A Rational Approach to Perioperative Fluid Management

Abstract

PERIOPERATIVE fluid application has been a topic of debate in past years. After the ongoing controversy on colloids versus crystalloids1–3 and proposing the ideal composition of saline fluids,4–7 the main focus is now on the amount of applied fluids in general.8–13 The discussion is still dominated by the advocates of a more liberal regimen.14–20 Most perioperative fluid overload is regarded as a minor problem, and studies showing increased fluid accumulation in tissue have not changed this attitude.21,22 Rather, preoperative volume loading is considered indispensable by many,15,19,23–26 and fluid boluses are part of most recommendations for perioperative care.11,27 This statement is mainly based on four generally unquestioned pathophysiologic “fundamentals”: (1) The preoperatively fasted patient is hypovolemic because of ongoing insensible perspiration and urinary output10; (2) the insensible perspiration increases dramatically when the surgeon starts cutting the skin barrier27; (3) an unpredictable fluid shift toward the third space requires generous substitution28; and (4) hypervolemia is harmless because the kidneys regulate the overload.29