Fluid management and its role in enhanced recovery

Abstract

Enhanced recovery programs have repeatedly been shown to safely reduce perioperative morbidity and hospital length of stay for surgical patients, and they are being used across an increasing number of surgical specialties. For these programs to be successful, appropriate fluid management is essential throughout the whole perioperative period with the main aim being to maintain physiological normality for patients wherever possible. While excessive fluid administration increases the risk of harm through tissue edema and surgical ileus formation, insufficient fluid administration will result in end-organ failure. To minimize these risks and maintain a “zero-balanced” approach, patients should start surgery minimally dehydrated, be given fluids only to replace what is lost intraoperatively, and then converted to normal enteral intake again as soon as possible after the operation is finished. Good clinical assessment is essential throughout the perioperative period to evaluate how fluid-responsive the patient is at that time and whether they would benefit from further volume, or more inotropic support instead. Increasingly in mechanically ventilated patients, dynamic markers such as stroke volume variation have been shown to be the most effective way of doing this, although these measures do have a number of limitations that need careful consideration. Another approach is targeting fluid administration to a patient’s cardiac output-so-called “goal-directed therapy." Again, there is good evidence that like enhanced recovery pathways, goal-directed therapy can also reduce perioperative morbidity and surgical patient’s length of stay. National guidelines currently recommend that every surgical patient should have an individualized fluid plan as part of their enhanced recovery program and that goal-directed therapy should be considered as part of this approach-particularly in either high-risk patients and/or more major surgical procedures.