Review
Use of fluid therapy in perioperative adult patients: A narrative reviewUso de fluidoterapia en el periodo perioperatorio en pacientes adultos: revisión narrativa

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Abstract

The administration of intravenous fluids is the most common intervention in hospitalised patients in the perioperative setting and critical care units. The aim of this narrative review is to provide an overview of balanced solutions for fluid therapy in the perioperative period in adult patients, and to review new trends and solutions in fluid therapy.
The evidence was grouped into 3 areas: intraoperative fluid administration, fluid administration in critically ill patients, and the importance / benefit of balanced crystalloid solutions.
Although a number of high-quality studies have been published in recent years, the scientific evidence regarding the type of fluid, the dose, and rate of administration is still limited. The choice of fluid therapy during the perioperative period must be tailored to patient-specific factors, the nature of the surgery, expected fluid loss, and other relevant factors. Finally, more robust clinical evidence and physician training is of the utmost importance.

Resumen

La administración de líquidos intravenosa es la intervención más común en los pacientes hospitalizados en el ámbito perioperatorio y las unidades de cuidados críticos. El objetivo de esta revisión narrativa es aportar una visión general de las soluciones balanceadas en fluidoterapia en el periodo perioperatorio en pacientes adultos, así como revisar las nuevas tendencias y soluciones de la fluidoterapia.
Se agrupó la evidencia en 3 áreas: administración intraoperatoria de líquidos, administración de líquidos en pacientes críticos y relevancia/beneficio de las soluciones de cristaloides balanceadas.
Aunque en los últimos años se ha producido una mejora de los estudios de gran calidad publicados, la evidencia científica en cuanto a la elección de los líquidos, así como sus dosis y tasa de administración sigue siendo limitada. Debe individualizarse la elección de fluidoterapia durante el periodo perioperatorio, considerando los factores específicos del paciente, la naturaleza de la cirugía, la pérdida de sangre prevista y otros factores relevantes. Por último, deberá ser de máxima importancia la evidencia clínica robusta y la formación de los facultativos.

Introduction

The administration of intravenous fluids to critically ill patients is one of the most frequent interventions in emergency departments (ED), hospital wards, operating rooms, and intensive care units (ICU)1 worldwide. The indications for fluid administration include resuscitation, rehydration, and maintenance. Each year, over 30 million patients in United States receive intravenous fluids for resuscitation, to maintain intravascular volume, or as a vehicle for medication.2 The type of fluid therapy administered will be determined by the clinician, institutional protocols, product availability, patient profile, and cost. Fluid solutions are mainly classified into 2 groups in accordance with their composition and physicochemical properties: colloids (synthetic or natural), and crystalloids.3 All fluids should be considered drugs.
The aim of this narrative review is to provide an overview of balanced solutions for fluid therapy in the perioperative period, and to review new trends and management in fluid therapy.
Crystalloids are solutions of mineral or organic salts in water that are capable of crossing semi-permeable membranes. These solutions are initially classified according to their tonicity with respect to plasma. Crystalloid solutions can be: i) balanced - solutions in which chloride anions are in part replaced by bicarbonate or buffers to reduce the acid-base disturbance caused by fluid administration; or ii) unbalanced - 0.9% saline solution also known as normal saline, which contains 154 mmol/L of sodium and chloride.4
Clinical practice guidelines recommend the use of crystalloids to achieve the 5 goals of fluid therapy, also called the 5Rs: 1) Resuscitation; 3) Routine maintenance; 3) Replacement; 4) Redistribution; and 5) Reassessment. In the case of resuscitation, however, they only recommend colloids when crystalloids would not suffice.5, 6
Saline solution ([SS] 0.9% sodium chloride) is the most widely used fluid in clinical practice.7 It contains equal amounts of Na+ and Cl−, making it both hypernatraemic and hyperchloremic relative to plasma (Table 1). Despite its popularity, SS has been associated with adverse events, such as hyperchloremia, metabolic acidosis, renal vasoconstriction, hypotension, and immune alterations.1, 3, 4, 7
Balanced solutions have an electrolyte composition more similar to plasma (Table 1), and should therefore cause less acid-base balance disturbance than SS. Balanced crystalloids are buffered with organic anions (mainly lactate or acetate) to balance the total positive charges of the solution.4, 7 Acetate-based balanced crystalloids include Ringer’s acetate (RA), Plasmalyte®, Ionolyte®, Isofundin® and Benelyte® (Fig. 1).
Some clinical studies have shown that balanced solutions may have several benefits: less kidney damage, less need for renal replacement therapy (RRT), and lower mortality than other solutions.8, 9, 10, 11
The Stewart approach (strong ion difference [SID] theory) gives the most accurate assessment of acid-base balance in critically ill patients. SID is the difference between the sum of strong cations (mainly Na+, K+, Mg2+, Ca2+) and the sum of strong anions (mainly Cl–, lactate), according to the following formula.12Abbreviated formula SID7 = (Na+ + K+) – (Cl–)
This approach helps clarify the mechanisms responsible for acid-base disturbances such as hyperchloremic acidosis.12
Normal SID values in plasma are close to ∼40−44 mEq L−1; however, contrary to intuition, replacing volume with a solution with these values might cause metabolic alkalosis due to progressive weak-acid dilution in plasma. Therefore, to achieve an acid-base balance, the value of the effective SID in the solution should be between ∼24 mEq L−1 and ∼28 mEq L−1, which is the value of HCO3− in plasma.7, 12
All crystalloids have the potential to significantly alter the acid-base balance because of their different ionic composition in relation to plasma. The in-vitro SID in crystalloids and colloids is 0, but ranges from 0 to 50 mEq L−1 in vivo due to the addition of metabolically active organic anions (e.g., lactate, acetate, or gluconate). When a solution is rapidly administered in plasma, it prevents a rapid decrease in SID values by buffering the initially acidotic effect and achieving more physiological SID and pH values after infusion.7, 12
It is important to understand the importance of in vivo SID values in balanced crystalloid solutions, because the solution will either have minimal effect on the acid-base balance and will bring the effective SID close to 24–28 mEq L−1, or its Cl- content will be ≤110 mEq L−1, thus avoiding supra-physiologic Cl- levels. This is true of all balanced crystalloids, and the clinical importance of these elements will be discussed below.
For the purpose of this narrative review, we searched Medline, Scopus, Web of Science, Dimensions.ai, Google Scholar, and the evidence-based medicine repositories Epistemonikos and Trip Database for articles published up to 22/09/2022. Search strings were constructed using the MeSH term “Fluid Therapy” and all its equivalents or synonyms, which were combined using Boolean operators.
All articles that included adult patients scheduled for surgery that presented postoperative complications or postoperative electrolyte disturbances published from 2015 onwards in English and Spanish were retrieved and screened for inclusion. We also hand-searched the references of all included articles. Studies that did not investigate the topic of interest were excluded, as were abstracts, posters, letters to the editor, commentaries, editorials, and all unpublished studies.
Articles were screened for inclusion by an independent researcher not involved in the study.
Evidence on fluid therapy was grouped into 3 areas: intraoperative fluid administration, fluid administration in critically ill patients, and the importance / benefit of balanced crystalloid solutions.

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Section snippets

Intraoperative fluid administration

This section reviews studies comparing the intraoperative administration of acetate- based balanced fluids, lactate-based balanced fluids, and SS for fluid maintenance therapy and their impact on kidney function and metabolic acidosis (Table 2).
Adequate fluid administration is especially important in patients undergoing cardiac surgery, given their limited tolerance of hypervolemia and hypovolemia. In a randomized clinical trial (RCT), patients undergoing cardiac surgery were randomized to

Importance/benefits of balanced crystalloid solutions

The main benefits of balanced crystalloids are their ability to prevent hyperchloremic metabolic acidosis and other electrolyte abnormalities. In terms of electrolytes, they contain higher concentrations of physiological sodium and chloride than SS, and this gives them certain advantages.4, 7
Chlorine plays a predominant role in blood pressure control, gas decarboxylation/transport, kidney function, gastrointestinal homeostasis, and acid-base disturbances. Hyperchloremia is associated with

Fluid quality: there is no ideal fluid

During the perioperative period, numerous medical and surgical interventions, including the administration of intravenous fluids, are performed to maintain homeostasis and patient well-being.
The correct choice of a balanced fluid with an optimal SID is of outmost importance to maintain an adequate ion balance and prevent acid-base imbalances that may have negative consequences for the patient.38 An inappropriate SID can result in metabolic acidosis or alkalosis, and this can affect organ

Contributors

The manuscript was drafted by MJC and revised following critical review by all authors. All authors read and approved the final version of the manuscript.

Funding

This project was funded by Fresenius Kabi España S.A.U.

Conflicts of interest

MJC reports personal fees from C.S.L, Vifor Behring, Baxter and Fresenius Kabi not related to this study. PGM reports personal fees from Fresenius Kabi. JRM reports personal fees from Edwards Lifesciences and Fresenius Kabi.
Maheshwari K, 2020 (SOLAR study): single-centre alternating cohort controlled study.
Semler MW, 2018 (SMART study): pragmatic, cluster-randomized, multiple-crossover trial.
Self WH, 2018 (SALT ED study): single-centre, pragmatic, multiple-crossover trial.

Acknowledgements

None.

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