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Intraoperative Fluids: How Much Is Too Much?

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Intraoperative Fluids: How Much Is Too Much? British Journal of Anaesthesia 109 (1): 69–79 (2012) Advance Access publication 1 June 2012 . doi:10.1093/bja/aes171 Intraoperative fluids: how much is too much? M. Doherty1* and D. J. Buggy1,2 1 Department of Anaesthesia, Mater Misericordiae University Hospital, University College Dublin, Ireland 2 Outcomes Research Consortium, Cleveland Clinic, OH, USA * Corresponding author. E-mail: [email protected] Downloaded from Summary. There is increasing evidence that intraoperative fluid therapy Editor’s key points decisions may influence postoperative outcomes. In the past, patients undergoing major surgery were often administered large volumes of † Both too little and excessive fluid http://bja.oxfordjournals.org/ during the intraoperative period can crystalloid, based on a presumption of preoperative dehydration and adversely affect patient outcome. nebulous intraoperative ‘third space’ fluid loss. However, positive perioperative fluid balance, with postoperative fluid-based weight gain, is associated with † Greater understanding of fluid increased major morbidity. The concept of ‘third space’ fluid loss has been kinetics at the endothelial glycocalyx emphatically refuted, and preoperative dehydration has been almost enhances insight into bodily fluid eliminated by reduced fasting times and use of oral fluids up to 2 h before distribution. operation. A ‘restrictive’ intraoperative fluid regimen, avoiding hypovolaemia † Evidence is mounting that fluid but limiting infusion to the minimum necessary, initially reduced major at Fundação Coordenação de Aperfeiçoamento Pessoal Nível Superior on September 12, 2012 therapy guided by flow based complications after complex surgery, but inconsistencies in defining restrictive haemodynamic monitors improve vs liberal fluid regimens, the type of fluid infused, and in definitions of perioperative outcome. adverse outcomes have produced conflicting results in clinical trials. The † It is unclear whether crystalloid or advent of individualized goal-directed fluid therapy, facilitated by minimally colloid fluids or a combination of both invasive, flow-based cardiovascular monitoring, for example, oesophageal produce the optimal patient outcome Doppler monitoring, has improved outcomes in colorectal surgery in and in what clinical context. particular, and this monitor has been approved by clinical guidance authorities. In the contrasting clinical context of relatively low-risk patients undergoing ambulatory surgery, high-volume crystalloid infusion (20–30 ml kg21) reduces postoperative nausea and vomiting, dizziness, and pain. This review revises relevant physiology of body water distribution and capillary- tissue flow dynamics, outlines the rationale behind the fluid regimens mentioned above, and summarizes the current clinical evidence base for them, particularly the increasing use of individualized goal-directed fluid therapy facilitated by oesophageal Doppler monitoring. Keywords: fluid therapy; fluids, i.v. Fluid therapy is fundamental to the practice of intraoperative various volumes and types of fluid therapy in different intra- anaesthesia, but the precise type, amount, and timing of its operative clinical contexts. Discussion of preoperative fluid administration is still the subject of extensive debate. Almost resuscitation and continuing postoperative fluid therapy is all patients presenting for general anaesthesia will be admi- outside the scope of this review. nistered some form of i.v. fluid. Evidence is increasing that perioperative fluid therapy can affect important longer-term Physiology postoperative outcomes. Traditional practice involving intra- operative administration of large crystalloid fluid volumes Body water distribution to all patients are being challenged by recent evidence- Water comprises 60% of the lean body mass, 42 litres in a based, individualized goal-directed therapy (GDT). Although 70 kg man. Of this, about two-thirds are intracellular (28 many research questions about the balance of crystalloid litres); therefore, extracellular volume (ECV) comprises 14 and colloid fluid remain unanswered, current research is fo- litres. The extracellular compartment can be further divided cusing on gaining greater understanding of fluid movement into interstitial (11 litres) and plasma (3 litres) with small at the vascular barrier and how surgery and anaesthetic amounts of transcellular fluids, for example, intraocular, interventions can influence it in the intraoperative period. gastrointestinal secretion, and cerebrospinal fluid completing This review revises the relevant physiology underpinning the distribution (Fig. 1). These transcellular fluids are consid- body fluid distribution and capillary flow dynamics. It also ered anatomically separate and not available for water and discusses the current evidence-based rationale for using solute exchange.1 & The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected] BJA Doherty and Buggy Total body water (TBW) can be estimated by using dilution Capillary tissue fluid dynamics tracer techniques. Isotopically labelled water using deuter- Fluid shifts between the intravascular and remainder of the ium or tritium diffuses through the TBW compartment. Extra- extracellular space occurs at the vascular endothelial cellular fluid (ECF) measurement requires that the marker barrier. The forces governing this were described by Starling4 used must cross capillaries but not cell membranes. Radiola- in 1896 and remain the basis of our understanding of fluid 35 22 82 2 belled sulphate ( SO4 ) or bromide ( Br ) ions are the most movement in the microvasculature. The fluid components commonly used extracellular tracers. Intracellular fluid of the blood are contained within the vessels of the microcir- Downloaded from volume (ICV) is calculated indirectly by subtracting ECV culation mainly by the inward pull of colloid osmotic pressure from TBW. The intravascular volume can be measured (COP) produced by the protein content of the plasma (Fig. 2). using radiolabelled albumin or with the dye Evans Blue. This opposes the high outward hydrostatic pressure, which Interstitial volume is then calculated by subtracting intravas- tends to push plasma out of the vessels and into the intersti- cular volume from ECV. tium. Both the hydrostatic and colloid osmotic pressure in the http://bja.oxfordjournals.org/ The capillary endothelium is freely permeable to water, interstitium are low. The net result of these forces is a small anions, cations, and other soluble substances such as outward leak of fluid and protein from the vasculature to the glucose but is impermeable to protein and other large mole- interstitium which is continually returned to the blood cules .35 kDa, which are largely confined to the intravascu- 5 + vessels via the lymphatic system. The vascular endothelium lar space.2 In the ECF, Na is the principal cation and Cl2 the + is permeable to water but impermeable to protein and other main anion. In contrast, in the intracellular compartment, K large molecules. Movement across the vascular endothelium 22 is the major cation and PO4 the principal anion, with a high of small molecules such as sodium, potassium, chloride, and 3 protein content. As the cellular membrane is freely perme- glucose occurs freely across specialized pathways between at Fundação Coordenação de Aperfeiçoamento Pessoal Nível Superior on September 12, 2012 able to water but not to ions, osmotic equilibrium is main- the endothelial cells. Macromolecule transport may occur tained. In a healthy individual, daily fluctuations in TBW are via large pores in the endothelium or by transport by vesi- small (,0.2%) and are finely balanced with modifications cles.2 Fluid movement across the capillary endothelium can of thirst mechanisms and fluid balance, controlled by the be classified into two types. Type 1 (physiological) occurs renin–angiotensin anti-diuretic and atrial natriuretic continuously with an intact vascular barrier and is returned peptide (ANP) hormone systems. The basal fluid requirement to the vascular compartment by the lymphatic system, in a normothermic adult with a normal metabolic rate is thereby avoiding interstitial oedema. Type 2 (pathological) 21 21 1.5 ml kg h . fluid movement occurs when the vascular barrier becomes COLLOID SALINE GLUCOSE Mg2+ Interstitial Ca2+ ICF Fluid − 28 litre Plasma 11 litre HCO3 3 litre PROTEINS ECF 14 litre K+ 2– PO4 Blood Cells CI– 2 litre Na+ 150 75 0 75 150 Fig 1 Body fluid compartments with main ion distribution. ICF, intracellular fluid. ECF, extracellular fluid. 70 Intraoperative fluids BJA p Pi Interstitial i Endothelial cell layer Downloaded from p Pc c Intraluminal Endothelial cell layer http://bja.oxfordjournals.org/ Interstitial a s p p Jv Kf[(Pc–Pi)– ( c– i)] at Fundação Coordenação de Aperfeiçoamento Pessoal Nível Superior on September 12, 2012 Fig 2 Classic Starling equation with net efflux of fluid to the interstitial space. Jv, net filtration; Kf, filtration coefficient; Pc, capillary hydrostatic pressure; Pi, interstitial hydrostatic pressure; s, reflection coefficient; pc, capillary oncotic pressure; pi, interstitial oncotic pressure. damaged or dysfunctional, allowing excessive fluid accumu- difference. When a colloid solution is infused in this situation, lation leading to interstitial oedema.6 it distributes through the plasma volume, maintaining COP while increasing capillary pressure and therefore fluid filtra- The endothelial
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