1
Fluid use in the scheduled surgical patient
Uso de líquidos en el paciente quirúrgico programado
Ernesto Arriaga-Morales MD 1, George Benjamín E. Sánchez de la Barquera MD2, Angélica Contreras-Muñoz MD 3,
Alejandro Pérez-Arreguín4, Ricardo Sánchez Zamora MD 5, Rubén Isaac Olvera Rodríguez MD 6, Patrick James Atherton
Avila 7, Ángel G. Nájera-Albarrán MD 8, H. MD, José Eduardo Rovelo Lima MD 9.
1 Emergency Department, Hospital San Ángel Inn Sur, Ciudad de México, México.
2 Orthopaedics and trauma, Hospital San Ángel Inn Sur, Ciudad de México, México.
3 Ear, Throat & Nose, Hospital Ángeles Pedregal, Ciudad de México, México.
4 Emergency Department, Hospital San Ángel Inn Sur, Ciudad de México, México.
5 Gynaecology and Obstetrics, Hospital Ángeles Universidad, Ciudad de México, México.
6 Emergency Department, Hospital San Ángel Inn Sur, Ciudad de México, México.
7 Medical Intern, Hospital San Ángel Inn Sur, Ciudad de México, México.
8 Cardiology department, Hospital San Ángel Inn Sur, Ciudad de México, México.
9 Teaching Department, Hospital San Ángel Inn Sur, Ciudad de México, México.
Critical Care and Emergency Medicine
https://doi.org/10.58281/ccem23112304
Revisión Narrativa
Fluid administration is almost universally accepted as a part
of the treatment of any hospitalized patient, but this is based
on old perspectives and an incomplete understanding of the
intravenous fluid dynamics. A long time ago Shires et al de-
scribed and defined a “third space” which is a nonfunctional
fluid that can be considered a fluid loss and must be replaced;
this understanding led to over reanimation1, 2. The surgical
scheduled patient is a perfect example, most of those proce-
dures don’t compromise the oral route, don’t imply large flu-
id loses, and don’t need large intravenous fluids even in
complex cases like congenital heart defects3, 4.
The lack of understanding has led to persistent overuse of
intravenous fluids. New evidence suggests that the fluid re-
sponse for hypotension is not the rule, but an exception to
the rule in a specific situation. There is even evidence that
the excretion of crystalloid fluid during hypotension is di-
minished and implies an increased risk of overload. Hanh
conducted a trial in which 30 volunteers and 48 anesthe-
tized patients received a single fluid bolus of lactated or ace-
tated Ringer’s solution over 30 minutes and took samples
every 5 minutes for the first 30 minutes and then every 1015
minutes. Using clinical monitoring and computerised analysis
they ascertained that the rate of elimination of crystalloid
fluid decreased with the mean arterial pressure (MAP) and
patient age, the elimination rate constant was 6.5 (95% con-
fidence interval, 5.27.9) × 10−3 × (MAP/mean MAP)5.2 ×
(Age/mean Age)−1.5. they concluded that the rate of elimina-
tion of crystalloid fluid decreased in proportion to MAP but
was independent of general anaesthesia and moderate-sized
surgery5.
The present evidence indicates that intravenous fluids
can be deleterious for critically ill patients including sepsis,
trauma, and anaphylaxis6, 7, 8.
Is undoubtedly true that this is the same for the non-criti-
cally ill patient, there are evidence and recommendations for
this, including the Enhanced Recovery After Surgery (ERAS)
protocols that include many recommendations including late
intravenous fluid therapy and early intravenous fluid with-
drawal. The implementation and adherence of these recom-
mendations has been largely ignored by most hospitals
worldwide9.One of the biggest problems with the use of solu-
tions for reanimation is the concept of oxygen delivery, the
solutions cannot provide oxygen delivery and then it is not
probable that those interventions can improve perfusion10.
The current management of intravenous (IV) fluids in sur-
gery involves maintaining hydration, hydro-electrolytic bal-
ance, macro, and micro-circulation, returning intracellular
fluid volume to normal, and replacing ongoing losses11.
The choice between different fluids, their dosage, man-
agement, and monitoring remain controversial, but the use
2 Volumen 2 • Tomo 1
of balanced crystalloids seems to be the best approach;
newer evidence cannot find a difference, but it is apparently
related to the lower infused volume compared with previous
studies12, 13.
In an observational study on fluid therapy management in
surgical 6314 adult patients, the most widely used fluid was
balanced crystalloids. The study found that hourly surgery
volume tended to be more restrictive in high-risk patients
with 5% of the patients receiving advanced fluid monitoring
in the intraoperative setting, and 10% of the postoperative
patients, confirming hardly any monitoring in the fluid thera-
py outside the intensive care unit.
The ERAS14 protocol bundle has showed excellent results
improving outcomes, but individual impact of each interven-
tion is not fully established. In 2011, Gustafsson et al. per-
formed a single centre prospective cohort study before and
after the reinforcement of ERAS protocol, focusing on the
effect of various ERAS elements including 114 variables, and
nine hundred and fifty-three consecutive patients with col-
orectal cancer: 464 patients treated in 2002 to 2004 and
489 in 2005 to 2007. The most relevant finding was that
the fluids given before the day of the surgery and the use of
preoperative carbohydrate load were major independent
predictors of postoperative outcomes. They found that for
each additional litre of fluids given during the day of opera-
tion, the risk of postoperative symptoms delaying recovery
increased by 16% (OR, 1.16; 95% CI, 1.021.31) and the prob-
ability of postoperative complications increased by 32%
(OR, 1.32; 95% CI, 1.171.50). Fluid overload increased the
risk of cardiorespiratory complications (OR, 1.20; 95% CI,
1.101.31)15, 9.
The ASER (American Society for Enhanced Recovery) and
POQI (Perioperative Quality Initiative) joint consensus
statement on perioperative fluid management within an en-
hanced recovery pathway for colorectal surgery recommend
unrestricted clear fluids for oral intake up to 2 hours before
the induction as well as recommending adding at least 45g of
carbohydrate to improve insulin sensitivity, while recom-
mending against the administration of intravenous fluids to
replace preoperative fluid losses after bowel preparation
with iso-osmotic preparations; noting that there is no evi-
dence that iso-osmotic mechanical bowel preparation leads
to adverse effects on preoperative volume status16.
The type of fluids administered during surgery indepen-
dent of the surgical specialty must be individualized accord-
ing to the anatomical site of surgery; the patient’s clinical
status, and the type of surgery performed, respecting con-
traindications, and selecting the best place for care14, 17, 18.
Figure 1. Proposed phases of fluid use in the scheduled surgical patient, reducing administration to specific situations and promoting the oral route.
Fluid use in the scheduled surgical patient 3
What’s the best approach?
We know from diverse sources that restrictive strategies
improve outcomes for surgical patients in different special-
ties, and overload worsens the outcomes19.
Malbrain et al.20 explain the approach to fluid therapy in 4
stages, for the scheduled patient a similar approach can be
used, but there is no need for reanimation and usually no
need for optimization because the scheduled patient does
not have hypotension. Also, the de-reanimation phase is not
needed if no large fluid volumes were used. Three phases are
proposed, oral phase, maintenance phase and second oral
phase. (Figure 1)
The type of fluids administered during surgery can vary
based on the patient’s physiological conditions, type of surgery
performed, and the clinical status of the patient21, 11, 14, 17, 22,
even differences between balanced crystalloids and 0.9%
saline varies according to the procedure for example, in total
hip arthroplasty, the use of crystalloids and colloids has been
reported, with no significant differences in outcomes, in con-
trast, in total knee arthroplasty, the use of crystalloids has
been reported to be more effective than colloids18, the RE-
LIEF study showed that a totally restrictive strategy increas-
es the risk of acute kidney injury than those in the liberal fluid
group (8.6% vs. 5%, P < 0.001) in this study the restrictive
regimen led to a median of 1.7 L of fluid administered intra-
operatively, and 3 L with the liberal regimen a moderately
liberal fluid with slightly above “zero-fluid” balance can im-
prove outcomes in some surgeries23.
Other types of major surgery not associated with such ex-
tensive fluid shifts are unlikely to need as much intraopera-
tive IV fluid administration to achieve a moderate positive
fluid balance at the end of surgery23.
Preoperative phase (oral phase)
In critically ill patients, there is a “Resuscitation” phase – in
the scheduled surgical patient this stage is not applicable.
The correct evaluation of the volume status is the most im-
portant step at this point. Before the IV line is placed there is
no iatrogenic fluid overload but, preexisting disease like
chronic kidney failure or cardiac failure can present fluid over-
load at admission. BLUE protocol for lung oedema and inferior
vena cava measurement or simplified versions with basal lung
ultrasound and portal doppler curve evaluation are the best
options for the early evaluation of fluid status24, 25, 26, 27.
There are some patients that are dehydrated or even hy-
povolemic at admission28. The most frequently observed
cause is low oral intake before the surgery, but chronic dehy-
dration that is a very challenging diagnosis and according to
some small studies can impact health outcomes specially in
older patients, increases mortality and complication rate
in hip fractures29, 30, also the fluid administration in the elder-
ly confers specific challenges, like the need for glucose ad-
ministration and avoiding sodium increase.31
If the patient is hemodynamically stable and tolerates oral
intake, dehydration can be managed by improving oral intake
even in large surgeries like hip fractures, the oral route being
preferred32, 33. When the oral route is not available the cautious
administration of intravenous fluids is indicated34, 35, 36.
The use of solutions in the pre-surgical patient in the Oto-
laryngology specialty is required only for the administration
of drugs, like antibiotic prophylaxis, immediately before sur-
gery and during anaesthesia. Fluids can be withdrawal when
the patient’s general condition allow it and oral feeding can
be restarted.37, 38
Some procedures, like bowel preparation, can cause fluid
loses, but do not cause severe dehydration and can be man-
aged with, oral fluids until 2 hours before surgery39, 40, 41.
Stress response is not a problem in most cases and is not re-
ally a reason to provide extra intravenous fluids42, 43. Preoper-
ative haemorrhages is not really a reason to provide
intravenous fluids, especially in the scheduled patient except
for some procedures, but in those cases, the best option can
be blood transfusion or preoperative scheduled iron reposi-
tion44, 45. Frequent indication for blood transfusion or iron
supplementation in the scheduled patient are gynaecology
patients with abnormal uterine bleeding46, 47, 48.
Probably at this point, most scheduled surgical patients
aren’t candidates for intravenous fluids.
Zero fluid in the preoperative setting can improve out-
comes and even reduce surgical bleeding in major abdominal
surgery, but it is important to individualize treatment, be-
cause some patients can have a worse outcome with totally
restrictive strategies49, 3, 50.
Some patients with hypotension or hypoperfusion can
benefit from fluid therapy, for example, a patient with no
oral intake for many days and no available oral route can
benefit from some fluids, this is often present in patients
with cancer51, 52, 53 in those cases, when the urine output is de-
creased and hypoperfusion is present, a small fluid bolus can
be used, (figure 2) with close monitoring with clinical and ul-
trasound protocols to prevent overload24, 27. If the urine out-
put increases then no further intravenous fluid boluses are
recommended; infusion can be started with close monitor-
ing. In the opposite scenario if the patients don’t increase or
even further decrease urine output, extensive evaluation of
the volume status should be performed. Inferior vena cava
measurement, VexUS and other ultrasound protocols27, 27
should be performed to assure the patient is hypovolemic. In
these cases, another fluid bolus can be attempted, if no re-
sponse, no further IV boluses are necessary and can be dele-
4 Volumen 2 • Tomo 1
terious, as addressed before. The hypotensive patient is
more prone to retain fluids5, but more importantly, an injured
kidney can take its time to start uresis27, 54, 55. Recommenda-
tions for acute kidney injury recommend performing a furo-
semide stress test56, if no hypovolemia is present, and waiting
as long as possible before initiating renal replacement thera-
py with acute kidney injury until absolute criteria is met.
These recommendations are based on the slow response of
the kidney to acute insults and no clinical difference in the
outcomes when early or delayed renal replacement therapy
is administered. (figure 3)57, 58, 59
Surgical phase (maintenance phase)
During the anaesthesia induction, a fluid load is a common
option for treating hypotension, but the evidence on the
preload strategy is contradictory, for example, a study from
Yuhong found that the stroke volume can decrease as much
as 62% from base line during anaesthesia induction and can
be restored with crystalloids to 68% of the basal. Additional
boluses can increase the stroke volume by >10% in patients
with dehydration. They concluded that preload ameliorated
the decrease in stroke volume, and that dehydration, but no
hemodynamic response to the induction was correlated
with fluid responsiveness60, on the other hand, Rusell et al
conducted a trial with 1065 critically ill patients, evaluating
the incidence of cardiovascular collapse, they didn’t find
statistical differences with the administration of fluid bolus
vs no fluid bolus with 21.0% vs 18.2% respectively. The use
of push dose vasopressor if hypotension presents, but not
prophylactically, is safe and a preferred practice over fluid
bolus61, 62, 63, 64, but more importantly, appropriate selection
and dosing of sedatives and even vasopressors can prevent
hypotension and adverse effects during induction.65, 63
As soon as 1990 A.J. Coe and B. RevanäsIn proved in a
small open label trial that during spinal block, the use of va-
sopressors does not improve outcomes specially with high
level block above T7. Above T4 all patients required vaso-
pressors, and crystalloid preload has no effect in the preven-
tion of hypotension after spinal block.66
Total intravenous anaesthesia (TIVA) improves the visual-
ization of structures during endoscopic and laparoscopic sur-
gery and reduces bleeding compared to inhaled anaesthesia
and inhaled plus intravenous anaesthesia. These modalities
have been studied extensively in functional endoscopic sinus
surgery, other otolaryngology endoscopic and open proce-
dures, gynaecology, and obstetrics surgery during which it
may result in a cleaner surgical field and less blood loss67, 68, 69.
Figure 2. Preoperative assessment of hypovolemic patient to select the appropriate approach, delaying unnecessary procedures when the patient is unstable.
Fluid use in the scheduled surgical patient 5
From the R.O.S.E. algorithm during surgery we are in the
optimization phase, there are algorithms to use fluids. These
protocolized algorithms can improve outcomes and reduce
morbidity and mortality and include recommendations for
intraoperative fluid restriction9, zero balance, goal directed
fluid restriction or avoidance of salt and water excess.
During surgery there the main causes of hypotension are
blood lose70, loss of sympathetic response (vasodilatation)71
over sedation 72, chronic cardiac failure decompensation73, 74
and non-haemorrhagic hypovolemia. Each one can be treated
according to its own algorithm, and only the last one can totally
respond to intravenous fluid administration. Therefore, not ev-
ery hypotension during a procedure should be treated directly
with fluid boluses, a correct assessment of the aetiology can
improve outcomes and adequate monitoring with invasive and
non-invasive techniques can help us to provide best care75, 76.
For monitoring during the operation, there is a complex
relationship that is non-linear with the blood pressure, organ
perfusion and cellular function, which means that a multipa-
rameter monitoring protocol should be the best approach
including basic options like capillary refill77, 78, non-invasive
blood pressure with some interesting bias79, 80, 81, lung ultra-
sound82, 83 and invasive monitoring including central venous
pressure84, 85, 86, invasive blood pressure monitoring87. The
correct selection of the modality of monitoring should be
based on the complexity of the procedure and the patient
basal and expected condition.88, 89
Postoperative phase (second oral phase)
Considering the R.O.S.E. concept we should be now in the
Stabilization phase, at this point we can consider using fluids
during the fasting time, to provide adequate hydration. For
the scheduled patient, the postoperative fasting usually is
short, ERAS and ESPEN protocol recommends initiating the
oral intake immediately after surgery in the postoperative fa-
cilities. If there is no other indication for the intravenous
route, even withdrawing the intravenous route can be the
next step39, 90, 91. Large surgeries, like hip fracture or oncologic
surgeries, can be treated only via the oral route.
Certain92, 93, 94, 9 exceptions would contraindicate the start
of the diet, such as patients with oesophageal fistulas, post-
operative laryngectomies, complicated bowel surgeries, and
extensive neck surgeries. These specific cases would condi-
tion continuation of the administration of antibiotics and
pain management parenterally95.
For a patient without an oral route, only maintenance flu-
id can be enough; boluses or high infusions are not recom-
mended, unless there are high fluid losses during surgery, as
they increase the probability of fluid overload and then local
and systemic complications, including surgical site complica-
tions. A nutritional assessment is recommended after sur-
gery and should be performed by a nutritionist39 there are
not many contraindications for avoiding the oral route: nau-
sea or vomiting, intestinal failure,96 failed gastrointestinal
surgery97.
Late postoperative phase
The late phase the de-escalation/de-resuscitation is a
phase that should not be part of any fluid treatment algo-
rithm, because it implies that we administered more fluid
than needed for optimal management and the patient al-
ready has fluid overload. This situation carries a big risk for
Figure 3. Hypovolemia is not always the cause of anuria, and uresis is not always improved by fluid administration, other causes must be evaluated to avoid
fluid overload.
6 Volumen 2 • Tomo 1
major complications98, classically the perioperative manage-
ment is the responsibility of the surgeon, but the anaesthesi-
ologist is becoming the manager of the whole perioperative
management99. The correct assessment previous to, during,
and immediately after the surgery can reduce the risk of fluid
overload. Point of care ultrasound, wireless monitoring, and
the reemerge of the capillary refill as a reliable tool to asses
perfusion100, 101, provide the information to prevent complica-
tions associated with the fluid therapy.
For the treatment of fluid overload diuretics, classically
the first line therapy in fluid overload, the loop diuretics are
widely used. Furosemide inhibits tubular reabsorption of so-
dium and chloride in the proximal and distal tubules and the
thick ascending loop of Henle results in an increased excre-
tion of water along with sodium, chloride, magnesium, and
calcium. The onset for the oral route is 1 hour, with a peak
effect in 1 to 2 hours. In the bioavailability the absorption is
slower than normal in patients with oedema, especially in
those with cardiac failure102. Furosemide is useful in anuric
patients as a diagnostic tool when performing a furosemide
stress test to predict the need for renal replacement thera-
py103, 104. The oral route is also an option reducing the intrave-
nous fluids administration considering the conversion: 20mg
of intravenous furosemide = 40 mg of oral furosemide = 20
mg of torsemide = 1 mg of bumetanide105.
Fluid restriction is critical from the beginning with the goal
of maintaining gas exchange and organ perfusion and func-
tion, including hemodynamic stability.
Since severe complications can arise from fluid overload,
for example, congestive heart failure, pulmonary oedema,
delayed wound healing, tissue breakdown, and impaired
bowel function, brain oedema, and even increased mortality,
renal replacement therapy (extracorporeal therapies) can be
used in severe non diuretic responding cases to maintain sta-
bility and optimize organ function. In this setting the accura-
cy of the estimation of patient’s fluid status and the right use
of ultrafiltration is the key to successful treatment, since the
best management in acute kidney injury is still not defined
the first modality needs to be based on availability of re-
sources, local expertise, patient’s hemodynamic status106.
It is important to remember that the accumulation of flu-
ids can produce severe complications specific to the surgical
site, including surgical wound dehiscence by incrementing the
vascular permeability and causing interstitial oedema and in-
flammation that impairs the regeneration of collagen, thereby
causing weakening of the tissue incrementing the risk of
wound infection, wound rupture, and anastomotic leakag 6.
Conclusions
The fluid management in the perioperative scheduled pa-
tient must be individualized, the correct analysis of the pa-
tient’s situation including the actual volume status. The
expected fluid loses (distinguishing blood loses from other
fluid loses), the utilization of the oral route as the first option,
and avoiding as much as possible the utilization of fluid infu-
sion in patients conserving the oral route can improve out-
comes. The correct monitoring according to clinical status
including non-invasive devices like ultrasound and non-inva-
sive blood pressure monitoring, as well as clinical findings
like mottling and retarded capillary refill helps clinicians to
select the best approach.
Mild dehydration has little to no effect in the prognosis of
scheduled surgeries, on the other hand fluid overload is a
major risk factor for complications. Patients with comorbidi-
ties like diabetes, hypertension, and hypothyroidism must
receive the control of them before scheduled procedures.
Critically ill patients are rarely candidates for scheduled pro-
cedures; delaying those procedures until disease control can
prevent complications and mortality.
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