Grocott MPW, Mythen MG, Gan TJ: Perioperative fluid management and clinical outcomes in adults

Centre for Anaesthesia, University College London, United Kingdom.
Anesthesia & Analgesia (Impact Factor: 3.47). 05/2005; 100(4):1093-106. DOI: 10.1213/01.ANE.0000148691.33690.AC
Source: PubMed


The administration of IV fluid to avoid dehydration, maintain an effective circulating volume, and prevent inadequate tissue perfusion should be considered, along with the maintenance of sleep, pain relief, and muscular relaxation, a core element of the perioperative practice of anesthesia. Knowledge of the effects of different fluids has increased in recent years, and the choice of fluid type in a variety of clinical situations can now be rationally guided by an understanding of the physicochemical and biological properties of the various crystalloid and colloid solutions available. However, there are few useful clinical outcome data to guide this decision. Deciding how much fluid to give has historically been more controversial than choosing which fluid to use. A number of clinical studies support the notion that an approach based on administering fluids to achieve maximal left ventricular stroke volume (while avoiding excess fluid administration and consequent impairment of left ventricular performance) may improve outcomes. In this article, we review the available fluid types and strategies of fluid administration and discuss their relationship to clinical outcomes in adults.

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Available from: Michael PW Grocott
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    • "Fluid administration in this setting allows a continuous flush line for the administration of anesthesia drugs, and may facilitate faster recovery and promote patient satisfaction. Clinically measureable adverse outcomes of fasting and bowel preparation (such as hypotension, drowsiness, nausea, vomiting, dehydration, dizziness and thirst) have been widely documented [5-8], but there is limited data from randomized studies examining routine fluid management practices during colonoscopy, and the role of fluid prescription in the prevention of such events continues to be poorly understood [9,10]. There is additional cost and workload if fluid is to be routinely administered to all patients [11], and emerging evidence that fluid administration to patients undergoing colonoscopy may not reduce peri-procedural adverse events [4]. "
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    ABSTRACT: Background Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy. Methods With Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. Data collected: size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study. Results We collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18–83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12–48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our institution fluid therapy currently cost about AUD$4.90 per patient: 1 L crystalloid $1.18 and fluid delivery set $3.77 Our institution performs over 9000 endoscopic procedures annually with fluid therapy costing about $45,000/year. Conclusions Routine fluid prescription by anesthesiologists managing patients undergoing colonoscopy was ineffective with low actual fluid volumes delivered during the procedure. There was no association between volumes of fluid delivered and procedural hypotension, adverse events, or procedure duration. Anesthesiologists should question the clinical and pharmaco-economic value of routine fluid administration for patients undergoing elective endoscopy.
    Full-text · Article · Jun 2014 · BMC Research Notes
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    • "However, too restrictive fluid therapy may result in under-resuscitation and potentially associated adverse sequelae, again including gastrointestinal hypoperfusion, anastomotic leaks, nausea, vomiting, and others, which can be prevented in part by more liberal (colloid or crystalloid) fluid loading [30,54,59-63]. Perioperative, goal-directed hemodynamic optimization by (mostly colloid, sometimes crystalloid) fluids may better reduce postoperative complications, because of dosing fluids to individual needs in the patient and by taking individual cardiac reserve into account, than either liberal or restrictive policies [2,4,22,52,53,61,64-66]. "
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    ABSTRACT: In this narrative review, an overview is given of the pros and cons of various crystalloid fluids used for infusion during initial resuscitation or maintenance phases in adult hospitalized patients. Special emphasis is given on dose, composition of fluids, presence of buffers (in balanced solutions) and electrolytes, according to recent literature. We also review the use of hypertonic solutions. We extracted relevant clinical literature in English specifically examining patient-oriented outcomes related to fluid volume and type. A restrictive fluid therapy prevents complications seen with liberal, large-volume therapy, even though restrictive fluid loading with crystalloids may not demonstrate large hemodynamic effects in surgical or septic patients. Hypertonic solutions may serve the purpose of small volume resuscitation but carry the disadvantage of hypernatremia. Hypotonic solutions are contraindicated in (impending) cerebral edema, whereas hypertonic solutions are probably more helpful in ameliorating than in preventing this condition and improving outcome. Balanced solutions offer a better approach for plasma composition than unbalanced ones, and the evidence for benefits in patient morbidity and mortality is increasing, particularly by helping to prevent acute kidney injury. Isotonic and hypertonic crystalloid fluids are the fluids of choice for resuscitation from hypovolemia and shock. The evidence that balanced solutions are superior to unbalanced ones is increasing. Hypertonic saline is effective in mannitol-refractory intracranial hypertension, whereas hypotonic solutions are contraindicated in this condition.
    Full-text · Article · Aug 2013
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    • "Components of crystalloid solutions include inorganic ions such as sodium, chloride, potassium, magnesium, and calcium, as well as small organic substances such asglucose or lactate [6]. Examples of commonly used crystalloid solutions and their compositions are summarized in Table 1. "
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    ABSTRACT: Intravenous fluid therapy has evolved significantly over time. From the initial report of the first intravenous administration of sodium-chloride-based solution to the development of goal-directed fluid therapy using novel dynamic indices, efforts have focused on improving patient outcomes. The goal of this review is to provide a brief overview of current concepts for intravenous fluid administration in the ICU. Results of recently published clinical trials suggesting harmful effects of starch-based solutions on critically ill patients are discussed. Concepts for goal-directed fluid therapy and new modalities for the assessment of fluid status as well as for the prediction of responsiveness to different interventions will continue to emerge. Advances in technology will have to be critically evaluated for their ability to improve outcomes in different clinical scenarios.
    Full-text · Article · Mar 2013 · Critical care (London, England)
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