what, when and how much fluid to give in surgery

1. Amr Hany
MBBS, MRCS
Perioperative Fluid Therapy
for Major Surgery

2. What’d you say?
• What type of fluids to use and
when?
• Will the patient benifit from
fluids?
• Before the OR
• Inside the OR
• After the OR
Serve the vein and
starve the gut?

3. Quick overview

4. What fluid to use?
Fluid therapy
Maintainance
therapy
Volume
therapy
Depends on what you want to do

5. Maintainance
Balancd fluids
• E.g. Hartmann’s and lactated
Ringer’s
• More closely aligns with plasma
electrolytes and acid–base
equilibrium.
• Lower incidence of acute kidney
injury.
• Lower incidence of death and new-
onset renal replacement therapy.
0.9% “normal” saline
• Large observational evidence
suggesting 0.9% saline should
not be used during major
surgery.
• It is associated with
hyperchloremia, metabolic
acidosis, and acute kidney injury.

6. Volume (resuscitation)
• The choice remains controversial and most studies haven’t shown not any
meaningful difference between colloid and crystalloid.
• Physiologic rationale for using colloids because they tend to remain in the
IV space longer.
• In animal models of hemorrhage, resuscitation with colloids has also been
shown to be significantly faster than with crystalloids.
• Most goal-directed therapy studies have used colloid boluses for volume
therapy.
• Might reduce postoperative complications.
• In major hemorrhage scenarios, quickly restore circulating blood volume,
and this is probably best accomplished with red cell, plasma, and other
blood product transfusion.

7. Will this patient benifit from fluids?
• What is fluid responsiveness?
10% or greater increase in stroke volume
• How much fluid is a fluid chalange?
250 ml of colloid or 110 ml of crystalloid, both equally effective
• How can you know?
passive leg raising reliably predicts fluid responsiveness

8. Passive leg raising (PLR)
• Ideally, PLR should be done along with advanced monitoring like a pulse
contour device or esophageal Doppler to reflect changes in SV;
• if unavailable, the effect on systolic blood pressure can be used.
• can be used during and after surgery to ascertain intravascular volume
status at those times
JAMA int med

9. • lower risk of aspiration
• Improves comfort and safety, reduces thirst
and hunger
• does not increase gastric volumes, and
reduces the acidity of gastric content
Up to 2 h
before surgery
Allow
unristricted
intake of
clear fluid
Like water,
fruit juices without pulp,
carbonated beverages,
carbohydrate-rich drinks,
clear tea, and black coffee.
Before the OR

10. Carbohydrate-rich drinks, like maltodextrin
• Reduces insulin resistance.
• Reduces hyperglycemia postoperatively,
which is a risk factor for nosocomial
infection.
• Improves patient satisfaction by reducing
thirst and hunger.
• Reduces postoperative nausea and
vomiting.
• The metabolic benefits occurs by creating
a fed, anabolic state before surgery.

11. Intraop
fluid
volume?
Liberal Restrictive
monitor?
advanced Regular
Inside the OR

12. liberal
more than 6 L of fluid
on the day of surgery
restrictive zero fluid balance
So how much?
• moderately liberal fluid regimen
• aiming for an overall positive fluid balance of 1 to 2 L
at the end of surgery should be recommended
• that is, an overall crystalloid fluid infusion rate of 10
to 12 ml/kg/h during major abdominal surgery,
• and 1.5 ml/kg/ h in the 24-h postoperative period.
• more is associated with up to 4kg edematous weight
and less could result in AKI.

13. advanced
goal directed flow via
SV monitoring
regular
monitor pressure via
SBP
“It is a source of regret that the measurement of flow [i.e., SV] is so
much more difficult than the measurement of pressure. This has led to
an undue interest in the blood pressure manometer.”
Adolf Jarisch (1850-1902), Austrian dermatologist.

14. Consideration of goal-directed therapy and postoperative admission to a surgical
intensive care unit (SICU) in major surgery.

15. After the OR
• Early oral intake is encouraged
postoperatively in all patients whenever
possible.
• Minimize postoperative continuation of
all lines (IV and arterial), nasogastric
tube, urinary catheter, and drain tubes,
which further limit a patient’s ability to
ambulate.

16. Overall recommendation
• Minimize preoperative fasting times.
• Encourage unrestricted intake of clear fluids until 2 h before elective surgery.
• Passive leg raising followed by measurement of blood pressure or (ideally) stroke
volume is a useful test for predicting fluid responsiveness.
• Aim for a moderately liberal IV fluid regimen with an overall positive fluid balance
of 1–2 l at the end of surgery.
• Crystalloid infusion is rate of 10–12 ml/kg/h during surgery, and 1.5 ml/kg/h in
the 24-h postoperative period.
• Ensure that intravascular volume status is optimized before adding vasopressor
therapy.
• Use an advanced hemodynamic monitor to measure fluid responsiveness in
higher-risk patients having major surgery.
• Aim for early transition from IV to oral fluid therapy after surgery (usually within
24 h).

17. Source: Anesthesiology 2019; 130:825–32
Thank you