Fluid Balance

There is a narrow range for optimal fluid therapy with a goal of maintaining euvolemia and avoiding both underhydration and salt and water excess. The complication rate goes up with fluid overload of as little as 3L in elective bowel surgery, especially with crystalloids (1). Use of a balanced crystalloid solution (eg Ringer’s lactate) is preferred over “normal saline” which has higher chloride content than extracellular fluid (2). A “near zero” fluid balance should be the goal, as indicated by minimal weight gain (<2.5 kg) on POD1.

Intraoperatively: Patients in ERPs without prolonged fasting or bowel preparation have minimal deficits to be replaced and maintenance requirements during surgery can be achieved using a balanced crystalloid solution at 1-3 ml/kg/hr (3). Urine output should be replaced 1:1 with crystalloid and plasma losses due to bleeding and fluid shifts is replaced 1:1 with colloid (4). Several noninvasive devices provide continuous cardiac performance measures and can be used to tailor fluid management. Overall their use reduces complications after major surgery (5,6). However, benefits for this approach compared to a zero-balance regime for patients in an ERP have not been demonstrated, particularly in the context of their reliability with pneumoperitoneum and extreme patient positions (3,7)

For more information, see Chapter 11: Fluid Management in The SAGES / ERAS® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery

1. Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010 Nov;69(4):488-98

2. Shaw AD1, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, Kellum JA. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012 May;255(5):821-9

3. Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anaesth. 2015 Feb;62(2):158-68.

4. Feldman LS, Baldini G, Lee L, Carli F. Enhanced Recovery Pathways: Organization of Evidence-based, Fast Track Perioperative Care. ACS Surgery, 2013

5. Navarro LH, Bloomstone JA, Auler JO Jr, Cannesson M, Rocca GD, Gan TJ, Kinsky M, Magder S, Miller TE, Mythen M, Perel A, Reuter DA, Pinsky MR, Kramer GC. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond). 2015 Apr 10;4:3

6. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011 Jun;112(6):1392-402.

7. Gómez-Izquierdo JC, Feldman LS, Carli F, Baldini G. Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery. Br J Surg. 2015 May;102(6):577-89.

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