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Lorente, J.V.; Hahn, R.G.; Jover, J.L.; Del Cojo, E.; Hervías, M.; Jiménez, I.; Uña, R.; Clau-Terré, F.; Monge, M.I.; Llau, J.V.; et al. Clinical Applications of Crystalloids within Enhanced Recovery Pathways. Encyclopedia. Available online: https://encyclopedia.pub/entry/49426 (accessed on 04 August 2024).
Lorente JV, Hahn RG, Jover JL, Del Cojo E, Hervías M, Jiménez I, et al. Clinical Applications of Crystalloids within Enhanced Recovery Pathways. Encyclopedia. Available at: https://encyclopedia.pub/entry/49426. Accessed August 04, 2024.
Lorente, Juan V., Robert G. Hahn, José L. Jover, Enrique Del Cojo, Mónica Hervías, Ignacio Jiménez, Rafael Uña, Fernando Clau-Terré, Manuel I. Monge, Juan V. Llau, et al. "Clinical Applications of Crystalloids within Enhanced Recovery Pathways" Encyclopedia, https://encyclopedia.pub/entry/49426 (accessed August 04, 2024).
Lorente, J.V., Hahn, R.G., Jover, J.L., Del Cojo, E., Hervías, M., Jiménez, I., Uña, R., Clau-Terré, F., Monge, M.I., Llau, J.V., Colomina, M.J., & Ripollés-Melchor, J. (2023, September 20). Clinical Applications of Crystalloids within Enhanced Recovery Pathways. In Encyclopedia. https://encyclopedia.pub/entry/49426
Lorente, Juan V., et al. "Clinical Applications of Crystalloids within Enhanced Recovery Pathways." Encyclopedia. Web. 20 September, 2023.
Clinical Applications of Crystalloids within Enhanced Recovery Pathways
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This entry is adapted from the peer-reviewed paper 10.3390/jcm12185930

Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes.

fluid therapy postoperative complications enhanced recovery after surgery

1. Introduction

Since the late 1990s, there has been a resurgence in the recognition and exploration of surgical stress, driven by increasing concerns regarding its impact on patient recovery and surgical outcomes. This renewed focus has led to a better understanding of the physiological response to stress and its underlying mechanisms. As a result, a comprehensive set of measures has been devised and compiled aimed at adopting a less metabolically demanding approach during the perioperative period [1].
One prominent manifestation of this approach is the implementation and widespread adoption of Enhanced Recovery After Surgery (ERAS) protocols, which place significant emphasis on perioperative fluid therapy. These protocols have demonstrated remarkable efficacy in reducing surgical morbidity and mortality and hospital stays and overall healthcare costs [2].

2. Crystalloids as Resuscitation Fluids during the Perioperative Period

In the past three decades, numerous studies have investigated the use of balanced crystalloids compared to 0.9% saline for resuscitation fluids. These studies encompassed controlled trials involving healthy volunteers, observational studies, and clinical trials conducted in surgical settings and with adult critical patients.
The SPLIT trial (0.9% Saline versus Plasma-Lyte 148 for ICU Fluid Therapy) [3] involved 2278 patients undergoing cardiac surgery or during the immediate postoperative period. The primary endpoint of the study was the risk of death. Patients receiving Plasma-Lyte 148 were compared with those who received 0.9% saline before admission to the post-anesthesia care unit. The relative risk of in-hospital mortality for patients receiving balanced crystalloids compared with those receiving 0.9% saline was 0.87 (95% CI, 0.64–1.18). The SALT (Isotonic Solution Administration Logistical Testing) trial [4] included 974 adults admitted from the emergency department, with sepsis being the most common diagnosis. Most patients had received 0.9% saline before admission to the ICU and subsequently received isotonic crystalloids. The odds ratio for 30-day in-hospital mortality in patients receiving balanced crystalloids compared with 0.9% saline was 0.91 (95% CI, 0.64–1.30). The incidence of death, dialysis, or persistent renal dysfunction was lower with balanced crystalloids but higher among patients receiving increased volumes of isotonic crystalloids.
Building upon these studies, two large-scale clinical trials have recently been completed involving nearly 30,000 adults. The SMART (Isotonic Solutions and Major Adverse Renal Events Trial) trial [5] and the SALT-ED (Saline Against Lactated Ringer’s or Plasma-Lyte in the Emergency Department) trial [6] were randomized crossover trials comparing the administration of balanced crystalloids (Ringer Lactate or Plasma-Lyte) with 0.9% saline in critical care and emergency department patients.
The SMART trial [5] recruited 15,802 adult patients from critical care units, with a significant proportion admitted from the emergency department or surgery ward. The primary endpoint was the incidence of severe renal dysfunction, death, dialysis, or persistent renal dysfunction after 30 days. Patients receiving balanced crystalloids had a lower incidence of severe renal dysfunction compared with those receiving 0.9% saline (14.3% vs. 15.4%, p = 0.04). In patients with sepsis or septic shock, the 30-day in-hospital mortality was lower in the balanced crystalloid group compared with the 0.9% saline group (25.2% vs. 29.4%, p = 0.02). Using balanced crystalloids in patients at higher risk of severe renal damage or death resulted in absolute risk reductions of 3.7% and 4.2%, respectively.
The SALT-ED trial [6] enrolled 13,347 patients who received intravenous crystalloids in the emergency department and were subsequently hospitalized in a non-ICU facility. The primary endpoint was the length of the hospital stay, and the secondary endpoint included major adverse kidney events. Patients receiving balanced crystalloids had similar results in terms of the length of the hospital stay but showed better outcomes regarding major adverse kidney events.
Although the SMART and SALT-ED trials have limitations, such as being single-center studies with a low total volume of fluids infused, they provide valuable insights. Additionally, the SOLAR trial [7] (Saline or Lactated Ringer’s Trial), a cohort study in elective colorectal and orthopedic surgery patients, found no statistically significant differences between the Ringer lactate and 0.9% saline groups regarding postoperative complications and in-hospital mortality.
More recently, the PLUS (Plasmalyte 148 versus Saline) trial [8] and the BaSICS (Balanced Solutions in Intensive Care Study) trial [9] were conducted. The PLUS trial included 5037 patients requiring fluid resuscitation in the ICU and found no statistically significant differences in the onset of renal failure or 90-day mortality between balanced crystalloids and 0.9% saline. The BaSICS trial recruited over 11,000 patients from Brazilian ICUs and found no differences in renal or in-hospital mortality between patients receiving 0.9% saline and those receiving balanced solutions.
An updated meta-analysis [10] incorporating the PLUS and BaSICS trials and 11 other high-quality clinical trials indicated that the use of balanced crystalloids resulted in a relative reduction in mortality ranging from 9% to 1%. The analysis also demonstrated a similar reduction in the risk of renal dysfunction.
In conclusion, the evidence from these studies supports the use of balanced crystalloids as resuscitation fluids during the perioperative period. They have shown potential benefits, including reduced risks of severe renal dysfunction, in-hospital mortality, and major adverse kidney events when compared with 0.9% saline. However, further research is needed to address limitations and provide more robust evidence in specific patient populations and clinical settings.

3. Crystalloids as Maintenance Fluids during the Preoperative Period

Prolonged preoperative fasting is associated with various harmful effects on surgical patients, including anxiety, dehydration, nausea, vomiting, and impaired insulin resistance during the postoperative phase [11]. Intensified recovery strategies now recommend shorter fasting periods of 6 h for solids and 2 h for fluids [12]. Following these protocols has not been shown to affect the patients’ fluid status or increase their fluid responsiveness as measured via passive leg elevation just before surgery [13].
The preoperative administration of a carbohydrate-rich drink (200–300 mL), primarily consisting of maltodextrins, the night before surgery and up to 2 h preoperatively does not increase gastric volume or pose a risk of aspiration and has been found to enhance postoperative recovery [14]. The routine use of systematic mechanical bowel preparation (MBP) in the pre-operative setting should be avoided [15]. Current evidence supporting its use is limited to specific cases of rectal surgery where a protective stoma is anticipated [16]. With a significant reduction in the number of patients requiring MBP and a shortened preoperative fasting period, prescribing crystalloids as maintenance fluid therapy before elective surgery is physiologically unnecessary [11]. However, a maintenance intravenous infusion of 5% glucose with electrolytes might be considered to improve well-being in fasting patients who are operated on in the late afternoon.

4. Fluid Therapy Strategies during Surgery

There are three main strategies for the administration of fluid during surgery.
-
Fluid balance approach: The anesthetist summarizes measured and perceived losses of fluid during the surgery and replaces the volumes according to the known plasma volume (PV) expansion effects of crystalloid and colloid infusion fluids. This individualized method is the most common worldwide and is appropriate for surgeries of short duration [17].
-
Outcome-based approach: Here, researchers have compared the incidence of postoperative complications in groups of patients randomized to receive one of two pre-determined fluid regimens, such as liberal/restrictive or crystalloid/colloid. A fluid strategy according to this approach is appropriate for intermediate-length surgery (1–3 h) without major hemorrhage.
Over the past two decades, numerous studies have compared various intraoperative infusion protocols, using multiple definitions of liberal and restrictive regimens. Typically, in major abdominal surgery, a regimen that administers an intraoperative infusion exceeding 7 mL/kg/h is categorized as liberal, while an approach characterized by an infusion rate not surpassing 5 mL/kg/h is considered a restrictive strategy [18][19].
-
Goal-directed fluid therapy should be applied for major surgery with an expected larger hemorrhage, such as the Whipple operation or abdominal cancer surgery. The fluid administration is then guided according to invasive hemodynamic measurements whereby the stroke volume is maintained at the flat portion of the Frank–Starling curve. The interested reader is referred to special literature on this topic [20]. Historically, colloid fluids with or without augmentation with vasopressors have been used for this purpose. However, crystalloid fluid is probably most commonly used in the clinical setting today.
Adhesion to the perioperative protocols for goal-directed fluid therapy can result in volume overload if applied in intensive care. Here, fluid boluses should be provided when signs of poor organ perfusion (liver, kidney, etc.) or hemodynamic instability appear.

5. Crystalloids as Maintenance Fluids during Intraoperative Period

The need for PV expansion during surgery is mainly due to the previously mentioned reduction in the MCFP. In addition, the excreted urine, bled volume, and insensible fluid losses need to be replaced. The goal is to maintain constancy in the internal environment despite the complex fluid balance situation that is at hand. Traditionally, insensible losses during surgery have been overestimated [21]. This, coupled with the assumption (yet unproven) of a non-functional extracellular space known as the third space [22] and the supposed hypovolemia resulting from preoperative fasting [13], has led to misguided liberal fluid therapy regimens, which have been associated with poorer postoperative outcomes [21]. In theory, balanced crystalloids are the most appropriate choice for intraoperative maintenance fluid therapy due to their ability to distribute within the extracellular space. The term “crystalloid fluid” commonly denotes electrolyte-containing fluid, but solutions based on glucose are also crystalloids. They may be indicated especially in the postoperative period, but only on special indications during ongoing surgery due to the risk of hyperglycemia, which promotes postoperative infection and osmotic diuresis [23][24]. The recommended crystalloid dose is 3 mL/kg/h for laparoscopic surgery and 5 to 7 mL/kg/h for laparotomy and abdominal surgery [25]. Rates of 2 mL/kg/h are associated with an increased incidence of postoperative nausea [26].

6. Fluid Creep

Fluid creep refers to the amount of fluid (and sodium) administered to dilute intravenously administered drugs, infuse prediluted medications, facilitate catheter flushing, or aid in the advancement of medication through a catheter. A retrospective study conducted in a Belgian ICU involving nearly 15,000 patients concluded that fluid creep accounted for one-third of a critically ill patient’s fluid intake during their ICU stay [27]. However, fluid creep not only contributes to fluid intake but also to sodium intake. Certain prediluted drugs, such as ciprofloxacin, contain dosage forms that include 2.82 g of sodium per daily dose [28], surpassing the maximum recommended daily sodium intake of 2.3 g by the World Health Organization (WHO) or 1.5 g per day in the presence of comorbidities [29]. A 5% glucose solution may serve as a safe alternative for diluting most medications, limiting the sodium content from the saline solution and promoting glycemic control in critically ill patients. Among commonly used drugs, only amoxicillin-clavulanic acid, phenytoin, somatostatin, and acyclovir require dilution in 0.9% saline [30].

7. Postoperative Maintenance Fluid Therapy

Oral intake should be encouraged as soon as possible, and the administration of intravenous fluids should be limited [1]. However, in certain situations related to the surgery, the patient, or the patient’s inability to adhere to enhanced recovery programs, maintenance fluid therapy may be necessary [31]. The goal of postoperative maintenance fluid therapy is to provide adequate free water and electrolytes to maintain homeostasis in the internal environment and sufficient glucose to prevent a shift toward anaerobic cellular metabolism (ketosis) when oral intake alone is insufficient to meet daily requirements [32]. Daily requirements typically include 25–30 mL/kg of water, 0.5–1 mmol/kg of potassium, 1 mmol/kg of chloride, 1 mmol/kg of sodium, and 50–100 g/day of glucose [33].
A cross-sectional observational study on fluid therapy by Uña et al. revealed that fluid therapy regimens prescribed in clinical practice often fail to meet patients’ daily requirements, frequently providing excessive amounts of sodium and chloride and insufficient amounts of potassium, calcium, and magnesium [34]. Such imbalances in nutrient supply have been associated with poorer postoperative outcomes [35]. Maintenance fluid therapy contributes more fluids, sodium, and chloride to critically ill patients during their ICU stay compared with fluid resuscitation therapy [27]. In pediatric literature, it is emphasized that isotonic maintenance fluids protect children from the morbidity associated with hyponatremia [36]. This population is particularly vulnerable to the development of neurological symptoms due to electrolyte imbalances and to hypoglycemia [37]. However, recommending isotonic maintenance solutions for all hospitalized patients to prevent hyponatremia is likely unnecessary because only a minority of patients are at risk of developing the condition, particularly among adults who typically obtain sodium from multiple sources and have their sodium levels measured frequently during their hospital stay [30]. The use of hypotonic maintenance fluids may be considered a safe alternative, as concluded by two recent studies: one conducted on healthy volunteers [38] and another on post-operative thoracic surgery patients [39]. The results demonstrate that through restricting sodium and chloride intake in patients, a more balanced water balance is achieved, leading to reduced kidney damage as measured via plasmatic neutrophil gelatinase-associated lipocalin (NGALp), in comparison to a group receiving isotonic maintenance fluids. Current evidence does not associate the use of hypotonic maintenance fluids with the occurrence of symptomatic or severe episodes of hyponatremia.

References

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  2. Mythen, M.G.; Swart, M.; Acheson, N.; Crawford, R.; Jones, K.; Kuper, M.; Mcgrath, J.S.; Horgan, A. Perioperative Fluid Management: Consensus Statement from the Enhanced Recovery Partnership. Perioper. Med. 2012, 1, 2–5.
  3. Young, P.; Bailey, M.; Beasley, R.; Henderson, S.; Mackle, D.; McArthur, C.; McGuinness, S.; Mehrtens, J.; Myburgh, J.; Psirides, A.; et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial. JAMA 2015, 314, 1701–1710.
  4. Semler, M.W.; Wanderer, J.P.; Ehrenfeld, J.M.; Stollings, J.L.; Self, W.H.; Siew, E.D.; Wang, L.; Byrne, D.W.; Shaw, A.D.; Bernard, G.R.; et al. Balanced Crystalloids versus Saline in the Intensive Care Unit. The SALT Randomized Trial. Am. J. Respir. Crit. Care Med. 2017, 195, 1362–1372.
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  17. Joshi, G.P. Enhanced Recovery Pathways for Ambulatory Surgery. Curr. Opin. Anaesthesiol. 2020, 33, 711–717.
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  20. Wilms, H.; Mittal, A.; Haydock, M.D.; van den Heever, M.; Devaud, M.; Windsor, J.A. A Systematic Review of Goal Directed Fluid Therapy: Rating of Evidence for Goals and Monitoring Methods. J. Crit. Care 2014, 29, 204–209.
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  38. Van Regenmortel, N.; De Weerdt, T.; Van Craenenbroeck, A.H.; Roelant, E.; Verbrugghe, W.; Dams, K.; Malbrain, M.L.N.G.; Van Den Wyngaert, T.; Jorens, P.G. Effect of Isotonic versus Hypotonic Maintenance Fluid Therapy on Urine Output, Fluid Balance, and Electrolyte Homeostasis: A Crossover Study in Fasting Adult Volunteers. Br. J. Anaesth. 2017, 118, 892–900.
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Subjects: Anesthesiology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Juan V. Lorente
,
Robert G. Hahn
,
José L. Jover
,
Enrique Del Cojo
,
Mónica Hervías
,
Ignacio Jiménez
,
Rafael Uña
,
Fernando Clau-Terré
,
Manuel I. Monge
,
Juan V. Llau
,
Maria J. Colomina
,
Javier Ripollés-Melchor
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Revisions: 2 times (View History)
Update Date: 21 Sep 2023
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