Review

Perioperative fluid management for major elective surgery

N. Heming1,2 , P. Moine1,2, R. Coscas3,4 and D. Annane1,2
1
General Intensive Care Unit, Raymond Poincaré Hospital, GHU APHP University Paris-Saclay, Garches, 2 U1173 Laboratory of Inflammation and
Infection, University of Versailles Saint-Quentin-en-Yvelines (UVSQ) and University Paris-Saclay – Institut National de la Santé et de la Recherche
Médicale (INSERM), Montigny-le-Bretonneux, 3 Department of Vascular Surgery, Ambroise Paré Hospital, GHU APHP University Paris-Saclay,
Boulogne-Billancourt, and 4 U1018, Centre de Recherche en É pidémiologie et Santé des Populations, UVSQ and University Paris-Saclay, Villejuif,
France
Correspondence to: Professor D. Annane, Department of Intensive Care Medicine, Raymond Poincaré Hospital, University Paris-Saclay, 104
boulevard Raymond Poincaré, 92380 Garches, France (e-mail: [email protected])

Background: Adequate fluid balance before, during and after surgery may reduce morbidity. This
review examines current concepts surrounding fluid management in major elective surgery.
Method: A narrative review was undertaken following a PubMed search for English language reports
published before July 2019 using the terms ‘surgery’, ‘fluids’, ‘fluid therapy’, ‘colloids’, ‘crystalloids’,
‘albumin’, ‘starch’, ‘saline’, ‘gelatin’ and ‘goal directed therapy’. Additional reports were identified by
examining the reference lists of selected articles.
Results: Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing
major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative
phase. Zero-balance fluid therapy should be aimed for. In high-risk patients, individualized
haemodynamic management should be titrated through the use of goal-directed therapy. The optimal
type of fluid to be administered during major surgery remains to be determined.
Conclusion: Perioperative fluid management is a key challenge during major surgery. Individualized
volume optimization by means of goal-directed therapy is warranted during high-risk surgery. In most
patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional
research on the optimal type of fluid for use during major surgery is needed.

Paper accepted 12 November 2019

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11457

Introduction
Euvolaemia can be obtained through goal-directed therapy.
Advances in both surgery and anaesthesia have contributed This review describes the different means of achieving
to reducing surgery-associated morbidity and mortality euvolaemia, including goal-directed therapy, and appraises
over time1,2. This improvement has occurred even different fluid types and the evidence supporting their
though older and frailer patients are undergoing surgery. use during major surgery.
Major surgery has been defined as ‘any intervention
occurring in a hospital operating theatre involving the Preoperative phase
incision, exci- sion, manipulation, or suturing of tissue,
Dehydration before elective surgery is common, and
and that usually requires regional or general anaesthesia or
frequently relates to fasting and bowel preparation. Pro-
profound seda- tion to control pain’3. Undesirable events
longed fasting may exacerbate dehydration and lead to
can be associ- ated with major surgery, including
discomfort. A meta-analysis9 of available trials found that
myocardial infarction, stroke or death in 2 – 3 per cent
a shorter preoperative fast was not associated with an
of patients4,5. Low peri- operative arterial BP is associated
increased risk of aspiration and was not associated with
with myocardial injury, acute kidney injury and maybe
larger volumes of gastric content. Current European10
even death, and may be preventable6. Fluid therapy and
and American11 guidelines promote the intake of clear
vasoactive drugs are used to maintain BP levels during
fluids up to 2 h before elective surgery. In addition, sys-
surgery7. Fluid therapy aims to maximize stroke volume
tematic mechanical bowel preparation before colonic
and treat hypovolaemia 8. How- ever, fluid overload can
surgery may be unnecessary12. Multiple RCTs, confirmed
cause harm in all types of surgery.

Published by John Wiley & Sons

Ltd
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Published by John Wiley & Sons

Ltd
 Perioperative fluid management for major elective e

Fig. 1 Typical intraoperative goal-directed therapy protocol

Stroke volume variations ≥ 10% Fluids

< 10%

Mean arterial BP > 60 mmHg

< 60 mmHg

Cardiac index < 2·5 l per min per m2 Inotrope agent

> 2·5 l per min per m2

Vasoconstrictor

by meta-analysis, found that omitting mechanical bowel complications compared with fluid imbalance (relative risk
preparation before colonic surgery was not associated (RR) 0⋅59, 95 per cent c.i. 0⋅44 to 0⋅81; P < 0⋅001) and a
with anastomotic leakage or wound infection12 – 16. Fluid shorter hospital stay (mean difference – 3⋅44 (95 per cent
management before surgery aims to maintain euvolaemia
c.i. – 6⋅33 to – 0⋅54) days; P = 0⋅02). A subsequent large
and prevent preoperative dehydration that may increase randomized trial28 compared the safety of a modestly lib-
the risk of subsequent acute kidney injury17. eral fluid regimen with that of a truly stringent
restrictive regimen in 3000 patients undergoing
Perioperative phase abdominal surgery. Patients assigned to the modestly
liberal group had a bodyweight increase of 1⋅6 kg
Liberal versus zero-balance fluid therapy compared with 0⋅3 kg within 24 h in the severely restrictive
Fluid overload may induce interstitial oedema and group. The main outcome, disability-free survival at 1 year,
impair gastrointestinal motility, wound healing, did not differ significantly between the two groups.
coagulation and lead to cardiopulmonary However, the incidence of acute kidney injury was higher
complications18. Perioperative fluid overload may be in the severely restricted group. Therefore, as both a
especially harmful in certain circum- stances, such as after severely restrictive fluid regimen and fluid overload are
pulmonary resection, where it could lead to pulmonary detrimental, a zero-balance fluid therapy should be sought
oedema19. Following pneumonec- tomy, excessive fluid while maintaining kidney function28,29.
administration has been associated with increased in-
hospital mortality20. Observational studies21,22 have found Goal-directed therapy
an association between both exces- sive and insufficient Goal-directed therapy tailors haemodynamic and fluid
intraoperative fluid administration and increased therapy through the perioperative monitoring of a set of
morbidity and duration of hospital stay. Zero-balance cardiovascular indices, including stroke volume, cardiac
fluid therapy, compared with standard treat- ment, in output, oxygen delivery, BP and diuresis. In practice,
patients undergoing abdominal aortic aneurysm repair fluids and vasoactive drugs are guided by standardized
or colorectal surgery reduces the number of post- algorithms aimed at reversing hypotension and low cardiac
operative complications and, in some reports, the duration output (Fig. 1). To function optimally, vital organs require
of hospital stay23 – 26. These findings are supported by a adequate blood flow and BP. Physiological responses to
meta-analysis27, including nine RCTs, accounting for 801 hypovolaemia maintain BP despite decreased blood flow;
patients undergoing elective abdominal surgery, which therefore, blood flow rather than BP monitoring may be
confirmed that zero-balance fluid therapy leads to fewer optimal. Stroke volume varies during positive pressure

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 e N. Heming, P. Moine, R. Coscas and D.

Table 1 Composition of commonly used fluids

Sodium Hartmann’s Hydroxyethylstarch Gelatin Albumin
chloride 0⋅9% solution Plasmalyte 6% 130/0.4 (Gelofusine®) (Albumex® 4)
(Voluven®)
Na+ (mmol/l) 154 131 140 154 154 148
Cl– (mmol/l) 154 112 98 154 120 128
K+ (mmol/l) 5⋅4 5
Ca2+ (mmol/l) 2
Lactate (mmol/l) 28
pH 4⋅5–7 5 –7 6⋅5–8 4 –5⋅5 7⋅1–7⋅7 6⋅7–7⋅3
Osmolarity (mosm/l) 308 278 294 308 274 250

Voluven® (Fresenius Kabi, Friedberg, Germany); Gelofusine® (B. Braun, Melsungen, Germany); Albumex® 4 (CSL Behring, Broadmeadows, Australia).

ventilation, and the amplitude of these variations may

predict individual patient responsiveness to fluid ther- increasingly preferred to 0⋅9 per cent sodium chloride
apy. When small volumes of fluid are administered to solution, which is wrongly named normal saline (Table 1).
fluid-responsive patients, large increases in stroke volume Administration of chloride-rich solutions may cause
are seen30. Fluid responsiveness is typically defined by a hyperchloraemic acidosis42 – 45, renal vasoconstriction
stroke volume increasing by 10 per cent or more and acute kidney injury46 – 48. A propensity-matched
following fluid challenge. cohort study49 of more than 20 000 patients undergoing
In cardiac surgery, goal-directed therapy reduces mor- non-cardiac surgery showed that hyperchloraemia was
tality and major complications31. The largest RCT present in one-fifth of patients, and was associated with
(OPTIMISE, Optimization of Peri-operative Cardio- increased 30-day mortality. A registry-based study50 of
vascular Management to Improve Surgical Outcome) 32 of more than 30 000 patients undergoing major abdominal
goal-directed therapy versus standard treatment included surgery reported lower morbidity following adminis-
high-risk patients undergoing gastrointestinal surgery. tration of balanced crystalloids compared with normal
The primary outcome (a composite of predefined 30-day saline. A large trial51 comparing balanced crystalloids with
moderate or major complications and mortality) occurred normal saline in 13 347 non-critically ill patients in the
in 36⋅6 per cent of the intervention and 43⋅4 per cent of emergency department found no difference in the main
the usual-care group, with a RR of 0⋅84 (95 per cent c.i. outcome (hospital-free days) both in the general popu-
0⋅71 to 1⋅01; P = 0⋅07) in favour of goal-directed therapy. lation and in the surgical subgroup. However, balanced
A subsequent meta-analysis32 of 38 trials, including 6595 crystalloids were associated with a reduced risk of major
participants, concluded that goal-directed therapy reduced adverse kidney events (composite of death, need for renal
the incidence of postoperative infection (RR 0⋅81, 0⋅69 replacement therapy or persistent renal dysfunction). A
to 0⋅95) and reduced duration of hospital stay (mean second trial52 conducted in 15 802 critically ill patients
reduction 0⋅79 (95 per cent c.i. 0⋅96 to 0⋅62) days). These also found that balanced crystalloids were associated with
findings have been confirmed by other researchers33 – 35. fewer major adverse kidney events than normal saline.
Goal-directed therapy may also help reduce costs related A recent trial53 comparing normal saline with buffered
to postoperative complications 36,37. Moreover, achieving solutions in patients undergoing major abdominal surgery
preoperative oxygen delivery values during the postoper- was terminated prematurely because of the increased
ative phase reduced postoperative morbidity 38. Current need for vasopressor therapy in the saline group,
guidelines39,40 recommend the use of goal-directed therapy possibly related to hyperchloraemic metabolic acidosis.
in high-risk surgery, and a large trial is ongoing41. Among balanced fluids, data are still lacking to guide
selection of the optimal buffer (lactate or acetate)54.
Crystalloid versus colloid Colloids are composed of larger molecules than crystal-
The type of fluid used during major surgery may affect loids (Table 1) and are expected to stay in the circulation
outcomes. Two major families of fluid solutions are longer than crystalloids. In terms of volume-sparing
used during surgery, namely crystalloids and colloids. effects, the colloid to crystalloid equivalence ratio is
Crystalloids are salt solutions that diffuse to the intersti- approximately 1 : 1⋅355 – 57. Colloids include dextrans,
tium shortly after intravascular administration. Among hydroxyethyl starches (HES), gelatins and albumin. Stud-
crystalloids, balanced solutions containing electrolytes ies comparing outcomes in surgical patients receiving
and an acid– base balance close to that of plasma are colloid or crystalloid fluid replacement have generally
found no difference in outcomes. A subgroup analysis of

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 Perioperative fluid management for major elective e

the surgical population of a large randomized trial 57,58 in on renal function or mortality compared with normal saline in
ICU found no mortality difference between crystalloid- critically ill patients 78. Subgroup analysis in this group found an
and colloid-treated populations. A meta-analysis59 of 69 increased risk of death in
studies accounting for 30 020 critically ill patients found
no increased risk of death for patients treated by colloids
compared with crystalloids. Further meta-analyses 60 – 64 of
current trials in surgical patients have found no
increased risk of mortality, acute kidney injury or use of
renal replacement therapy associated with the use of
colloids.
Use of HES in the ICU has been associated with an
increased risk of acute kidney injury and/or death 55,56,65. In
the field of liver transplantation, a retrospective compar-
ison of HES versus albumin in patients undergoing liver
transplantation found an association between HES and
acute kidney injury66. However, a recent randomized trial67
including 160 patients undergoing major surgery found
that the intraoperative administration of HES was asso-
ciated with a lower incidence of adverse events
compared with use of balanced crystalloids. One-year
follow-up of the same population did not show any
difference in renal outcome between the HES and
crystalloid population68, but the disability-free survival
rate was higher in the HES group. A large trial69
comparing the administration of normal saline versus
HES in surgical patients is ongoing.
Gelatins are macromolecules derived from bovine
colla- gen. Data on the benefit : risk ratio of gelatins in the
surgi- cal setting are scarce. Gelatins impair clot formation 70
– 72, compared with crystalloids or albumin, and may
induce anaphylactic reactions73. However, ex vivo
inhibition of clot formation is not associated with
excessive perioper- ative bleeding74. Aggregated data
from six clinical trials (accounting for 305 patients)
comparing gelatins with albu- min or crystalloids in
elective surgical patients found that mortality did not
significantly differ between the groups (RR 0⋅97, 95 per
cent c.i. 0⋅21 to 4⋅38; P = 0⋅14)74.
Albumin is harvested from healthy human donors and
treated to prevent pathogen transmission. It is used fre-
quently during major surgery, including hepatic proce-
dures. Potential advantages include the maintenance of
colloid osmotic pressure, preservation of renal function
and a good safety record75. Albumin is, however, expen-
sive, with a short shelf-life. Albumin induces less
bleeding than HES after cardiopulmonary bypass76. A
retrospective analysis77 of data from almost 20 000
patients undergo- ing cardiac bypass found that the
mortality rate was lower among albumin-treated
patients. In non-cardiac surgery, current efficacy and
safety data on albumin derive from large ICU trials78.
These trials found that albumin did not have an impact

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 Perioperative fluid management for major elective e
albumin-treated patients with traumatic 181 – 187.
brain injury. In a further large trial79 there 6 Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A,
was no mortality difference between patients Rodseth RN et al. Relationship between intraoperative
mean arterial pressure and clinical outcomes after
with sepsis who were treated with either
noncardiac surgery: toward an empirical definition of
albumin or crystalloids. A meta-analysis80 of hypotension. Anesthesiology 2013; 119: 507 – 515.
14 studies (18 916 patients) found that 7 Futier E, Lefrant JY, Guinot PG, Godet T, Lorne E,
albumin administration was associated with Cuvillon P et al. Effect of individualized vs standard blood
reduced mortality in sepsis80. Owing to its pressure management strategies on postoperative organ
cost, many institutions have restricted the dysfunction among high-risk patients undergoing major
use of albumin, in particular in surgical
ICUs, without any negative impact on
patient outcomes81,82.

Overview

Optimizing perioperative fluid management is

a key objec- tive during major surgery. A
zero-fluid balance goal, with maintenance of
preoperative bodyweight, should be aimed for.
Goal-directed therapy is warranted during
high-risk surgery. Balanced crystalloids are
increasingly being con- sidered as the first-
line fluid therapy in the operating the- atre.
Ongoing trials may shortly provide more
information about the optimal type of fluid
for major surgery.

Disclosure

The authors declare no conflict of interest.

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Published by John Wiley & Sons