Perioperative Fluid Management

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Ehab Farag • Andrea Kurz
Editors

Perioperative Fluid
Management
Editors
Ehab Farag Andrea Kurz
Professor of Anesthesiology Professor of Anesthesiology
Cleveland Clinic Lerner College of Medicine Cleveland Clinic Lerner College of Medicine
Director of Clinical Research Chairman of General Anesthesia
Staff Anesthesiologist Cleveland Clinic
General Anesthesia and Outcomes Research Cleveland
Cleveland Clinic Ohio
Cleveland USA
Ohio
USA

ISBN 978-3-319-39139-7 ISBN 978-3-319-39141-0 (eBook)

DOI 10.1007/978-3-319-39141-0

Library of Congress Control Number: 2016955238

© Springer International Publishing Switzerland 2016

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To my daughter Becky for her
compassionate, listening ear, and assistance
in many of my publications.
– Ehab Farag
Foreword

Perioperative fluid management has been a debated topic for decades within the
anesthesia, surgical, and critical care literature. The “classic” approach to fluid
administration was based upon the duration of fasting, patient weight, duration of
surgery, and extent of tissue disturbance. The high degree of evolution that has
occurred on this topic is evidenced by perusing the contents of this book.
Drs. Ehab Farag and Andrea Kurz have assembled an incredible group of recog-
nized authorities and experts in this field. Collectively, they have amassed one of the
world’s most comprehensive collections of evidence-based literature that supports
the newest concepts and approaches to perioperative fluid management. Yet this
book also provides a true historical perspective, beginning with the contribution of
Dr. Elizabeth Frost, followed by chapters on the revised Starling principle and func-
tions of endothelial glycocalyx. The content of this book is deep and broad in dis-
cussing all aspects of perioperative fluid management, thorough, and comprehensive.
No “stone is left unturned” in this discussion.
I have no doubt that this book will be used as a great reference for other academic
endeavors in this field, making it a “must read” and necessary inclusion to the
library of every anesthesiologist, surgeon, and critical care physician caring for
perioperative patients.
The overall design of this book is two parts. The first part covers the overall pro-
cess, techniques for monitoring and management, restricted vs liberal administra-
tion strategies, crystalloid vs colloid, patient outcome, and the role of fluid
management in enhanced recovery protocols. The second part provides a case-based
approach to fluid management in specific patient scenarios, broadly characterized as
abdominal, orthopedic, neurological, and septic shock.
The topic of perioperative fluid management has important implications on mor-
bidity, mortality, enhanced recovery, and perioperative outcomes. This book comes
at a time when financial pressures are closely linked to patient outcomes with the
evolution of bundled-payment models. A rational, evidenced-based, best practice
approach to fluid management can have a significant impact upon overall patient
outcomes and hence is a topic worthy of complete understanding in the manner in

vii
viii Foreword

which Drs. Farag and Kurz have undertaken. They are to be congratulated for their
outstanding contribution to the literature.
On a personal note, I am proud to be associated with the many authors of this
book who work at the Cleveland Clinic. Their outstanding contributions to this text-
book are a testament of their dedication and daily contribution toward patient care
that allows our institution to care for a wide variety of critically ill patients within
many surgical subspecialty areas. Their collaborative approach to this book illus-
trates the way they “act as a unit” with other physicians in the perioperative care of
our patients within a clinical approach that truly puts “patients first.”

Christopher A. Troianos, MD, FASE

Chair, Anesthesiology Institute
Cleveland Clinic
Cleveland, OH, USA
Preface

With the establishment of the society of microcirculation in the 1980s, our under-
standing of microcirculation and tissue perfusion has fundamentally changed. The
discovery of functions of endothelial glycocalyx and its essential role in maintain-
ing the intact vascular barrier by Professors Curry and Michel has led to a new era
in perioperative fluid management. The Starling Principle that was considered sine
qua non for governing tissue perfusion since the 1920s and was written on a tablet
of stone in medical textbooks was built on a false assumption of the structure of the
blood vessels. Therefore, the Revised Startling Principle has replaced it, thanks to
Drs. Curry and Michel’s work in the field of microcirculation. The concept of liberal
perioperative fluid management to compensate for the third space fluid loss was
shown to increase the incidence of mortality and morbidity, especially in critically
ill patients. The restrictive fluid management that properly should be named “nor-
movolemic fluid management” has become an integral part of the enhanced recov-
ery after surgery to improve the patients’ perioperative outcomes. In this first edition
of the Perioperative Fluid Management book, we tried our best to present the most
comprehensive coverage of the most recent evidence-based medicine of fluid man-
agement written by world-renowned experts in the field. The book chapters cover
different facets of fluid management, such as the history of intravenous fluid, goal-
directed fluid management, balanced and unbalanced solutions, the dilemma with
the use of hydroxyethyl starch solutions, the perioperative use of albumin, the effect
of fluid overload on perioperative mortality and morbidity, and many more. We are
honored to have the chapters for revised Starling Principle and endothelial glycoca-
lyx written by the founding fathers of the modern science of microcirculation Drs.
Curry and Michel who rewrote the story of the science of this field. Moreover, we
added case scenarios for fluid management in different clinical settings to help
guide the fluid management in a practical way.
We would like this book to benefit the understanding and fluid management of
perioperative physicians.

ix
x Preface

At the end, we would like to express our gratitude to our colleagues who authored
the book chapters for their efforts and hard work. In addition, we would like to thank
Ms. Maureen Pierce our developmental editor and the Springer publishing team for
all their help and support during the publishing process of this book.

Cleveland, OH Ehab Farag, MD, FRCA

Andrea Kurz, MD
Contents

Part I Fundamentals of Fluid Management

1 A History of Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Elizabeth A.M. Frost
2 The Revised Starling Principle and Its Relevance to
Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
C. Charles Michel, Kenton P. Arkill, and FitzRoy E. Curry
3 The Functions of Endothelial Glycocalyx and Their Effects on
Patient Outcomes During the Perioperative Period. A Review of
Current Methods to Evaluate Structure-Function Relations
in the Glycocalyx in Both Basic Research and Clinical Settings . . . . . 75
FitzRoy E. Curry, Kenton P. Arkill, and C. Charles Michel
4 Techniques for Goal-Directed Fluid Management. . . . . . . . . . . . . . . . 117
Paul E. Marik
5 The Perioperative Use of Echocardiography for Fluid
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Maged Argalious
6 Microcirculatory Blood Flow as a New Tool for
Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Daniel De Backer
7 Mean Systemic Filling Pressure Is an Old Concept
but a New Tool for Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . 171
Hollmann D. Aya and Maurizio Cecconi
8 Restricted or Liberal Fluid Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Thomas E. Woodcock
9 The Perioperative Use of Albumin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Ehab Farag and Zeyd Y. Ebrahim

xi
xii Contents

10 The Dilemma for Using Hydroxyethyl Starch Solutions for

Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Christiane S. Hartog and Konrad Reinhart
11 Balanced Versus Unbalanced Salt Solutions in the
Perioperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Sheldon Magder
12 Positive Fluid Balance and Patients’ Outcomes . . . . . . . . . . . . . . . . . . 279
John Danziger
13 Fluid Management and Its Role in Enhanced Recovery . . . . . . . . . . . 299
Andrew F. Cumpstey, Michael P.W. Grocott, and Michael
(Monty) G. Mythen

Part II Case Scenarios Management During Colorectal,

Orthopedic, and Spine Cases
14 Case Scenario for Perioperative Fluid Management in
Major Orthopedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Wael Ali Sakr Esa
15 Case Scenario for Perioperative Fluid Management for
Major Colorectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Kamal Maheshwari
16 Case Scenario for Fluid Therapy in Septic Shock . . . . . . . . . . . . . . . . 349
William Phillips
17 Case Scenario for Fluid Management in Liver Resection . . . . . . . . . . 361
Maged Argalious and Harendra Arora
18 Case Scenario for Fluid Management During
Major Spine Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Verna L. Baughman
19 Case Scenario for Fluid Management After
Subarachnoid Hemorrhage in the Neuro-intensive Care Unit . . . . . . 391
Jamil R. Dibu and Edward M. Manno

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Contributors

Maged Argalious, MD, MSc, MBA, MEd Anesthesiology Institute, Cleveland

Clinic, Cleveland Clinic Lerner College of Medicine, Center for Anesthesiology
Education, Cleveland, OH, USA
Kenton P. Arkill, PhD School of Medicine, University of Nottingham,
Nottingham, UK
Biofisika Institute (CSIC UPV/EHU) and Research Centre for Experimental
Marine Biology and Biotechnology, University of the Basque Country, Bilbao,
Bizkaia, Spain
Harendra Arora, MD Department of Anesthesiology, University of North
Carolina Hospitals, Chapel Hill, NC, USA
Hollmann D. Aya, MD Adult Critical Care Directorate, St. George’s University
Hospitals, NHS Foundation Trust and St George’s University of London, London, UK
Verna L. Baughman, MD Department of Anesthesiology, University of Illinois,
Chicago, IL, USA
Maurizio Cecconi, MD, FRCA, FICM, MD(UK) Anaesthesia and Adult
Critical Care Directorate, St George’s University Hospitals, NHS Foundation Trust
and St George’s University of London, London, UK
Andrew F. Cumpstey, MA (Cantab), BMBCh, MRCP Department
of Anesthesia and Critical Care Medicine, University of Southampton,
Southampton, UK
FitzRoy E. Curry, PhD Department of Physiology and Membrane Biology,
and Biomedical Engineering, School of Medicine, University of California, Davis,
Davis, CA, USA
John Danziger, MD, MPhil Division of Nephrology, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA
Daniel De Backer, MD, PhD Department of Intensive Care, CHIREC Hospitals,
Université Libre de Bruxelles, Brussels, Belgium
xiii
xiv Contributors

Jamil R. Dibu, MD Department of Neurocritical Care, Cerebrovascular Center,

Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
Zeyd Y. Ebrahim, MD Department of General Anesthesiology, Anesthesiology
Institute, Cleveland Clinic, Cleveland, OH, USA
Wael Ali Sakr Esa, MD, PhD Section Head Orthopedic Anesthesia, Department
of General Anesthesia and Pain Management, Cleveland Clinic Lerner College of
Medicine, Cleveland Clinic, Cleveland, OH, USA
Ehab Farag, MD, FRCA Professor of Anesthesiology, Cleveland Clinic Lerner
College of Medicine, Director of Clinical Research, Staff Anesthesiologist,
General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, OH,
USA
Elizabeth A.M. Frost, MBChB, DRCOG Department of Anesthesiology,
Icahn Medical Center at Mount Sinai, New York, NY, USA
Michael P.W. Grocott, BSc, MBBS, MD, FRCA, FRCP, FFICM Department
of Anesthesia and Critical Care Medicine, University of Southampton,
Southampton, UK
Christiane S. Hartog, MD Department of Anesthesiology and Intensive Care
Medicine and Center for Sepsis Control and Care, Jena University Hospital,
Jena, Germany
Andrea Kurz, MD Professor of Anesthesiology, Cleveland Clinic Lerner College
of Medicine, Chairman of General Anesthesia, Cleveland Clinic, Cleveland, OH,
USA
Sheldon Magder, MD Department of Medicine and Physiology, Critical Care
Division, McGill University Health Centre, Royal Victoria Hospital, Montreal,
QC, Canada
Kamal Maheshwari, MD, MPH Acute Pain Management, Outcomes Research,
Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
Edward M. Manno, MD Department of Neurocritical Care, Cerebrovascular
Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
Paul E. Marik, MBBCH, FCP(SA), FCCM, FCCP Division of Pulmonary and
Critical Care Medicine, Department of Internal Medicine,
Eastern Virginia Medical School, Norfolk, VA, USA
C. Charles Michel, DPhil, BM.BCh, FRCP Department of Bioengineering,
Imperial College, London, UK
Michael (Monty) G. Mythen, MBBS, MD, FRCA, FFICM, FCAI(Hon) Department
of Critical Care, Anaesthesia and Perioperative Medicine, University College London,
London, UK
Contributors xv

William James Phillips, MD Department of Anesthesiology, Center for Critical

Care Medicine, Cleveland Clinic, Cleveland, OH, USA
Konrad Reinhart, MD Department of Anesthesiology and Intensive Care
Medicine and Center for Sepsis Control and Care, Jena University Hospital,
Jena, Germany
Christopher Troianos, MD Anesthesia Institute, Cleveland Clinic, Cleveland,
OH, USA
Thomas Edward Woodcock, MB, BS, MPhil Department of Critical Care,
University Hospital Southampton, Southampton, UK
 Part I
Fundamentals of Fluid Management
Chapter 1
A History of Fluid Management

Elizabeth A.M. Frost

Abstract A history of fluid management is discussed focusing on the following

key points. Bloodletting has been performed for more than 2000 years and is still
used today, albeit for different reasons. While bloodletting was ordered by physi-
cians, it was usually carried out by barber surgeons, thus dividing the two. Circulation
of blood was not appreciated until William Harvey in the first century, and it was not
immediately accepted as it was contrary to the teachings of Galen and others. The
concept of the need for fluid replacement rather than bloodletting grew out of the
worldwide cholera epidemic of the nineteenth century. Only over the past 60 years
have fluids routinely been given intraoperatively.

Keywords History • Blood • Fluid management • Bloodletting • Circulation • Fluid

replacement • Cholera • Intravenous • Transfusion

Key Points
1. Bloodletting has been performed for more than 2000 years and is still used
today, albeit for different reasons.
2. While bloodletting was ordered by physicians, it was usually carried out
by barber surgeons, thus dividing the two.
3. Circulation of blood was not appreciated until William Harvey in the first
century, and it was not immediately accepted as it was contrary to the
teachings of Galen and others.
4. The concept of the need for fluid replacement rather than bloodletting
grew out of the worldwide cholera epidemic of the nineteenth century.
5. Only over the past 60 years have fluids routinely been given intraoperatively.

The life of the flesh is the blood (Leviticus 17:11–14)

Take drink…this is my blood which is shed for you for the remission of sins (Matthew 26)

E.A.M. Frost, MBChB, DRCOG

Department of Anesthesiology, Icahn Medical Center at Mount Sinai,
New York, NY, USA
e-mail: [email protected]; [email protected]

© Springer International Publishing Switzerland 2016 3

E. Farag, A. Kurz (eds.), Perioperative Fluid Management,
DOI 10.1007/978-3-319-39141-0_1
4 E.A.M. Frost

Earliest Times

Long before biblical times, blood and body fluids were believed to have magical
powers. Blood was the cornerstone of life and regarded as a gift. Hence, it was often
used in sacrificial offerings to appease the gods. The Sumerians of Mesopotamia
(4th–2nd millennium BCE) considered the vascular liver as the center of life [1, 2].
The priests of Babylon taught that there were two types of blood: bright red day
blood in the arteries and dark night blood in the veins. In the Yellow Emperor’s
Classic of Internal Medicine, the Nei Ching Su Wen, an ancient Chinese text com-
piled about 4500 BCE, the heart and pulse were connected and all the blood was said
to be under the control of the heart and flowed continually until death (Fig. 1.1) [3].
Egyptian physicians were aware of the existence of the pulse and also of a con-
nection between the pulse and heart. The Smith Papyrus, ascribed by some to
Imhotep who lived around 2650 BCE and was the chief official of the Pharaoh
Dosier, offered some idea of a cardiac system, although perhaps not of blood circu-
lation (Fig. 1.2) [4]. Distinction between blood vessels, tendons, and nerves was not
made. A theory of “channels” that carried air, water, and blood to the body was

Fig. 1.1 The Yellow

Emperor’s Classic of
Internal Medicine. On
page 34, one reads, “When
people lie down to rest, the
blood flows back to the
liver”