Editorial Views  |   March 2009
Goal-directed Perioperative Fluid Management: Why, When, and How?
Author Notes
  • Section of Surgical Pathophysiology 4074, Rigshospitalet Copenhagen University, Copenhagen, Denmark.
Article Information
Editorial Views / Renal and Urinary Systems / Electrolyte Balance
Editorial Views   |   March 2009
Goal-directed Perioperative Fluid Management: Why, When, and How?
Anesthesiology 3 2009, Vol.110, 453-455. doi:10.1097/ALN.0b013e3181984217
Anesthesiology 3 2009, Vol.110, 453-455. doi:10.1097/ALN.0b013e3181984217
PRINCIPLES of perioperative fluid management have received increased interest in recent years within type and amount of crystalloid and colloid, the concept of individualized goal-directed cardiovascular optimization (GDT), and finally assessed on a procedure-specific basis. In this issue, Kimberger et al.  ,1 investigated the underlying tissue mechanisms during GDT management with crystalloids or colloids for abdominal surgery with a colonic anastomosis. This elegant experimental study in pigs included detailed techniques of postsurgical assessments of conventional cardiovascular variables (blood pressure, heart rate, urinary output) and microcirculatory blood flow and tissue oxygen tension in healthy and perianastomotic colonic tissue. Three types of fluid management were instituted at the end of surgery: restricted Ringer lactate (RL) versus  GDT RL or GDT colloid to achieve a mixed venous oxygen saturation (Svo2) greater than 60%. The results show no significant differences between the groups in conventional cardiovascular functional parameters or urinary output, but an increased oxygen tension in healthy colonic tissue compared with RL and a further increase with GDT colloid compared with GDT RL. Of special interest, oxygen tension in perianastomotic tissue increased to 245% with GDT colloid versus  147% in the GDT RL group versus  116% in the restricted RL group. Furthermore, microcirculatory flow was higher with GDT colloid. Interestingly, anastomotic tissue edema was not different between groups.
The study by Kimberger et al.  1 may add important new knowledge to the understanding of the apparent beneficial effects of GDT in surgical patients, where the 11 randomized clinical studies have mostly shown outcome benefits within postoperative nausea and vomiting, ileus, morbidity, and hospital stay.2–5 Until now, however, only limited pathophysiological data are available to explain this benefit. Thus, Mythen and Webb showed GDT to improve morbidity and hospital stay after cardiac surgery related to the demonstrated increased gut mucosal perfusion (gastric intramucosal pH),6 but this could not be confirmed by a less well-designed study in abdominal surgery.4 In the colorectal surgery study by Noblett et al.  ,7 the reduced morbidity and hospital stay by GDT was associated with a reduced interleukin-6 response. These findings together suggest that GDT may attenuate stress-induced organ dysfunctions and thereby have a pivotal role on outcome, including anastomotic complications. The recent studies on perioperative changes of the vascular barrier suggest that the endothelial glycocalyx plays a key role,8,9 which needs to be studied within the context of GDT and use of colloid.
In the discussion of GDT, it is essential that the present individualized  GDT approach includes optimization of flow-related parameters, such as cardiac stroke volume, within the limit of the individual patient's cardiac capacity.2,3,10,11 The concept is therefore different from the original Shoemaker concept for optimization, which used predetermined supraphysiologic values of cardiac index and Do2as therapeutic goals.12 Interestingly, the study by Kimberger et al.  1 also used fixed goals for GDT optimization (Svo2> 60%) and not the individualized approach.
Most of the 11 clinical GDT outcome studies are positive2–5 and may have widespread implications for clinical practice; therefore, there is an urgent need to evaluate the pathophysiological mechanisms, such as done by Kimberger et al.  1 and others.6,7 In addition, when  to institute GDT needs to be clarified. The studies predominantly perform GDT in the intraoperative period, and there have been only 2 studies within the very early postoperative period13,14 and no studies in the later postoperative period, where major fluid shifts and requirements may occur. Interestingly, the GDT optimization by Kimberger et al.  was done postabdominal closure.1 However, the studies2–5 provide little or no detailed data of GDT in relation to type of anesthesia, including epidural anesthesia and its well-known effects on cardiovascular function; therefore, the practicing anesthesiologist is left with several unanswered questions for the interpretation of the GDT approach during the entire anesthetic-surgical period. In this context, precision of GDT requires averaging of stroke volume over at least 10 heartbeats when using the esophageal Doppler technology.15 Also, it has been suggested that the timing of GDT may be important because the total perioperative administration of crystalloid and colloid was not different between the GDT and control groups, despite major differences in outcome in favor of GDT.7 These results again call for confirmative studies, as well as pathophysiological explanations. Colloids for GDT have been used in the clinical studies2–5 and are supported by the study by Kimberger et al.  1 as well as by a previous study16 demonstrating that GDT-administered crystalloid is less beneficial or not beneficial. These findings may be explained by the more prolonged intravascular volume expansion and improved tissue oxygenation by colloids compared to crystalloids,17,18 and beneficial pharmacological effects of hetastarch preparations on the endothelium have been suggested.19,20 
Despite the apparent improvements in postoperative outcome by the GDT concept,2–5 all studies have problems with insufficient design regarding well-defined principles of perioperative care, discharge criteria, and information about reasons for postoperative hospitalization. Recent developments in perioperative care based on the concept of fast-track surgery,21 i.e.  , a multimodal approach by combination of single-modality, evidence-based care principles have shown major benefits with enhanced recovery, decreased need for hospitalization, and medical morbidity.21 The outcome benefits of the fast-track methodology are extensive and most often superior to what has been observed in the GDT studies.2–5 Therefore, future studies are urgently needed where GDT is combined with the fast-track methodology21 to obtain the maximum benefits of the GDT approach on a procedure-specific basis.22 
Finally, if we are going to recommend more widespread use of GDT, the choice of monitoring system to guide fluid administration must be addressed. The previous use of the pulmonary artery catheter12 may not be useful in the routine perioperative setting. Most clinical GDT outcome studies have used the esophageal Doppler system for stroke volume optimization,2,3 which therefore presently may be considered a feasible choice until other more simple techniques have been documented to achieve similar outcome results. In this context, only limited data exist to compare other more practical flow-related modalities such as near infrared spectroscopy, Svo2and model flow determined stroke volume with esophageal Doppler-based optimization.23 Kimberger et al.  1 used Svo2to guide fluid therapy, which may not respond as markedly as stroke volume during GDT optimization.23 Interestingly, Svo2optimization to a predetermined value of at least 70% has been associated with improved outcome in early treatment of sepsis,24 but it has not been documented in elective surgical settings. Other modalities such as pulse contour analyses (PiCCO, LiDCO) have acceptable precision25,26 and provide pulse pressure, systolic, and stroke volume variation, which may be reliable markers of fluid responsiveness during mechanical ventilation.27 However, application of these parameters in the perioperative setting only comes from two outcome studies,4,5 only one of which was positive.5 To summarize, further development and assessment of monitoring systems for perioperative GDT is required with a focus on precision, feasibility, invasiveness, requirement of skill, and expertise and application for the entire perioperative period.2 
In conclusion, the concept of individualized GDT in surgical patients seems to be an important component for optimization of perioperative fluid management and outcome in high-risk surgical patients.2,3,11 However, GDT must be integrated with existing knowledge on the role of total amount of fluid,9,10,22 the fast-track methodology,21,22 and then in a procedure-specific approach because different procedures have different fluid pathophysiology. The time is now for clinical studies to define components of GDT practice, including algorithms, monitoring systems, and guidelines for the entire perioperative period.2 
Section of Surgical Pathophysiology 4074, Rigshospitalet Copenhagen University, Copenhagen, Denmark.
Kimberger O, Arnberger M, Brandt S, Plock J, Sigurdsson GH, Kurz A, Hiltebrand L: Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology 2009; 110:496–504Kimberger, O Arnberger, M Brandt, S Plock, J Sigurdsson, GH Kurz, A Hiltebrand, L
Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H: Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 2007; 51:331–40Bundgaard-Nielsen, M Holte, K Secher, NH Kehlet, H
Abbas SM, Hill AG: Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008; 63:44–51Abbas, SM Hill, AG
Buettner M, Schummer W, Huettemann E, Schenke S, van Hout N, Sakka SG: Influence of systolic-pressure-variation-guided intraoperative fluid management on organ function and oxygen transport. Br J Anaesth 2008; 101:194–9Buettner, M Schummer, W Huettemann, E Schenke, S van Hout, N Sakka, SG
Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F: Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: A pilot randomized controlled trial. Crit Care 2007; 11:R100–9Lopes, MR Oliveira, MA Pereira, VO Lemos, IP Auler, JO Michard, F
Mythen MG, Webb AR: Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 1995; 130:423–9Mythen, MG Webb, AR
Noblett SE, Snowden CP, Shenton BK, Horgan AF: Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006; 93:1069–76Noblett, SE Snowden, CP Shenton, BK Horgan, AF
Jacob M, Bruegger D, Rehm M, Welsch U, Conzen P, Becker BF: Contrasting effects of colloid and crystalloid resuscitation fluids on cardiac vascular permeability. Anesthesiology 2006; 104:1223–31Jacob, M Bruegger, D Rehm, M Welsch, U Conzen, P Becker, BF
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
Grocott MP, Mythen MG, Gan TJ: Perioperative fluid management and clinical outcomes in adults. Anesth Analg 2005; 100:1093–106Grocott, MP Mythen, MG Gan, TJ
Spahn DR, Chassot PG: CON: Fluid restriction for cardiac patients during major noncardiac surgery should be replaced by goal-directed intravascular fluid administration. Anesth Analg 2006; 102:344–6Spahn, DR Chassot, PG
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS: Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94:1176–86Shoemaker, WC Appel, PL Kram, HB Waxman, K Lee, TS
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED: Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005; 9:R687–93Pearse, R Dawson, D Fawcett, J Rhodes, A Grounds, RM Bennett, ED
McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M: Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ 2004; 329:258–63McKendry, M McGloin, H Saberi, D Caudwell, L Brady, AR Singer, M
Jørgensen CC, Bundgaard-Nielsen M, Skovgaard LT, Secher NH, Kehlet H: Stroke volume averaging for individualized goal-directed fluid therapy with oesophageal Doppler. Acta Anaesthesiol Scand 2009; 53:34–8Jørgensen, CC Bundgaard-Nielsen, M Skovgaard, LT Secher, NH Kehlet, H
Hiltebrand LB, Pestel G, Hager H, Ratnaraj J, Sigurdsson GH, Kurz A: Perioperative fluid management: Comparison of high, medium and low fluid volume on tissue oxygen pressure in the small bowel and colon. Eur J Anaesthesiol 2007; 24:927–33Hiltebrand, LB Pestel, G Hager, H Ratnaraj, J Sigurdsson, GH Kurz, A
Lang K, Boldt J, Suttner S, Haisch G: Colloids versus  crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesth Analg 2001; 93:405–9Lang, K Boldt, J Suttner, S Haisch, G
McIlroy DR, Kharasch ED: Acute intravascular volume expansion with rapidly administered crystalloid or colloid in the setting of moderate hypovolemia. Anesth Analg 2003; 96:1572–7McIlroy, DR Kharasch, ED
Matharu NM, Butler LM, Rainger GE, Gosling P, Vohra RK, Nash GB: Mechanisms of the anti-inflammatory effects of hydroxyethyl starch demonstrated in a flow-based model of neutrophil recruitment by endothelial cells. Crit Care Med 2008; 36:1536–42Matharu, NM Butler, LM Rainger, GE Gosling, P Vohra, RK Nash, GB
Boldt J, Brosch C, Rohm K, Lehmann A, Mengistu A, Suttner S: Is albumin administration in hypoalbuminemic elderly cardiac surgery patients of benefit with regard to inflammation, endothelial activation, and long-term kidney function? Anesth Analg 2008; 107:1496–503Boldt, J Brosch, C Rohm, K Lehmann, A Mengistu, A Suttner, S
Kehlet H, Wilmore DW: Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248:189–98Kehlet, H Wilmore, DW
Holte K, Kehlet H: Fluid therapy and surgical outcomes in elective surgery: A need for reassessment in fast-track surgery. J Am Coll Surg 2006; 202:971–89Holte, K Kehlet, H
Bundgaard-Nielsen M, Ruhnau B, Secher NH, Kehlet H: Flow-related techniques for preoperative goal-directed fluid optimization. Br J Anaesth 2007; 98:38–44Bundgaard-Nielsen, M Ruhnau, B Secher, NH Kehlet, H
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
Marquez J, McCurry K, Severyn DA, Pinsky MR: Ability of pulse power, esophageal Doppler, and arterial pulse pressure to estimate rapid changes in stroke volume in humans. Crit Care Med 2008; 36:3001–7Marquez, J McCurry, K Severyn, DA Pinsky, MR
Belloni L, Pisano A, Natale A, Piccirillo MR, Piazza L, Ismeno G, De Martino G: Assessment of fluid-responsiveness parameters for off-pump coronary artery bypass surgery: A comparison among LiDCO, transesophageal echochardiography, and pulmonary artery catheter. J Cardiothorac Vasc Anesth 2008; 22:243–8Belloni, L Pisano, A Natale, A Piccirillo, MR Piazza, L Ismeno, G De Martino, G
Auler JO Jr, Galas F, Hajjar L, Santos L, Carvalho T, Michard F: Online monitoring of pulse pressure variation to guide fluid therapy after cardiac surgery. Anesth Analg 2008; 106:1201–6Auler, JO Galas, F Hajjar, L Santos, L Carvalho, T Michard, F