CON: Fluid Restriction for Cardiac Patients During Major
Noncardiac Surgery Should be Replaced by Goal-Directed
Intravascular Fluid Administration
Donat R. Spahn, MD, FRCA, and Pierre-Guy Chassot, MD
intestinal motility, compromised tissue oxygenation,
wound healing problems, and blood coagulation im-
pairment (1–3). Patients with a cardiac comorbidity
undergoing major noncardiac surgery may be partic-
ularly vulnerable and, therefore, perioperative fluid
restriction might appear to be beneficial.
However, there are at least 4 prospective random-
ized trials showing that a goal-directed perioperative
plasma volume expansion decreases major postoper-
ative morbidity and the duration of hospitalization
significantly (4–7). In all these studies, stroke volume
in the descending aorta was assessed by esophageal
Doppler monitoring. Two hundred mL of colloids
were given over 10 min and stroke volume was as-
sessed every 15 min. This was repeated until no fur-
ther increase in stroke volume was detected. Indeed,
higher Doppler cardiac outputs were observed at the
end of surgery in the goal-directed perioperative
plasma volume expansion groups (4,5,7). Interest-
ingly, the reduction of duration of hospitalization was
2 days in general surgery in relatively young and
healthy patients (mean age, 55–60 yr) (4), 4 days in
cardiac surgery in 65-yr-old patients (7), and 4 to 8
days in 75- to 85-yr-old patients undergoing proximal
femoral fracture repair (5,6). Older age and increasing
comorbidity thus does not seem to limit but rather to
increase the benefit of a goal-directed perioperative
plasma volume expansion.
It is important to note that, first, supplemental fluid
was not just given on a routine basis but administered
goal-directed, the goal being the optimization of the
stroke volume as assessed by esophageal Doppler
monitoring (4–7). Second, goal-directed fluid therapy
reduces postoperative morbidity more when done
with colloids than with crystalloids (8), potentially
hydration may result in pulmonary edema, car-
diac complications, delayed recovery of gastro-
havebeen expressed thatover-
related to a lesser development of intestinal edema in
patients treated with colloids (9). This appears to be
particularly relevant in gastrointestinal surgery, where,
in the context of “fast-tracking,” intraoperative fluid re-
striction has become a hot topic (3). Crystalloid fluid
restriction and the individualized goal-directed admin-
istration of colloids thus are not opposing but rather
Esophageal Doppler monitoring used in the afore-
mentioned studies is easy to learn, but it is not widely
used and lacks validation. In contrast, arterial cathe-
ters are used extensively in daily practice, are easy to
place, and are rarely associated with serious compli-
cations. They continuously display the arterial wave-
form on the screen. The differential pressure between
systolic and diastolic values, the pulse pressure, and
the area under the curve, both easy to evaluate by
visually analyzing the curve, are proportional to the
actual blood volume pulsed toward the periphery.
Mechanical ventilation interferes with cardiac filling
and induces variations in stroke volume (10). The
degree of stroke volume variation is proportional to
the degree of hypovolemia and has been shown to
accurately forecast fluid responsiveness (10–13).
In contrast, central venous and capillary wedge
pressures are poor markers of volume status because
the relationship between pressure and volume, or
compliance of the cardiac chambers, cannot be deter-
mined clinically (14). Moreover, the compliance curve
is nonlinear. At low volume, filling pressure variations
are minimal in comparison with volume changes;
their sensitivity for hypovolemia thus is low. At high
filling pressure, however, the relationship is clinically
useful because volume changes are associated with
significant pressure changes (Fig. 1); the measurement
of filling pressures gives an accurate image of the
upper limit of fluid administration in patients with
cardiac dysfunction and may serve to avoid over-
hydration once stroke volume has been optimized
(Fig. 1). If cardiac compliance is abnormal, such as in
diastolic dysfunction, the filling pressure will be much
higher than expected for the same filling volume (Fig.
1). Most of the studies on invasive monitoring, such as
Swan-Ganz catheters in noncardiac surgery, have
given disappointing results because their populations
Accepted for publication October 17, 2005.
Address correspondence and reprint requests to Donat R. Spahn,
MD, FRCA, Professor and Chairman, Department of Anesthesiol-
ogy, University Hospital Lausanne (CHUV), CH – 1011 Lausanne,
Switzerland. Address e-mail to email@example.com.
©2006 by the International Anesthesia Research Society
Anesth Analg 2006;102:344–60003-2999/06
have not been selected and because the retrieval of the
monitored data has not been accompanied by a goal-
directed protocol of fluid administration (15–17). In ad-
dition, more complications were observed in the group
with invasive monitoring (18).
The cardiac dysfunction in a given patient may be
diastolic, systolic, or both. In each case, their optimal
end-diastolic wall stress, or filling volume, has a rela-
tively narrow range. Outside this range, their stroke
volume and cardiac output decrease by insufficient
wall stress in case of hypovolemia (Frank-Starling
phenomenon), or by congestive failure in case of hy-
pervolemia. In general, patients with a significant car-
diac dysfunction are exquisitely sensitive to volume
variations, which should be minimized.
How should we thus proceed practically? After an-
esthesia induction many patients are in a situation of
functional hypovolemia or reduced effective preload
from anesthetic vasodilatation and positive pressure
ventilation (10). These patients are thus on the ascend-
ing limb of the Frank-Starling curve and will benefit
from individualized goal-directed intravascular fluid
administration (Fig. 1), which moves them to the right
of their end-diastolic volume – stroke volume relation-
ship close to their optimum stroke volume (Fig. 1).
Once stroke volume has been optimized, this position
needs to be maintained and filling pressure monitored
to avoid over-filling resulting in severe complications
such as pulmonary edema (2). In addition, optimum
cardiac filling will prevent tachycardia from hypovo-
lemia, which dramatically increases the myocardial
oxygen consumption, and is particularly dangerous in
patients with or at risk of coronary artery disease.
It needs to be stressed once more that advanced
monitoring alone is neither sufficient nor beneficial. In
contrast, such monitoring may be associated with
complications in patients with cardiac comorbidities
undergoing noncardiac surgery (15,18). Only combin-
ing monitoring with a clear management algorithm
aiming at the optimization of the stroke volume with
colloid boluses in the presence of a knowledgeable
anesthesiologist (19) will improve the outcome of pa-
tients with concomitant cardiac disease undergoing
1. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical
implications of perioperative fluid excess. Br J Anaesth 2002;89:
2. Arieff AI. Fatal postoperative pulmonary edema: pathogenesis
and literature review. Chest 1999;115:1371–7.
3. Joshi GP. Intraoperative fluid restriction improves outcome af-
ter major elective gastrointestinal surgery. Anesth Analg 2005;
4. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative
fluid administration reduces length of hospital stay after major
surgery. Anesthesiology 2002;97:820–6.
5. Sinclair S, James S, Singer M. Intraoperative intravascular vol-
ume optimisation and length of hospital stay after repair of
proximal femoral fracture: randomised controlled trial. BMJ
6. Venn R, Steele A, Richardson P, et al. Randomized controlled
trial to investigate influence of the fluid challenge on duration of
hospital stay and perioperative morbidity in patients with hip
fractures. Br J Anaesth 2002;88:65–71.
7. Mythen MG, Webb AR. Perioperative plasma volume expan-
sion reduces the incidence of gut mucosal hypoperfusion during
cardiac surgery. Arch Surg 1995;130:423–9.
Figure 1. Frank-Starling and compliance curves with pulse pressure
variations in relation to end-diastolic volume for normal hearts and
hearts with diastolic and systolic dysfunctions. Pulse pressure vari-
ations describe systolic and pulse pressure variation in relation to
variations of intrathoracic pressure resulting from mechanical ven-
8. Moretti EW, Robertson KM, El-Moalem H, Gan TJ. Intraopera-
tive colloid administration reduces postoperative nausea and
vomiting and improves postoperative outcomes compared with
crystalloid administration. Anesth Analg 2003;96:611–7.
9. Prien T, Backhaus N, Pelster F, et al. Effect of intraoperative
fluid administration and colloid osmotic pressure on the forma-
tion of intestinal edema during gastrointestinal surgery. J Clin
10. Michard F. Changes in arterial pressure during mechanical ven-
tilation. Anesthesiology 2005;103:419–28.
11. Coriat P, Vrillon M, Perel A, et al. A comparison of systolic
blood pressure variations and echocardiographic estimates of
end-diastolic left ventricular size in patients after aortic surgery.
Anesth Analg 1994;78:46–53.
12. Tavernier B, Makhotine O, Lebuffe G, et al. Systolic pressure
variation as a guide to fluid therapy in patients with sepsis-
induced hypotension. Anesthesiology 1998;89:1313–21.
13. Berkenstadt H, Margalit N, Hadani M, et al. Stroke volume
variation as a predictor of fluid responsiveness in patients un-
dergoing brain surgery. Anesth Analg 2001;92:984–9.
14. Cunnion RE, Natanson C. Echocardiography, pulmonary artery
catheterization, and radionuclide cineangiography in septic
shock. Intensive Care Med 1994;20:535–7.
15. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled
trial of the use of pulmonary-artery catheters in high-risk sur-
gical patients. N Engl J Med 2003;348:5–14.
16. Connors AF, Speroff T, Dawson NV, et al. The effectiveness of
right heart catheterization in the initial care of critically ill
patients. JAMA 1996;276:889–97.
17. Practice guidelines for pulmonary artery catheterization: an
updated report by the American Society of Anesthesiologists
Task Force on Pulmonary Artery Catheterization. Anesthesiol-
18. Polanczyk CA, Rohde LE, Goldman L, et al. Right heart cathe-
terization and cardiac complications in patients undergoing
noncardiac surgery: an observational study. JAMA 2001;286:
19. Arbous MS, Meursing AE, van Kleef JW, et al. Impact of anes-
thesia management characteristics on severe morbidity and
mortality. Anesthesiology 2005;102:257–68.
EDITORIALS ANESTH ANALG