Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

doi:10.3390/jcm12185930

Review

. 2023 Sep 12;12(18):5930.

doi: 10.3390/jcm12185930.

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Juan V Lorente^{1

2}, Robert G Hahn³, José L Jover^{2

4}, Enrique Del Cojo^{2

5}, Mónica Hervías^{6

7}, Ignacio Jiménez^{2

8}, Rafael Uña⁹, Fernando Clau-Terré^{2

10}, Manuel I Monge², Juan V Llau¹¹, Maria J Colomina^{2

12}, Javier Ripollés-Melchor^{2

13

14}

Affiliations

¹ Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain.
² Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain.
³ Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden.
⁴ Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain.
⁵ Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain.
⁶ Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain.
⁷ Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain.
⁸ Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain.
⁹ Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain.
¹⁰ Vall d'Hebron Institut Recerca, Vall d'Hebrón University Hospital, 08035 Barcelona, Spain.
¹¹ Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain.
¹² Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain.
¹³ Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain.
¹⁴ Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain.

PMID: 37762871
PMCID: PMC10531658
DOI: 10.3390/jcm12185930

Review

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Juan V Lorente et al. J Clin Med. 2023.

. 2023 Sep 12;12(18):5930.

doi: 10.3390/jcm12185930.

Authors

Affiliations

¹ Department of Anesthesiology and Critical Care, Juan Ramón Jiménez University Hospital, 21005 Huelva, Spain.
² Fluid Therapy and Haemodynamics Working Group of the Haemostasis, Fluid Therapy and Transfusional Medicine of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain.
³ Karolinska Institute, Danderyds Hospital (KIDS), 171 77 Stockholm, Sweden.
⁴ Department of Anesthesiology and Critical Care, Verge del Lliris Hospital, 03802 Alcoy, Spain.
⁵ Department of Anesthesiology and Critical Care, Don Benito-Villanueva de la Serena Health District, 06400 Don Benito, Spain.
⁶ Department of Anesthesiology and Critical Care, Gregorio Marañón General University Hospital, 28007 Madrid, Spain.
⁷ Paediatric Anaesthesiology Section, Spanish Society of Anesthesiology and Resuscitation (SEDAR), 28003 Madrid, Spain.
⁸ Department of Anesthesiology and Critical Care, Virgen del Rocío University Hospital, 41013 Seville, Spain.
⁹ Department of Anesthesiology and Critical Care, La Paz University General Hospital, 28046 Madrid, Spain.
¹⁰ Vall d'Hebron Institut Recerca, Vall d'Hebrón University Hospital, 08035 Barcelona, Spain.
¹¹ Department of Anesthesiology and Critical Care, Doctor Peset Hospital, 46017 Valencia, Spain.
¹² Department of Anesthesiology and Critical Care, Bellvitge University Hospital, University of Barcelona, 08907 Barcelona, Spain.
¹³ Department of Anesthesiology and Critical Care, Infanta Leonor Hospital, 28031 Madrid, Spain.
¹⁴ Department of Toxicology, Universidad Complutense de Madrid, 28040 Madrid, Spain.

PMID: 37762871
PMCID: PMC10531658
DOI: 10.3390/jcm12185930

Abstract

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 recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body's internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient's physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles.

Keywords: enhanced recovery after surgery; fluid therapy; postoperative complications.

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Conflict of interest statement

J.V.L. (Juan V. Lorente): Payment for courses, research, and conferences from Edwards Lifesciences and bioMérieux. Payment for courses and conferences from Fresenius Kabi, Grifols, Vifor Pharma and Baxter. R.G.H.: The author declares no conflict of interest related to the article. J.L.J.: Honoraria for Baxter and Fresenius Kabi conferences. E.D.C.: Conference fees and clinical consultancy for Teleflex, MBA, BBRAUN, and Grünenthal Pharma. M.H.: The author declares no conflict of interest related to the article. I.J.: Payment for courses and conferences from Edwards Lifesciences. R.U.: Honoraria for Baxter conferences. F.C.-T.: The author declares no conflict of interest related to the article. M.I.M.: Payment for conferences, courses, and research from Edwards Lifesciences; acted as medical advisor for Edwards Lifesciences. J.V.L. (Juan V. Llau): The author declares no conflict of interest related to the article. M.J.C.: Payments for conferences from Octapharma, C.S.L. Behring, and Fresenius Kabi. J.R.-M.: Payments for conferences, courses, and research from Edwards Lifesciences; payments for conferences from Biomerieux and Fresenius Kabi.

Figures

**Figure 1**
Fluid load versus perioperative morbidity risk (modified from Bellamy) [18]. Curve A represents the hypothesized line of risk. Broken line B represents a division between patient groups in a ‘wet vs dry’ study. Broken line C represents a division between patient and groups in an ‘optimized vs non-optimized’ study.

**Figure 2**
Variables that independently influence the pH of biological fluids according to Stewart’s theory. A_TOT—total weak acid concentration; SID—strong ion difference; P_aCO₂—partial CO₂ pressure. If the SID of the infused solution is below 24 mEq/L, it will result in metabolic acidosis, and if it is above 24 mEq/L, it will induce metabolic alkalosis. An increase in A_TOT is linked to acidosis, while a decrease in A_TOT leads to alkalosis.

**Figure 3**
Fluid infusion and distribution of body fluid in the 3 compartments (modified from Zampieri et al.) [76].

**Figure 4**
Changes in the distribution rates of crystalloid fluid resulting from general anesthesia as compared to the conscious state.

**Figure 5**
Fluid therapy indications in the surgical setting.

**Figure 6**
Patient’s volume status at different phases (modified from Hoste et al.) [115].

See this image and copyright information in PMC

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References

1. Gordon D., Spiegel R. Fluid Resuscitation: History, Physiology, and Modern Fluid Resuscitation Strategies. Emerg. Med. Clin. N. Am. 2020;38:783–793. doi: 10.1016/j.emc.2020.06.004. - DOI - PubMed
1. 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. doi: 10.1186/2047-0525-1-2. - DOI - PMC - PubMed
1. Bose S., Talmor D. Who Is a High-Risk Surgical Patient ? Curr. Opin. Crit. Care. 2018;24:547–553. doi: 10.1097/MCC.0000000000000556. - DOI - PubMed
1. Navarro L.H.C., Bloomstone J.A., Auler J.O.C., Cannesson M., Rocca G.D., Gan T.J., Kinsky M., Magder S., Miller T.E., Mythen M., et al. Perioperative Fluid Therapy: A Statement from the International Fluid Optimization Group. Perioper. Med. 2015;4:3. doi: 10.1186/s13741-015-0014-z. - DOI - PMC - PubMed
1. Kambhampati G., Ross E.A., Alsabbagh M.M., Asmar A., Pakkivenkata U., Ejaz N.I., Arif A.A., Ejaz A.A. Perioperative Fluid Balance and Acute Kidney Injury. Clin. Exp. Nephrol. 2012;16:730–738. doi: 10.1007/s10157-012-0623-5. - DOI - PubMed

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[1] Gordon D., Spiegel R. Fluid Resuscitation: History, Physiology, and Modern Fluid Resuscitation Strategies. Emerg. Med. Clin. N. Am. 2020;38:783–793. doi: 10.1016/j.emc.2020.06.004. - DOI - PubMed

[2] Gordon D., Spiegel R. Fluid Resuscitation: History, Physiology, and Modern Fluid Resuscitation Strategies. Emerg. Med. Clin. N. Am. 2020;38:783–793. doi: 10.1016/j.emc.2020.06.004. - DOI - PubMed

[3] 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. doi: 10.1186/2047-0525-1-2. - DOI - PMC - PubMed

[4] 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. doi: 10.1186/2047-0525-1-2. - DOI - PMC - PubMed

[5] Bose S., Talmor D. Who Is a High-Risk Surgical Patient ? Curr. Opin. Crit. Care. 2018;24:547–553. doi: 10.1097/MCC.0000000000000556. - DOI - PubMed

[6] Bose S., Talmor D. Who Is a High-Risk Surgical Patient ? Curr. Opin. Crit. Care. 2018;24:547–553. doi: 10.1097/MCC.0000000000000556. - DOI - PubMed

[7] Navarro L.H.C., Bloomstone J.A., Auler J.O.C., Cannesson M., Rocca G.D., Gan T.J., Kinsky M., Magder S., Miller T.E., Mythen M., et al. Perioperative Fluid Therapy: A Statement from the International Fluid Optimization Group. Perioper. Med. 2015;4:3. doi: 10.1186/s13741-015-0014-z. - DOI - PMC - PubMed

[8] Navarro L.H.C., Bloomstone J.A., Auler J.O.C., Cannesson M., Rocca G.D., Gan T.J., Kinsky M., Magder S., Miller T.E., Mythen M., et al. Perioperative Fluid Therapy: A Statement from the International Fluid Optimization Group. Perioper. Med. 2015;4:3. doi: 10.1186/s13741-015-0014-z. - DOI - PMC - PubMed

[9] Kambhampati G., Ross E.A., Alsabbagh M.M., Asmar A., Pakkivenkata U., Ejaz N.I., Arif A.A., Ejaz A.A. Perioperative Fluid Balance and Acute Kidney Injury. Clin. Exp. Nephrol. 2012;16:730–738. doi: 10.1007/s10157-012-0623-5. - DOI - PubMed

[10] Kambhampati G., Ross E.A., Alsabbagh M.M., Asmar A., Pakkivenkata U., Ejaz N.I., Arif A.A., Ejaz A.A. Perioperative Fluid Balance and Acute Kidney Injury. Clin. Exp. Nephrol. 2012;16:730–738. doi: 10.1007/s10157-012-0623-5. - DOI - PubMed

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Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Affiliations

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

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Cited by

References

Publication types

LinkOut - more resources

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