Perioperative Fluid Management: Science, Art or Random Chaos
Perioperative Fluid Management: Science, Art or Random Chaos
We currently 'hang salt by default.' This is irrational. Consider our model of electrolyte and fluid homeostasis in the human organism after a physiological stress, such as major surgery. The body is avidly holding on to salt and water. Does it make sense to infuse yet more?
If patients receive consistently judged intraoperative fluid therapy and arrive at the end of surgery euvolaemic, it seems appropriate to provide ~1 ml kg h or less afterwards. And why should we not hang dextrose water 5% as our baseline maintenance, reserving isotonic crystalloids for replacement of losses?
Lactated Ringer solution and normal saline are not maintenance solutions, because their sodium content is much too high for this purpose. A single litre bag of Hartmann's solution contains around twice the recommended daily intake of sodium chloride. Accordingly, three bags of this stuff hung as daily maintenance creates a large salt load. On a cautionary note, we emphasize that no more than 2 litres per day of dextrose water 5% should be infused and that i.v. maintenance should be taken down as soon as patients are drinking freely. If a patient remains nil by mouth for an extended period for clinical reasons then electrolytes should be checked; in this situation, dextrose saline with potassium is a reasonable choice if plasma sodium is normal and 'routine maintenance' is the aim.
Can we as a clinical community agree? I.V. fluids should be administered with the same rigour as with any other drug. We have been researching perioperative fluid therapy for a very long time, yet because of inconsistent trial design we are no closer to the truth. In the absence of clearer evidence, in our view fluid management according to the standard practice group in the OPTIMISE trial is a reasonable approach to adopt for current best practice. It may be true that aspects of expert consensus guidelines are controversial, but surely treatment according to individual provider habit is even harder to justify? An acceptable alternative is that hospitals produce their own local perioperative fluid guidelines based on reliable local audit. But continued apathy is not the answer.
What Should We Hang After Surgery?
We currently 'hang salt by default.' This is irrational. Consider our model of electrolyte and fluid homeostasis in the human organism after a physiological stress, such as major surgery. The body is avidly holding on to salt and water. Does it make sense to infuse yet more?
If patients receive consistently judged intraoperative fluid therapy and arrive at the end of surgery euvolaemic, it seems appropriate to provide ~1 ml kg h or less afterwards. And why should we not hang dextrose water 5% as our baseline maintenance, reserving isotonic crystalloids for replacement of losses?
Lactated Ringer solution and normal saline are not maintenance solutions, because their sodium content is much too high for this purpose. A single litre bag of Hartmann's solution contains around twice the recommended daily intake of sodium chloride. Accordingly, three bags of this stuff hung as daily maintenance creates a large salt load. On a cautionary note, we emphasize that no more than 2 litres per day of dextrose water 5% should be infused and that i.v. maintenance should be taken down as soon as patients are drinking freely. If a patient remains nil by mouth for an extended period for clinical reasons then electrolytes should be checked; in this situation, dextrose saline with potassium is a reasonable choice if plasma sodium is normal and 'routine maintenance' is the aim.
Can we as a clinical community agree? I.V. fluids should be administered with the same rigour as with any other drug. We have been researching perioperative fluid therapy for a very long time, yet because of inconsistent trial design we are no closer to the truth. In the absence of clearer evidence, in our view fluid management according to the standard practice group in the OPTIMISE trial is a reasonable approach to adopt for current best practice. It may be true that aspects of expert consensus guidelines are controversial, but surely treatment according to individual provider habit is even harder to justify? An acceptable alternative is that hospitals produce their own local perioperative fluid guidelines based on reliable local audit. But continued apathy is not the answer.
Source...