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temperature, and severe disease can increase sensible perspiration. Patients in emer­gency surgical conditions (such as sepsis or shock) may experience signicant sen­sible perspiration.
B. Brandstrup and A. M. Møller
Diuresis
The production of urine is approximately 1L per day for a healthy individual with normal body weight, food- and uid intake. In elderly patients, normal volumes of urine may not indicate sufcient diuresis. Assessing the adequacy of diuresis for each individual patient requires understanding their osmotic load and the kidney’s ability to concentrate urine.
The glomerular ltration rate (GFR), which reects kidney function, is approxi­mately 140mL/min/1.73m2 in young, healthy adults. It decreases by about 8mL/ min/1.73m2 every 10years after the age of 40 [23]. Elderly patients generally have lower muscle mass, resulting in decreased creatinine production. As a result, the creatinine concentration may remain normal despite a reduced GFR [23, 24]. Aging is associated with a signicant decline in the kidney’s ability to both concentrate and dilute urine, as well as perform free water clearance [25].
In young, healthy male volunteers, urinary osmolality under different conditions is as follows:
500–950mosm/kg after overnight fasting [26, 27]. Approximately 1100mosm/kg after 24h of fasting [27]. Maximum 1420mosm/kg after fasting for 4days [28].
In elderly healthy male volunteers (67–75years of age), values reduce to around 700mosm/kg following overnight fasting, and approximately 950mosm/kg urine after fasting for 24h [27].
For an 80-year-old person, urinary osmolality following 12h of fasting can be as low as 400–600mosm/kg urine [25].
Furthermore, plasma sodium levels increased signicantly in elderly male vol­unteers, compared to volunteers aged 20–31. Despite the elevated plasma sodium, elderly participants do not consume as much water as younger individuals, result­ing in sustained elevation of plasma sodium and osmolality for more than ve days [27].
The corresponding information for women is unknown; therefore gender correc­tions are not currently adopted.
Sodium Excretion
It represents only a small fraction of total urine osmolality. With no pharmacologi­cal interference, urinary excretion of Na+ can vary between less than 0.1% and no more than 3% of the ltered load (H2O can vary between 0.3 and 15% of the intake)
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[28]. In healthy young male volunteers given a dietary salt load (tablets) of up to 32g/day, the maximum sodium excretion reached 300mmol/L urine [29].
This explains why drinking seawater is unwise. The salt concentration in seawa­ter is approximately 600mmol/L, and considering the kidneys’ maximum ability to concentrate 300mmol of sodium in 1L of urine (in young males), drinking seawa­ter would provide the body with salt instead of water. Indeed regular consumption of just moderate excess of salinity in drinking water is already associated with arte­rial hypertension [29].
Classically the hormonal stress response in emergency surgical disease and after surgery tends to retain salt and water in the body, even though there are exceptions, such as severe spinal cord injury [30, 31]. Therefore, the formation of edema in surgical patients should not always be attributed to excessive hydration, even though this is relatively common. The presence of an osmotically active substance, namely sodium, is usually required to retain water. More accurately, postoperative edema formation can be seen as “over salting,” and providing water to facilitate salt excre­tion, along with the administration of the diuretic furosemide (which promotes excretion of sodium), can help reduce edema.
Lactated or acetated Ringer’s solutions have a sodium content at 130mmol per liter, not signicantly different from normal saline with 154mmol per liter. However, lactate is metabolized into CO2 and water by the cellular metabolism, making these uids slightly hypotonic, thus providing the kidneys with slightly more water to excrete the salts.
It is important to note that without adequate water intake, all synthetic colloids will form a gel in the kidney tubules, potentially leading to kidney injury. Even in the absence of water deprivation, kidney damage is more likely with these articial plasma expanders than with crystalloids.
The daily requirements can be summarized as follows for an 80kg person (body surface of 1.85m2) with normal kidney function [19]:
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Sodium: 75–150mmol Potassium: 60–100mmol Glucose: 850mmol=150g (the brains basal requirement) Water: 2000–3000mL
Therefore, 2–3L of a solution containing approximately 40mmol of sodium, 20–30mmol of potassium, and 50mmol of glucose will meet the daily requirements.
Fluid Therapy During Preoperative Fasting
In an emergency setting, the emptying of the stomach is often slowed down by the underlying disease, and the patient may be dehydrated and/or hypovolemic. Several studies have demonstrated that preoperative administration of sugar-containing u­ids (oral or intravenous) improves well-being, reduces hunger and thirst, enhances muscle strength, and decreases postoperative insulin resistance in elective
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abdominal surgical patients [32–34]. However, no evidence exist on the role of glucose- containing uids in emergency surgical patients [35]; therefore the paren­teral route is preferred.
In elective surgical patients, uid and electrolyte loss during fasting will be nor­mal, and if intravenous uid supplementation is necessary, choosing a uid that replaces normal losses is the logical approach, such as a solution containing K-Na­Glucose or Glucose 5%. In emergency surgical patients without hypovolemia the same choice of uid seems rational, depending on the patients’ blood glucose levels that might be elevated due to the emergency disease. In circumstances of hypovole­mia or electrolyte disturbances, uids correcting these conditions are a better choice.
B. Brandstrup and A. M. Møller
During Surgery
Emergency surgical patients may experience blood loss, ascites formation, or pro­longed ileus; however, basal uid and electrolyte losses are not increased.
Is There a“Third Space” Compartment?
The historical non-anatomical third-space loss described a transfer of extracellular volume (ECV), resulting in a decreased total ECV.It was believed that the surgical trauma in itself or severe hemorrhagic shock caused a redistribution of body uid compartments, leading to a reduction in ECV by several liters. The uid was not found in the ECV, and later studies showed that it was not found in the intracellular volume (ICV) either, leading to speculation that there must be a yet unidentied “third space.”
This decrease in ECV was recommended to be treated with intravenous uids (0.9% NaCl or Ringer’s solution), according to generous algorithms. However, there is a lack of evidence for the occurrence of this ECV loss [36], and it has not been shown that the administration of additional intravenous uids has any bene­cial effect for the patient. On the contrary, the prognosis of abdominal surgical patients is signicantly worsened by this “replacement.” [37] We have therefore totally abandoned the entire concept.
Effects ofIntestinal Manipulation andSurgical Trauma
The surgical trauma itself and manipulation of the intestines during surgery can cause cellular damage and result in mild edema formation. Experimental studies have shown that the formation of a small bowel anastomosis increases the water content in the surrounding tissue by 5–10% [38]. If the same occurs in humans and the weight of the anastomosis is similar to that of a stoma removed during the
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reversal of the Hartmann’s procedure (50g) [39], the amount of uid “lost to the traumatized tissue” is estimated to be approximately 2.5–5g or 2.5–5mL.
Intravenous uid therapy exacerbates this edema formation and destabilizes the bowel anastomosis. When administered at a rate of 15mL/kg/h, the local water con­tent more than doubles to 10–20%, and the stability of the anastomosis decreases, making it more prone to bursting under lower pressure [40]. Additionally, inamma­tion around the anastomosis increases [41]. These ndings are consistent with the research by Jacob etal. [42], who describe how uid overload can disrupt the endo­thelial glycocalyx, leading to inammation and uid leakage into the interstitial space.
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Exudation andBlood Loss
During open surgery, uid may seep from the wound and intestines. Often, this ascitic uid is contained in a suction bottle or/and absorbed by surgical dressings, and its volume is estimated.
In abdominal surgery where the viscera are exteriorized, the surgeon can use a plastic bag to collect and measure the uid loss more accurately. The exudate typi­cally contains albumin, and manipulation of the intestines can increase the albumin content. In patients treated by open abdomen, the protein content was estimated as 2g of nitrogen per liter of abdominal uid output [43].
Unless the patient is experiencing signicant visible bleeding or occult blood loss (such as from a bleeding ulcer in the intestines), blood loss can be measured fairly accurately by assessing the content in suction bottles and monitoring changes in the weight of the surgical dressings.
The perspiration from the open abdomen is usually so small that it often needs no consideration. However, during maximal eventration about 1 mL/kg/h can be eliminated [44, 45]. Probably most of the uid decit in such circumstances stems from bowel edema [44, 45]. Placing the viscera in a plastic bag can ameliorate evaporation.
Intraoperative hypothermia is more common than previously estimated, both during open and laparoscopic interventions, even though the contribution of water evaporation is incompletely known [46].
The extent of evaporative uid loss during laparoscopic surgery has been calcu­lated as <1mL/h only, when dry CO
is insufated, and thus insignicant [47].
2
Conventional Protocols
Epidural Analgesia
The administration of epidurals blocks both sensory and sympathetic bers in the affected area of the spinal cord, resulting in a reduction in heart rate (in cases of high blocks) and vasodilation, leading to a decrease in arterial blood pressure. Early
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studies suggested that a uid bolus of 500mL of colloid or 1000mL of crystalloid could counteract this decrease in blood pressure [48, 49]. However, subsequent ran­domized clinical trials have failed to validate these ndings. In fact, they have dem­onstrated that intravenous uid administration alone is ineffective in treating the blood pressure decline caused by epidural dilation, and overall cardiac output remains largely unchanged [50–56]. Epidural and spinal anesthesia are effectively an iatrogenic sympathectomy. As a consequence, moderate uid therapy should be combined with vasopressors, and various pharmacologic regimens are currently available [50].
B. Brandstrup and A. M. Møller
Goal-Directed Fluid Therapy (GDT)
GDT has been implemented in various clinical trials, although there is inconsis­tency in dening the specic goals that characterize a trial as “goal directed,” as indicated in published reviews.
Initially, the trials employed a pressure-controlled approach, focusing on parameters like blood pressure and central vein pressure [57, 58]. Most accepted goals now revolve around optimizing stroke volume (SV) or stroke volume variation (SVV), which can be considered as a form of flow-controlled fluid therapy.
Additionally, the concept of “zero uid balance” or restricted uid therapy has been included in the goal-directed uid therapy approach [59], resembling a balance- controlled strategy. Some trials have explored biochemical markers such as lactate or central venous oxygen tension as targets for a biochemical-controlled therapy [60–64].
Combining multiple of the above goals is likely the most effective approach. Henceforth, GDT refers to the administration of a uid (colloid) to achieve near-
maximal SV.
In elective abdominal surgical procedures, some investigations demonstrated benets [65–70], whereas others did not [62, 71–73]. Notably, only a few trials measured the volume of intravenous uids administered postoperatively, and those that did only measured uid intake for the remainder of the surgery day [62, 65, 69,
72]. Interestingly, large amounts of crystalloid uids were administered alongside
colloid-based stroke volume optimization. This could be interpreted in two ways: either the crystalloid acted as a temporary uid overload that quickly left the circu­lation (as typically observed in normovolemic individuals), or crystalloids are inef­fective in increasing stroke volume. Another intriguing nding is that colloid solutions, including hydroxyethyl starch (HES), appeared to have positive effects on outcomes in elective bowel surgery without the side effects observed in septic patients [74].
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Restricted Fluid Therapy Approach (Near Zero Fluid Balance)
It is believed that GDT (based on a near zero balance principle) is not superior to restricted uid therapy [75–80]. In comparative studies, generally the group receiv­ing the smallest uid volume achieves the best outcomes. Still perioperative uid therapy in major abdominal surgery requires nding the appropriate balance. In a study conducted by Warrillow etal. in 2010 [81], patients in their institution received a median of 4.2L of intravenous uid intraoperatively and 6.3L postoperatively, resulting in a total of 10.5L.They observed that 21% developed pulmonary edema, 12% experienced anastomotic leaks, and the overall complication rate was 57%, with 32% being major complications.
In our trial published in 2003 [37], uid overload with saline and the subsequent increase in body weight (4kg) were detrimental. By avoiding uid overload, we have signicantly reduced the incidence of postoperative atrial brillation, pulmo­nary congestion, edema, and acute respiratory distress syndrome (ARDS).
The benet of restricted or near zero-balance uid volumes has been conrmed in patients undergoing gastrointestinal [37, 63], urologic [82], pulmonary [83], car­diac [84], vascular [85], and mixed [63] surgical procedures, as well as in surgical patients in the intensive care unit [86]. The ndings were consistent across these studies: there are adverse consequences associated with uid overload.
The largest trial to date comparing restricted versus liberal uid therapy was conducted by Myles etal., involving 3000 patients [87]. The median body weight increase was 0.3kg in the restricted group versus 1.6kg in the liberal group 24h after surgery, indicating that both approaches were fairly restricted. Although no difference was found regarding one-year disability-free survival, more patients in the restricted uid group experienced renal failure. However, it is worth noting that the restricted group did not have a protocol for administering uids in cases of post­operative oliguria, suggesting that the restricted regimen may have been excessively restrictive and thus caused harm. The trial itself has several limitations [88], and it is possible that an optimal uid strategy lies somewhere between the two treat­ment arms.
Weaknesses
Clinical randomized trials involving uid therapy in general possess inherent weak­nesses. It is challenging to blind such trials as uid administration leads to observ­able changes in body weight, urinary output, and the formation of subcutaneous edema. Using length of stay (LoS) as an endpoint also poses challenges. The
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introduction of fast-track surgery has highlighted that patient and physician expec­tations play a crucial role in determining the LoS.Patients tend to remain in the hospital for the duration they are advised to stay.
Furthermore, controlling for other potential confounding factors is not always successful, such as laparoscopic or open surgery, the use of drains and tubes, the allowance for patients to resume oral uid and food intake, and the type of postop­erative analgesia administered. For instance, the occurrence of postoperative nausea and vomiting (PONV) is heavily inuenced by the use of opiates.
B. Brandstrup and A. M. Møller
The Emergency Surgical Setting
One trial of emergency surgical patients showed, that a multimodal treatment including fast CT-scan, early preoperative treatment of hypovolemia with goal­directed uid therapy to near-maximal stroke volume achieved with bolus infusions of HES (Voluven®), and fast surgical intervention (<3h from arrival to hospital) improved the outcome with reduced mortality compared with a historic control group [89].
Especially in Great Britain fellow researchers have argued that the lack of supe­riority of GDT can be attributed to the overall good health of the patients included in the trials of elective surgery. To meet this, we did a clinical randomized trial of the sickest patients we could think of, namely patients with gastrointestinal perfora­tion or bowel obstruction needing emergency surgery. Up until now this is the only clinical randomized trial of uid therapy specically focusing on emergency abdominal surgical patients [2]. However, even for this patient population, we found no signicant benets in outcomes with GDT uid therapy compared to restricted uid therapy. On the contrary, the restricted uid group had a shorter length of hos­pital stay (LoS).
A retrospective study of patients having emergency surgery for bowel obstruc­tion or GI-perforation found a U-shaped relationship between the development of complications and uid balance. The frequency of cardiopulmonary complications was lowest at a balance of 0–1000mL, while the frequency of renal complications was lowest at approximately 0–2000mL [90]. This trial, however, may suffer from indication-induced bias. In synthesis, even the emergency surgical patients are best treated following the principles of “restricted uid therapy.”
Recommendations forPre- andIntraoperative Fluid Therapy
We recommend that uid be replaced quantitatively (in volume) and qualitatively (with similar electrolyte content), starting preoperatively (upon admission) and only as needed, possibly guided by central hemodynamic values, exceeding measured losses by no more than +1–2L.
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1. Fasting: Give 80 mL per hour of fasting. Use Ringer’s uid or a glucose-
containing uid. Note that glucose may have contraindications in women giving birth and be aware of blood glucose.
2. Epidural preloading: There is no need for preloading. If uid is administered,
consider it as replacing the fasting decit or as early replacement for expected blood loss.
3. Insensible perspiration and evaporation from open surgical wounds is small and
usually need no consideration. Medical water in antibiotics, etc. is sufcient to replenish these losses unless the surgery is prolonged.
4. Drainage of pathological uid: If ascites is drained, it does not need to be
replaced. However record it in the intraoperative uid chart. Note that postopera­tive reaccumulation of such uid may lead to hypovolemia.
5. Bleeding and exudation: Replace blood loss with Ringer’s uid at a ratio of
1:2–3. Monitor hemoglobin (Hb) levels. Administer red blood cells to maintain Hb levels above 4.5 mmol/L (7 g/L) in young, healthy patients and above
5.6mmol/L (9g/L) in elderly patients with cardiopulmonary conditions. Refer to Table19.1 for specic recommendations.
6. Continuous blood loss: Close control with TEG/ROTEM.After 6units of red
blood cells are transfused, administer fresh frozen plasma. Initiate platelet supplementation.
7. Emergency ongoing bleeding: Utilize “transfusion packages” with the ratio of
4 units of erythrocytes, 4 units of plasma, and 1 unit of platelets (similar to full blood).
8. Urine output: Intraoperative urinary loss does not need to be replaced. Low
diuresis during surgery can be due to factors other than uid decit. If hypovo­lemia is ruled out, a reduced intraoperative diuresis is acceptable.
9. Maintain a background infusion rate of no more than 2 mL/kg/h and closely
monitor blood loss to achieve these objectives.
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Postoperative Fluid Therapy
In brief, we recommend the following postoperative uid therapy:
1. Hypotonic uid to meet their daily water, sodium, potassium, and glucose
requirements (see above).
2. Replace pathological uid losses with a uid in similar volume and containing
similar electrolyte content as the loss.
3. The electrolyte content in the different GI-uid losses can be found in refer-
ence [91].
4. Maintain postoperative urinary output at 0.5–1mL/kg/h.
5. Examine all patients with oliguria or hypotension and treat them accordingly. If
hypovolemia is the cause, give additional IV crystalloid. In cases of epidural analgesia overdose, reduce the dose.
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B. Brandstrup and A. M. Møller
6. Address dehydration by providing additional water or IV-glucose.
7. Initiate feeding as soon as possible after surgery.
8. Avoid a weight increase >1–2kg.
Enhanced Recovery After Surgery (ERAS)
Recommendations for uid therapy in ERAS programs advocate for a zero uid balance with no more than a 2–2.5kg body weight gain [92]. Specialized ERAS programs for elderly individuals are available and highly recommended.
We recommend that patients be allowed to drink and eat freely after surgery, whenever tolerated. Intravenous uid therapy should be considered if oral intake is insufcient, the patient has paralytic ileus, high output stoma, or complications have occurred.
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