It has been more than 50 yr since the landmark article in which holliday and segar pediatrics 1957. Fluid and electrolyte disturbances are extremely common in the perioperative period. Apa consensus guideline on perioperative fluid management in children v 1. The concept of the glycocalyx facts that influence perioperative fluid management. Preoperative fluid management strategies aim to avoid the patient arriving in the operating room in a hypovolemic or dehydrated state. Goaldirected therapy goal improved tissue perfusion and clinical outcome based on measuring key physiologic variables cardiac output or global o2 delivery achieved with administering fluids, and possibly inotropes, vasopressors, vasodilators, and. The third space may simply be the interstitium or sequestered fluid. Chappell d, jacob m, hofmannkiefer k, conzen p, rehm m. Rational perioperative utilisation and management during the covid19 pandemic. The consequence is a positive fluid balance and weight gain of up to 10 kg, which may be related to severe complications.
A 2012 metaanalysis found that standard or liberal approaches to fluid therapy in patients undergoing major abdominal procedures resulted in a. Among all fluid management strategies, goal directed strategy is the most rational approach to maintain optimum fluid balance. Maintenance fluid infusion, in conjunction with small 200250 ml boluses of fluid, achieves this objective. Mar 31, 2011 a rational approach to perioperative fluid management. A rational approach to perioperative uid management.
Much of our practice of fluid administration in the perioperative period is based on this article. Tracer methods to look for blood or fluid extravasation and shifts have been inconsistent. The postoperative goal is eating and drinking without intravenous fluid infusions. Fluid management is an essential part of postoperative therapy. Many postsurgical complications are related, at least in part, to insufficient or excessive fluid administration during the perioperative period. This can typically be achieved with overall intraoperative fluid requirements of approximately 3 l for a 3 to 4h procedure, but will obviously vary depending on blood loss and the surgical procedure and duration. We believe that perioperative goaldirected therapy is the rational approach for moderate to highrisk patients. Thirdspace losses are usually underestimated and postoperative fluid prescribing rarely takes them into account.
Perioperative fluid therapy has been studied extensively, but the optimal strategy remains controversial and uncertain. In practice, previously healthy patients with an uncomplicated perioperative course tolerate. Rational approach to clinical fluid balance in practice, previously healthy patients with an uncomplicated perioperative course tolerate even the most bizarre fluid regimens. A rational approach to perioperative fluid management. This paper provides a general approach to fluid therapy and practical recommendations. A rational approach to perioperative fluid management daniel chappell, matthias jacob, klaus hofmannkiefer, peter conzen, markus rehm anesthesiology 2008, 109 4. A more structured approach to fluid management is required to overcome these problems. Perioperative fluid therapy oxford academic journals. Balanced crystalloids are generally the first choice of fluids during major elective surgery. Postoperative intravenous maintenance fluid therapy ensures adequate organ perfusion, prevents catabolism, ensures electrolyte and phbalance, and may be all that is required for patients who undergo surgical procedures that do not significantly alter the hemodynamic milieu.
If such a rational approach was to be adopted worldwide, it may be possible to prevent every year almost 3 million postoperative complications and to save more than 800 000 lives. Conversely, the danger of hyperglycemia in the perioperative period is a real clinical issue that has table 3 guidelines for. Aggressive fluid resuscitation to achieve a central venous pressure cvp greater than 8 mm hg has been promoted as the standard of care, in the management of patients with severe sepsis and septic shock. Perioperative crystalloid and colloid fluid management in. These initiatives, being integral parts of enhanced recovery programs erps, are necessary because of the escalation in healthcare costs and increasing number of patients requiring surgical interventions. A rational approach to perioperative fluid management request. Maintaining effective circulating blood volume and pressure are key components of assuring adequate organ perfusion while avoiding the risks associated with either organ hypo or hyperperfusion. From physiology to improving clinical outcomes abstract perioperative fluid management is a key component in the care of the surgical patient.
Finally, we propose a rational approach currently used at our institution. Apr 10, 2015 although perioperative fluid management remains a highly debated subject, data suggests that goaldirected fluid therapy with the objective of hemodynamic optimization can reduce complications after major surgery. Perioperative fluid therapy bja education oxford academic. Apa consensus guidelines on perioperative fluid management in. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians.
Tpn and tube feeds consult dietician learn to do the calculation yourself. Goaldirected fluid therapy, perioperative pain management. Rational fluid management plan for a 70 kg man undergoing an open small bowel resection npo for 6 hours fluid deficit. Perioperative fluid management 77 fest clinically for days. If we are as good as we think we are at perioperative fluid therapy, then in. Chappell d1, jacob m, hofmannkiefer k, conzen p, rehm m.
Goaldirected fluid therapy gdt and perioperative pain management are approaches designed to improve care in the perioperative period. Conservative vs restrictive individualized goaldirected. Problems are much more common in those with preexisting renal or cardiopulmonary disease and those who develop complications. Nomenclature of solutionsnomenclature of solutions one mole of substance 6. Current perioperative fluid therapy do we have a problem. The focus of perioperative fluid therapy has shifted from a fixeddose approach based on static measures towards titration of fluids guided by dynamic indices of fluid responsiveness. A rationale approach to perioperative fluid therapy in adult patients.
A rational approach to lymphedema risk reduction practices. There are 2 main, partially overlapping strategies in perioperative fluid management. Fluid management, liberal versus restricted, colloid versus crystalloid, intraoperative fluid background fluid management in the perioperative period has been extensively studied but, despite that, the right. Rational fluid management plan for a 70 kg man undergoing an open small bowel resection npo for 6 hours second hour. View enhanced pdf access article on wiley online library html view. Fluid management in the perioperative period has been extensively studied but, despite that, the right amount still remains uncertain. Intraoperative fluid management and blood transfusion essentials. Impact of goaldirected perioperative fluid management in. Fluid resuscitation, perioperative fluids, goaldirected fluid. Replacement of assumed preoperative deficits, in addition to generous substitution of an unsubstantiated increased insensible perspiration and third space loss.
The glucose, electrolyte, and intravascular volume requirements of the pediatric surgical. Effect of intraoperative fluid management on outcome after intrabdominal surgery. Perioperative fluid management in kidney transplantation. Rational fluid management the key to enhanced recovery after surgery program description. While a restrictive fluid management approach has long been advocated, there is a paucity of data related to this approach in thoracic surgical patients specifically. Its purpose is to maintain or restore effective circulating blood volume during the immediate perioperative period. The occurrence of one or more postoperative complications adversely effects both shortterm and longterm survival and increases healthcare costs 1,2. Central venous pressure cvpguided volume infusion is the traditional approach in renal transplantation 7, 8 and involves intraoperative infusion of large volumes of fluid. It is common practice to include intraoperative fluids in the fluid balance on the day of surgery. Multiple international guidelines, including those from the american society of anesthesiologists, allow unrestricted intake of clear fluids up to 2 h before elective surgery. Specific hemodynamic goals include maintaining adequate circulating volume, perfusion pressure, and oxygen delivery.
Maintenance 110 ml plus remaining deficit 300 ml plus approx 4. Intraoperative fluid management and blood transfusion. Goaldirected therapy goal improved tissue perfusion and clinical outcome based on measuring key physiologic variables cardiac output or global o2 delivery achieved with administering fluids, and possibly inotropes, vasopressors, vasodilators, and rbcs targets are defined physiologic endpoints. Efficacy and harm of antiemetic interventions, and methodological issues, acta anaesthesiologica scandinavica, 45, 1, 4, 2001. Optimal fluid therapy has been shown to decrease delayed graft function after renal transplantation. Pertinent normal cardiovascular physiology the amount of blood pumped out of the heart cardiac output is equivalent to venous return volume entering the right atrium. The management of fluid in the postoperative surgical patient can vary from simple to complex. Perioperative fluid administration should be standardized based on the best evidence available and on the most rational physiologic end points. In general terms, based largely on the results of the relief trial, 8 the overall goal of fluid management for major surgery should now be considered to be a moderately liberal approach, with a positive fluid balance at the end of surgery of 1 to 2 l. The purpose of this paper is to summarize the state of the art of intraoperative fluid approach today. The aim of gdt is to guide fluid and pharmacological inotrope therapy, by using flowdirected hemodynamic parameters, to maintain adequate tissue blood flow, circulating volume, and oxygen delivery. The prevention of postoperative morbidity is a key factor in providing highquality, highvalue. Much of the current debate surrounds the type of fluids administered colloid versus crystalloid, the total volume administered restrictive versus liberal lvr, and whether the administration of fluids should be guided by hemodynamic goals goal directed gd versus not.
In the current medical literature there are only heterogeneous viewpoints that gives the idea of how confusing the situation is. Major surgery is a considerable physiologic insult that can be associated with significant morbidity and mortality. British consensus guidelines on intravenous fluid therapy for adult surgical patients giftasup. Request pdf a rational approach to perioperative fluid management replacement of assumed preoperative deficits, in addition to generous substitution of. This development can be attributed to the recognition that haemodynamic optimization by overzealous administration of i. Request pdf a rational approach to perioperative fluid management replacement of assumed preoperative deficits, in addition to generous substitution of an unsubstantiated increased insensible. The national lymphedema network nln position paper on lymphedema risk reduction practices offers a rational approach to risk reduction. A rational approach to perioperative fluid management the goal of perioperative fluid application is the same than that of the cardiovascular system under normal conditions. Perioperative medications associated with hyperchloremicmetabolic acidosis beneficial in closed head injury. Thus, a rational approach to perioperative fluid management is crucial to mitigate the risk of postoperative pulmonary injury. A rational approach to the control of postoperative nausea and vomiting. D chappell et al, a rational approach to perioperative fluid management. We have become desensitized to administration of high fluid volumes 56 liters for major surgical procedures1 patients typically gain 5kg of body weight after major surgical procedures2 4 1.
Perioperative fluid management must always be seen in light of a multi modal approach and must be balanced at the needs of the patient and the surgical approach chosen. In contrast to restrictive fluid therapy, which implies deliberate hypovolaemia 20, the aim is zero. Jan 25, 2018 optimal fluid management is essential to reduce perioperative complications. A rational approach to perioperative fluid management read. Evidence for conservative fluid administration following elective surgery.
Whether clinicians will quickly adopt perioperative fluid optimization strategies is another story. Perioperative fluid therapy remains a highly debated topic. Replacement of assumed preoperative deficits, in addition to generous substitution of an unsubstantiated increased insensible perspiration and third space loss, plays an important role in current perioperative fluid regimens. A rational approach to the control of postoperative nausea. Debate open access liberal or restricted fluid administration. Perioperative fluid therapy perioperative medicine biomed central. Traditionally, the perioperative volume infusion regimen in this patient population has been guided by central venous pressure as an estimation of the patients volume status and mean.
Tramer, a rational approach to the control of postoperative nausea and vomiting. Maintenance 110 ml plus 3rd space loss 280 space loss 280 ml plus 4 x 100 ml to replace blood loss 790. Approaches to fluid management the classic approach to fluid management. A rational approach to fluid therapy in sepsis british. A rational approach to fluid therapy in sepsis sciencedirect. A rational approach to perioperative fluid management pdf clinical practice guide for the choice of perioperative volumerestoring fluid in adult patients undergoing noncardiac surgery pdf fluid therapy recommendations for major abdominal surgery. These findings suggest that many perioperative physicians may have become too restrictive if using a zerobalance approach, and that a moderately liberal fluid regimen aiming for an overall positive fluid balance of 1 to 2 l at the end of surgery should be recommended 30 that is, an overall crystalloid fluid infusion rate of 10 to 12 ml. Perioperative fluid management strategies in major surgery. This is an individualized approach to fluid management2427, offering. Fluid administration should be strictly guided by defined physiologic end points and should not follow fixed standards. However recent clinical trials have demonstrated that this approach does not improve the outcome of patients with severe sepsis and septic shock. The incidence of delayed graft function in patients undergoing kidney transplantation remains significant.