.
Contributors: All authors contributed to each stage of the preparation
of this manuscript and approved the final version. RMP is the guarantor.
Funding statement: RMP is a National Institute for Health Research
(NIHR) clinician scientist. GLA is supported by an Academy of Medical
Sciences/Health Foundation clinician scientist award. This work was
undertaken at University College London Hospitals NHSTrust, University
College London, which received a proportion of funding from the
Department of Health UK NIHR Biomedical Research Centre funding
scheme.
Competing interests: All authors have completed the unified competing
interest format www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare that we have received no
support from any company for the submitted work; RMP has received
a research grant from LiDCO and honorariums from Covidien, Pulsion
Medical Systems, and Edwards Lifesciencescompanies that might
have an interest in the submitted work. The authors have no other
relationships or activities that could appear to have influenced the
submitted work.
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2 Findlay G, Goodwin A, Protopappa K, Smith N, Mason M. Knowing the risk: a review of
the peri-operative care of surgical patients . National Confidential Enquiry into Patient
Outcome and Death, 2011.
3 Anderson I. The higher risk general surgical patient: towards improved care for a forgotten
group . Royal College of Surgeons of England, Department of Health, 2011.
4 Powell-Tuck J, Gosling P, Lobo D, Allison S, Carlson G, Gore M, et al. British consensus
guidelines on intravenous fluid therapy for adult surgical patients, 2011.
5 Liu B, Finfer S. Intravenous fluids in adults undergoing surgery. BMJ 2009;338:b2418.
6 Guidet B, Soni N, Della Rocca G, Kozek S, Vallet B, Annane D, et al. A balanced view of
balanced solutions. Crit Care 2010;14:325.
7 Rosenberg AL, Dechert RE, Park PK, Bartlett RH. Review of a large clinical series:
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review of the ARDSnet tidal volume study cohort. J Intens Care Med 2009;24:35-46.
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restricting chloride-rich fluids in intensive care. Crit Care Med 2011;39:2419-24.
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11 Toomtong P, Suksompong S. Intravenous fluids for abdominal aortic surgery. Cochrane
Database Syst Rev 2010;(1):CD000991.
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13 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;112:1392-402.
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18 Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, et al.
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19 Neary WD, Heather BP, Earnshaw JJ. The physiological and operative severity score for
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20 Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC, et al. Perioperative
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21 Knowles S, Cohen H on behalf of the Serious Hazards of Transfusion (SHOT) Steering
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Cite this as: BMJ 2012;344:e2865
BMJ Publishing Group Ltd 2012
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Learning points
Perioperative fluid therapy is associated with potential benefits and harm, yet fluid prescribing practice varies much more widely than
would be accepted for other drugs
The inflammatory response generated by tissue injury causes complex changes in fluid and electrolyte balance. Although maintenance
requirements are reduced, many patients require replacement of fluid losses
Careful monitoring should be undertaken using clinical examination, fluid balance charts, and regular weighing when possible
For most patients fluid losses during surgery can be replaced with resumption of oral fluid and light diet after surgery
Patients undergoing complex major surgery (such as major gastrointestinal surgery, proximal femoral fracture repair) experience
variable fluid losses due to tissue injury, inflammation, and blood loss. For these patients, evidence supports an individualised approach
to fluid therapy often involving cardiac output monitoring during surgery
Fluid restriction and diuresis may decrease oedema in patients with poor ventricular function but may increase the incidence of acute
kidney injury. It is better to avoid excess fluid administration than to treat the consequences
Tables
Table 1| Normal daily requirements for fluid and electrolytes for a healthy adult
Requirement Item
1.5 ml/kg/hour Water
11.5 mmol/kg Sodium
1 mmol/kg Potassium
1.5 mmol/kg Chloride
0.20.5 mmol/kg Phosphate
0.10.2 mmol/kg Calcium
0.10.2 mmol/kg Magnesium
145 kJ/kg Energy
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Table 2| Constituents of commonly used crystalloid and colloid based intravenous fluids
Constituent
Fluid Other Glucose (dextrose) Chloride (mmol/L) Potassium (mmol/L) Sodium (mmol/L)
Crystalloids
154 154 0.9% saline
50 g/L 5% dextrose
40 g/L 30 30 0.18% saline + 4% dextrose
Lactate 29 mmol/L
Calcium 2 mmol/L
111 5 131 Hartmanns solution
Bicarbonate 1000 mmol/L 1000 Sodium bicarbonate 8.4%
Colloids
Gelatin 40 g/L 120 154 Gelofusine
Hetastarch 60 g/L 154 154 Hetastarch
Hydroxyethylstarch 60 g/L
Acetate 34 mmol/L
Magnesium 1.5 mmol/L
110 4 137 Volulyte
Albumin 45 g/L 136 mmol/L 150 Human albumin 4.5%
Crystalloids have various indications, whereas use of colloids is generally limited to intravascular fluid resuscitation. No commonly available fluid provides the
correct combination of water and electrolytes for maintenance requirements.
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Figures
Fig 1 Optimal perioperative fluid therapy requires a balance of the beneficial and adverse effects of intravenous fluid. This
requires an individualised approach to prescribing that is often neglected, resulting in poor patient outcomes
Fig 2 Use of cardiac output monitoring to guide replacement fluid therapy during and immediately after major surgery is
much more reliable than use of venous pressure. A physiological challenge with a small bolus of intravenous fluid will
result in an increase in venous return and hence stroke volume, but only in patients with a fluid deficit. Thus both inadequate
and excessive fluid administration may be avoided.
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