Free
Correspondence  |   May 2009
What Happens with the Fluid Replacement in the Septic Surgical Patient?
Author Affiliations & Notes
  • Matthias Jacob, M.D.
    *
  • *Ludwig-Maximilians University, Munich, Germany.
Article Information
Correspondence
Correspondence   |   May 2009
What Happens with the Fluid Replacement in the Septic Surgical Patient?
Anesthesiology 5 2009, Vol.110, 1198. doi:10.1097/ALN.0b013e3181a20636
Anesthesiology 5 2009, Vol.110, 1198. doi:10.1097/ALN.0b013e3181a20636
In Reply:—
We thank Dr. Navarro-Martinez and colleagues for their letter concerning our review on perioperative fluid management. In general, we would like to point out that our article was targeted on perioperative fluid therapy in patients who primarily have a steady state concerning their fluid compartments.1 In these patients an intact vascular barrier function ensures that, despite a positive pressure within the circulatory space, plasma constituents are not distributed evenly across the whole extracellular compartment.2,3 Rather, under normal physiologic conditions, they are predominantly retained where they are needed to maintain a sufficient cardiac preload. A small residual flow towards the interstitial space is managed by an intact lymphatic system.1 In this situation, requirement-adapted fluid handling might limit tissue edema by considering physiologic and pathologic shifting, provided that the vascular barrier is primarily fully functioning.1 
The septic patient, undergoing surgery or not, does not present such a steady state.4 The normally accompanying capillary leakage syndrome, as a result of an insufficient vascular barrier, leads to a barely calculable shift of fluid and macromolecules (such as proteins and colloids) towards the interstitial space, representing a primary problem during sepsis.5 Recent evidence suggested a deterioration of the endothelial glycocalyx by inflammatory mediators to be an important part of the underlying pathomechanism.6,7 Therefore, a careful differential indication between crystalloids and colloids as suggested for the perioperative steady state might not only be insufficient in this context, but in vain.1 Until today, we only know that we have to give enough, irrespective of the kind of fluid, to improve outcome of patients suffering from severe sepsis and septic shock.8 
We support most of the interesting considerations by Dr. Navarro-Martinez and colleagues. However, septic patients were not the focus of our rational approach.
*Ludwig-Maximilians University, Munich, Germany.
References
Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M: A rational approach to perioperative fluid management. Anesthesiology 2008; 109:723–40Chappell, D Jacob, M Hofmann-Kiefer, K Conzen, P Rehm, M
Jacob M, Bruegger D, Rehm M, Stoeckelhuber M, Welsch U, Conzen P, Becker BF: The endothelial glycocalyx affords compatibility of Starling’s principle and high cardiac interstitial albumin levels. Cardiovasc Res 2007; 73:575–86Jacob, M Bruegger, D Rehm, M Stoeckelhuber, M Welsch, U Conzen, P Becker, BF
Rehm M, Zahler S, Lotsch M, Welsch U, Conzen P, Jacob M, Becker BF: Endothelial glycocalyx as an additional barrier determining extravasation of 6% hydroxyethyl starch or 5% albumin solutions in the coronary vascular bed. Anesthesiology 2004; 100:1211–23Rehm, M Zahler, S Lotsch, M Welsch, U Conzen, P Jacob, M Becker, BF
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008; 34:17–60Dellinger, RP Levy, MM Carlet, JM Bion, J Parker, MM Jaeschke, R Reinhart, K Angus, DC Brun-Buisson, C Beale, R Calandra, T Dhainaut, JF Gerlach, H Harvey, M Marini, JJ Marshall, J Ranieri, M Ramsay, G Sevransky, J Thompson, BT Townsend, S Vender, JS Zimmerman, JL Vincent, JL
Marx G: Fluid therapy in sepsis with capillary leakage. Eur J Anaesthesiol 2003; 20:429–42Marx, G
Chappell D, Hofmann-Kiefer K, Jacob M, Rehm M, Briegel J, Welsch U, Conzen P, Becker BF: TNF-alpha induced shedding of the endothelial glycocalyx is prevented by hydrocortisone and antithrombin. Basic Res Cardiol 2009; 104:78–89Chappell, D Hofmann-Kiefer, K Jacob, M Rehm, M Briegel, J Welsch, U Conzen, P Becker, BF
Nelson A, Berkestedt I, Schmidtchen A, Ljunggren L, Bodelsson M: Increased levels of glycosaminoglycans during septic shock: Relation to mortality and the antibacterial actions of plasma. Shock 2008; 30:623–7Nelson, A Berkestedt, I Schmidtchen, A Ljunggren, L Bodelsson, M
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368–77Rivers, E Nguyen, B Havstad, S Ressler, J Muzzin, A Knoblich, B Peterson, E Tomlanovich, M