REVIEW

CURRENT
OPINION Fluid management before, during and after elective
surgery
Niels Van Regenmortel a,b, Philippe G. Jorens b, and Manu L.N.G. Malbrain a

Purpose of review
Fluid management is regarded as a cornerstone of successful perioperative care, but fluid prescription is
not always treated that way. New insights and guidelines have become available very recently.
Recent findings
Although most of the recent scientific attention went to resuscitation fluids and the place of hydroxyethyl
starches, recent guidelines also emphasize the importance of fluid prescription in a maintenance and a
replacement setting. The use of balanced solutions over saline 0.9% gains momentum because recent
evidence shows the deleterious effect of chloride-containing solutions on relevant clinical endpoints. Where
the debate on the use of starches in septic and critically ill patients seems to be settled after recent trials
pointed out several safety issues in the absence of a proven benefit, their intraoperative use is still a matter
of debate. A presumably correct use in this setting was proposed recently.
Summary
The combination of a careful prescription of maintenance fluids, additional replacement solutions tailored to
the patient’s eventual extra needs and a rational but nonaggressive goal-directed approach to resuscitation
fluids seems to be the best practice to avoid fluid-related morbidity. Isotonic balanced crystalloids seem the
best pragmatic choice for resuscitation purposes. In certain well defined conditions, colloids can still be
used.
Keywords
balanced solutions, colloids versus crystalloids, fluid indications, goal-directed therapy, perioperative

INTRODUCTION TAILORING FLUID PRESCRIPTION TO THE

Although being essential in the preoperative, post-
operative and intraoperative phase, until recently,
fluid therapy was widely regarded as an innocent
bystander or as necessary evil at best. It was dem-
onstrated that fluid prescription in the preoperative
and postoperative period was frequently left to the
most inexperienced member of the team, some-
times lacking training in even basic knowledge of
fluid and electrolyte balance [1]. Evidence has
shown, however, that a perioperative weight gain
of not more than 2–3 kg can lead to increased
morbidity and a longer length of hospital stay [2],
thus leading to increased awareness on the dangers
of fluid misuse. Another fierce debate has been
going on lately on the type of resuscitation fluids
used in case of acute hypovolemia, challenging the
place of the hydroxyethyl starches (HES). Because
perioperative fluid therapy is crucial to achieving
better clinical outcomes, we will try to concisely
distill the current best practice out of the most
relevant recent literature on the different indica-
tions in this setting.
PATIENT’S NEEDS: THREE DISTINCTIVE
FLUID INDICATIONS
It is important to acknowledge that three main
indications for fluid therapy exist in the perioper-
ative setting. Because the best fluid is probably the
one that has not been given to the patient,
thoroughly considering why fluids should be used,
followed by selecting the correct type and dose of
fluid for that indication, will be the key to limiting
fluid-related morbidity. There are three distinctive
categories. First, resuscitation fluids to correct an
intravascular volume deficit or acute hypovolemia.
Much of the recent scientific attention went to this
particular indication of fluid therapy, especially in
a
Ziekenhuisnetwerk Antwerpen, Campus Stuivenberg, Antwerp, Belgium
and bAntwerp University Hospital, University of Antwerp, Edegem,
Belgium
Correspondence to Niels Van Regenmortel, MD, Belgium. Tel: +32 3 217
70 36; e-mail: niels.vanregenmortel@zna.be
Curr Opin Crit Care 2014, 20:390–395
DOI:10.1097/MCC.0000000000000113

www.co-criticalcare.com Volume 20  Number 4  August 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS
 Whether the indication is maintenance, replacement or
resuscitation determines the prescription of the dose,
type and electrolyte content of the fluid.
 During resuscitation, isotonic balanced crystalloids are
gaining momentum, making them a pragmatic first
choice.
 Starches have probably better plasma-expanding
capacities, but should be given only in limited
indications and with great caution.
 Rational goal-directed therapy should be targeted to
relevant endpoints within the limits of the patient’s own
cardiac capacity.
the light of the recent colloid–crystalloid debate.
Therefore, it is sometimes overlooked that a relevant
part of the total infused volume during a patient’s
stay in the hospital does not fall into this category.
Second, maintenance solutions are specifically given
to cover the patient’s daily basal requirements of
water and electrolytes. Third, replacement solutions
are prescribed to correct existing or developing def-
icits that cannot be compensated by oral intake, as
seen in situations in which fluids are lost via drains or
stomata, fistulas, fever, polyuria and open wounds
(including evaporation during surgery or burns)
among others. A complete set of guidelines, algor-
ithms and instructions for intravenous fluid therapy
in adult hospitalized patients was recently provided
by the United Kingdom’s National Institute for
&&
Health and Care Excellence [3 ]. The somewhat
older British Consensus Guidelines on Intravenous
Fluid Therapy for Adult Surgical Patients [4] summar-
ize evidence especially for the management of surgi-
cal patients.
Maintenance solutions: purely dedicated to
daily needs
The aforementioned maintenance solutions are
specifically intended to cover daily needs. These basic
requirements are water, in an amount of 25–30 ml/kg
of body weight, 1 mEq/kg sodium and 1 mEq/kg
potassium per day. It is easily appreciated that with
1 l of NaCl 0.9%, with a sodium content of 154 mEq/l,
the daily need for salt is already grossly exceeded,
which makes the use of this and other isotonic
solutions improper in this indication [5]. Potassium,
on the other hand, is frequently underdosed, leading
to arrhythmias and the need for (potentially harmful)
additional doses. To prevent starvation ketosis in
adults, a minimum of 50–100 g of glucose should
be provided daily.
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Perioperative fluid management Van Regenmortel et al.
Although some specific maintenance solutions
are commercially available in certain countries, none
of them cover the precise daily needs of the average
adult patient (mostly they contain too little potass-
ium in relation to the salt or water content or both).
Therefore, in practice it will be necessary to tailor
them to the individual patient’s needs by adding
electrolytes to readily available glucose or dextrose
5 or 10% preparations. Because the amount of fluids
or electrolytes already administered by enteral intake
or as part of total parenteral nutrition is to be sub-
tracted from the maintenance prescription, the main
strategies to reduce unnecessary intravenous fluid
administration are shortening of preoperative fasting
regimens [6–8] and the promotion of early post-
operative feeding, even after abdominal surgery
[9–13]. Pursuing this is imperative as a first step in
avoiding tissue edema and reducing fluid-related
morbidity.
Replacement solutions: copy and paste the
fluids lost, but do not exaggerate
Data on replacement fluids are scarce. Several recent
&&
guidelines [3 ,4] advise to match the amount of fluid
and electrolytes as closely as possible to the fluid that
is being or has been lost. An overview of the compo-
sition of the different body fluids can be found in the
National Institute for Health and Care Excellence
&&
guidelines [3 ]. Most of the time isotonic balanced
solutions will do the job, although some forms of
diarrhea can be hypotonic. An exception is the loss of
gastric fluid, which is chloride rich and should be
replaced by high-chloride solutions, like saline 0.9%,
or fluids with a negative strong ion difference
(SID) (as discussed further) containing, for example,
ammonium chloride to avoid or treat metabolic alka-
losis. Replacement fluids are frequently overdosed in
the perioperative setting because of the misconcep-
tion that evaporation during surgery is always high. It
was shown already years ago that even open abdomi-
nal wounds with liberal exposure of organs are associ-
ated with a fluid loss of not more than 30 ml per hour
[14]. Also, the practice of using diuresis as a trigger for
fluid administration can easily lead to fluid overload
because both anesthesia and surgery slow down the
rate of elimination of crystalloids. Oliguria is poorly
correlated with hypovolemia in the perioperative
setting and should not trigger fluid administration,
although, on the other hand, increased diuresis is a
&
good indicator of hypervolemia [15,16 ].
Resuscitation fluids: the colloid–crystalloid
debate and beyond
Resuscitation fluids are indicated mainly intra-
operatively in situations of acute intravascular
www.co-criticalcare.com 391
 Intravenous fluids
hypovolemia and shock. Particularly in Europe, there
has been a long-standing tradition of using – at least
partly – colloids, such as HES and to a lesser degree
gelatins, in this indication. The use of even the latest
generation of HES has been challenged recently after
the publication of two large randomized controlled
& &
trials [17,18 ,19 ] and subsequent meta-analyses
[20–23] raising concern about their accumulation
in different tissues leading to increased acute kidney
injury or renal replacement therapy and – in septic
patients – increased mortality. A subsequent rando-
mized controlled trial comparing open-label colloids
versus crystalloids generated contradictory results
[24]. The discussion following these publications
divided key opinion leaders and the scientific com-
munity at large in a pro and contra colloid camp
[25,26], leaving many medical practitioners in the
field confused and in doubt. The most important
question at this time is whether the findings of the
big fluid trials can be extrapolated to the perioper-
ative setting. Where the opponents of colloid use will
point out the significant safety issues raised by the
aforementioned trials and the higher cost in the
absence of any proven benefit, clinicians in favor
of their use [27] are stressing their plasma-expanding
capabilities [28], leading to faster hemodynamic
stabilization with less fluid. For the time being their
plea not to throw out the baby with the bathwater in
the perioperative setting, generally implying patients
in a less-inflammatory state than the so-called
‘critically ill’, has been followed by regulatory
authorities in the United States and Europe. The
North American Food and Drug Administration
and the European Medicines Agency concluded a
tedious evaluation process with a restriction of the
indications of HES, but authorized them in the peri-
operative setting, not without proclaiming some
additional warnings. This led to updated product
information leaflets that are now different depending
on the continent where they are marketed.
For clinicians looking for an alternative to HES,
the isotonic balanced solutions seem to be the most
pragmatic choice as will be discussed below. Possibly
plasma volume expansion after crystalloid admin-
istration is not as poor as sometimes perceived. It
was suggested that in the case of a 20% reduction of
mean arterial pressure the distribution of fluid from
plasma to interstitial space is halted [15]. Moreover,
this redistribution process has a half-life of about
8 min and takes 30 min to complete. This means
that during routine surgery about 60% of the infused
crystalloids should remain in the intravascular com-
partment [29].
On the other hand, elegant research has shown
that the volume effect of crystalloids can be strikingly
small and the underlying hypovolemia often gets
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unnoticed when standard hemodynamic parameters
&
are used [30 ]. Clinicians wishing to continue to use
HES for acute hypovolemia in the perioperative
setting are strongly advised to take precautionary
measures regarding indication, dose and patient
selection. A ‘presumably correct approach’ to using
&
HES was proposed by Meybohm et al. [31 ] taking into
account the following six criteria. First, use HES early
after the onset of shock. Second, limit their use to
acute volume resuscitation for hemodynamic insta-
bility in case of hypovolemia for a maximum of 24 h.
Third, use reliable algorithms of fluid responsiveness
and predefined hemodynamic endpoints. Fourth,
comply with maximum dose. Fifth, use objective
indicators of hypovolemia (e.g., lactate). Sixth, avoid
them in preexisting or acute renal failure and if
oliguria is not responsive to fluids (with or without
HES) within a period of maximum 6 h. Although
these recommendations were developed from a
trial-designing perspective, we feel that they reflect
a good compromise between the available data on
possible risks and benefits of HES and the gut feeling
that they should be kept on the market as they may
still have a role in certain clinical situations. In turn,
colloid users should be aware that the volume effect
of a colloid solution is context-sensitive; although
their use in hypovolemia will lead to the desired
plasma expansion, administering them to normovo-
lemic patients will cause a swift extravasation of the
colloid from the intravascular space toward the inter-
stitium [32]. It was also noticed that starches promote
the accumulation of later-infused crystalloids and
even prolong their elimination half-life [33].
The older gelatins, besides having a shorter half-
life, a smaller volume effect and a higher chance of
developing anaphylactic reactions than HES, also
lack an actual scientific proof [34]. Iso-oncotic
human albumin was already shown not to be superior
to saline in a general ICU setting many years ago [35],
and there is no reason to assume that this would be
markedly different in a surgical population. There is
no evidence for the use of hyperoncotic albumin 20%
either, a statement becoming even stronger after the
recent ALBIOS trial did not show overall improve-
ment in survival over crystalloids even in a notori-
ously hypoalbuminemic situation such as severe
sepsis [36]. The indication for blood transfusion goes
beyond the scope of this review.
AVOIDING HYPERCHLOREMIC
METABOLIC ACIDOSIS. SHOULD WE GO
BALANCED?
Balanced solutions are solutions with an electrolyte
content closely resembling that of human plasma.
The most important characteristic of these solutions
Volume 20  Number 4  August 2014

is their positive SID due to the presence of a lower
amount of the strong anion chloride than its positive
counterpart sodium. This can only be achieved by the
addition of anions such as lactate, acetate, gluco-
nate or malate. A detailed description of the rationale
behind the use of balanced solutions, the so-called
Stewart approach, goes beyond the scope of this
review, but can be found in detail elsewhere
[37,38]. The appeal of balanced solutions lies in their
ability to avoid the development of hyperchloremic
metabolic acidosis (which is called SID-acidosis by
purists because it can theoretically arise in the
absence of hyperchloremia, for example, in case of
hyponatremia). Examples of balanced solutions are
the slightly hypotonic Hartmann’s, the different
Ringer’s and the isotonic PlasmaLyte (Baxter,
Deerfield, Illinois, USA) solutions. Also, starches
can be dissolved in a balanced core solution (e.g.,
VoluLyte, Fresenius Kabi, Bad Homburg, Germany).
The gelatins are regarded spontaneously balanced as
the gelatin itself is acting as a weak anion, creating
a certain strong ion difference [e.g., succinylated
gelatin Gelofusin 4% (B. Braun, Melsungen,
Germany) has an SID of 34 mEq/l without adding
buffer solutions].
There are many reports proving that the use of
balanced solutions results in a more stable acid-base
profile in different patient populations [39–44].
There also seems to be a favorable effect on fluid
retention, as balanced solutions, versus saline, lead
to earlier micturition and thus faster clearance of a
given fluid load [45]. Whether there is also an
advantage on more clinical and economic end-
points is still a matter of debate. Until recently,
the only available evidence came from animal stud-
ies [46–48] and experiments in healthy volunteers
[49,50]. After the proof of the deleterious effects of
long-term hyperchloremic metabolic acidosis on
kidney function has been delivered in the nephro-
logical literature [51], the issue now gets acknow-
ledged in surgical and critically ill populations. In
2012, the publication of an extensive observational
&
analysis [52 ] of a large United States insurance
database showed that the use of PlasmaLyte versus
saline 0.9% on the first day of major abdominal
surgery led to less postoperative morbidity in the
form of postoperative infections and renal failure
requiring dialysis and to lower acidosis-related
investigations and interventions, and thus costs.
In a prospective open-label sequential experiment
&
[53 ] in patients admitted to a tertiary ICU, the
chloride content of all the fluids used during
an intervention period was rigorously restricted,
leading to a significant risk reduction for acute
kidney injury according to the RIFLE classification
and a significant decrease in the need for renal
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Perioperative fluid management Van Regenmortel et al.
replacement therapy. Although some limitations,
such as the unblinded design and a shift in fluid
management that went beyond the chloride level
alone (e.g., iso-oncotic albumin was replaced by
hyperoncotic albumin during the intervention
period), hindered a definitive conclusion, the trial
provided clinicians with the first evidence against
the careless use of chloride-rich solutions such as
saline 0.9%. Similar results were found in a large
retrospective cohort trial [54] in a surgical population
in which postoperative hyperchloremia was associ-
ated with an increased risk of mortality at 30 days and
a longer hospital stay. Awaiting stronger evidence,
abandoning the use of saline 0.9% in favor of isotonic
balanced crystalloids seems a pragmatic choice,
especially in sicker patients or when large amounts
are necessary. The first randomized controlled trial to
address the potential clinical advantages of Plasma-
Lyte over saline in a mixed intensive care population
will soon take off (website: http://www.anzics.com.
au/ctg/current-research/33-clinical-trials-group/cur
rent-studies/354-split).
The fact that all currently commercially avail-
able isotonic balanced solutions contain a low
amount of potassium in the range of 4–5 mEq/l
has led to some concern about their use in patients
with acute or chronic renal failure. A few studies
have specifically addressed this question and unan-
imously found a higher potassemia in patients
undergoing renal transplant because of the use of
potassium-free saline versus balanced solutions con-
taining a low dose of potassium [55–57]. The expla-
nation lies in the release of potassium from the
extensive intracellular stores due to saline-induced
acidosis. This makes balanced solutions preferable
over saline 0.9% even in patients with impaired
kidney function.
LIBERAL VERSUS RESTRICTIVE:
GUARDING THE BORDERS OF GOAL-
DIRECTED THERAPY BY IMPROVED
ASSESSMENT OF FLUID THERAPY
Many recent trials and publications addressed the
important issue of restrictive versus liberal fluid
strategies in the perioperative setting. The difficulty
interpreting the different results originates from
the lack of definition and standard on ‘restrictive’
and ‘liberal’ fluid management, thereby precluding
the development of good guidelines for procedure-
specific perioperative fixed-volume regimens
&
[58,59 ]. Current best practice seems to be the com-
bination of a fixed crystalloid administration (the
combination of maintenance and replacement
solutions) and a rational goal-directed approach to
resuscitation fluids.
www.co-criticalcare.com 393
 Intravenous fluids
The practice of perioperative goal-directed fluid
therapy (GDT) involving the administration of IV
fluid boluses and inotropes to optimize predefined
hemodynamic goals has been known for some time
to be advantageous in terms of complication rate
and hospital length of stay after surgery [60].
Although certainly beneficial, especially in high-risk
surgery [61], the fact that these advantages some-
times come at the expense of a dramatically larger
amount of fluids needed cannot be ignored [62]. The
impact of this phenomenon has not been fully
elucidated to this day, but it may be the reason
why the practice is not always effective [63]. Because
problems seem to arise specifically when rather rigid
and sometimes supraphysiologic therapeutic goals
(e.g., fixed values of cardiac index or oxygen deliv-
ery are used, the key to the benefits seems to be in
the chosen targets. Clinicians need to perform GDT
always within the limits of the patient’s cardiac
tolerability. This can be done by using functional
hemodynamic endpoints, such as stroke volume
variation or pulse pressure variation in combination
with assessment of fluid responsiveness like the
passive leg raising test or central venous oxygen
saturation instead of more static parameters such
as mean arterial pressure or central venous pressure
[64]. GDT should not lead to a forgiving attitude
toward aggressive and potentially detrimental fluid
overload.
CONCLUSION
Fluid therapy in the perioperative setting should be
directed toward maximum effect with minimum
fluid, sodium and chloride load. After all, before
patients can recover, they must excrete the admin-
istered water and electrolytes. Therefore, common
sense must prevail and fluids should be seen as any
other drug with indications, contra-indications and
possible adverse effects. Fluid requirements depend
on the indication they are given for (maintenance,
replacement, resuscitation) and change over time.
Especially when the purpose is resuscitation, the
approach should be targeted and protocol driven.
Isotonic balanced salt solutions are a pragmatic
choice in the majority of perioperative resuscitation
settings. Although the use of colloids cannot be
discarded on the basis of the current literature, they
should be used only after careful deliberation.
Acknowledgements
None.
Conflicts of interest
N.V.R. has received speaker’s fees from Baxter, Fresenius-
Kabi and B. Braun. M.M. has received speaker’s fees
from Fresenius-Kabi and Nestec and is a member of the
394 www.co-criticalcare.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
medical advisory board of Pulsion Medical Systems.
N.V.R. and M.M. are chairs of the International Fluid
Academy Days (www.fluid-academy.org), a nonprofit
organization promoting education on fluid management
and hemodynamic monitoring. P.J. has no conflicts of
interest.
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