Perioperative Fluid Management: Evidence-Based Consensus Recommendations from the International Multidisciplinary Perioperative Quality Initiative

Academic Background

Perioperative fluid management is a critical component of surgical patient care, directly impacting postoperative recovery and complication rates. In recent years, with the continuous emergence of new evidence in the field of fluid management, clinical practices have evolved. However, despite the recognized importance of fluid management in surgery, inappropriate fluid management (e.g., unphysiological fluid composition, excessive or insufficient volume) can lead to increased postoperative complications and even affect long-term patient outcomes. Therefore, developing evidence-based fluid management strategies has become a significant focus in perioperative medicine.

The Perioperative Quality Initiative (POQI) is a multidisciplinary, nonprofit organization aimed at standardizing perioperative patient care through evidence-based assessments and consensus recommendations, while guiding future research directions. This article, authored by the POQI working group, provides the latest evidence-based consensus recommendations for perioperative fluid management, covering all types of surgery from preoperative to discharge (excluding burns and head and neck surgeries), and offers specific fluid management advice for different surgical types and patient populations.

Source of the Paper

This paper was co-authored by Marlies Ostermann and other experts from several internationally renowned institutions, including Guy’s & St Thomas’ Hospital in London, Cleveland Clinic in the United States, and the University Hospital of Münster in Germany. The paper was published online on September 27, 2024, in the British Journal of Anaesthesia, titled Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary perioperative quality initiative.

Research Process and Methods

1. Formation of the Expert Panel and Literature Review

POQI invited 17 international experts from fields such as anesthesiology, critical care, perioperative medicine, nephrology, and clinical outcomes research to form the Fluid Management Working Group. Prior to the conference, the working group held five virtual meetings to review the fluid management recommendations issued by POQI in 2016 and 2021, and updated the recommendations based on newly published clinical trials on fluid management. The working group searched PubMed, ClinicalTrials.gov, and the Cochrane Database for randomized controlled trials, observational studies, reviews, and meta-analyses on fluid management published between January 1, 2016, and June 1, 2023, ultimately identifying 329 relevant articles.

2. Consensus Development Methodology

The working group used a modified Delphi method to develop consensus recommendations. During the conference, the working group presented research questions and refined the recommendations through breakout sessions and plenary meetings, incorporating available evidence and expert opinions. The final recommendations underwent four rounds of revision and were voted on in a non-anonymous manner during the plenary meeting, with an 85% agreement rate set as the threshold for approval.

3. Evidence Quality Assessment

The working group used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to rate the certainty of evidence. For areas with insufficient evidence, the working group proposed recommendations for future research.

4. Public Voting on Consensus Recommendations

At the Evidence-Based Perioperative Medicine World Congress held on July 6, 2023, the working group presented the consensus recommendations to 91 attendees and conducted anonymous voting using the Slido app to assess the level of agreement with each recommendation.

Key Results and Recommendations

1. Elective Major Noncardiac Surgery

• Preoperative Fasting Time: It is recommended to shorten preoperative fasting time (2 hours for clear fluids) to reduce thirst and prevent preoperative dehydration (strong recommendation, moderate-quality evidence).
• Intraoperative Fluid Management: It is recommended to administer an adequate volume of fluid intraoperatively, generally aiming for a positive fluid balance of 1-2 liters by the end of the case (strong recommendation, high-quality evidence).
• Use of Colloids: Routine use of albumin or synthetic colloids for intraoperative fluid administration is not recommended (strong recommendation, low-quality evidence for albumin and high-quality evidence for synthetic colloids).
• Use of Buffered Crystalloids: In the absence of hypochloraemia, the use of buffered crystalloid solutions is recommended (weak recommendation, moderate-quality evidence).

2. Cardiopulmonary Bypass

• Use of Colloids: Routine use of albumin or synthetic colloids for priming the cardiopulmonary bypass circuit is not recommended (strong recommendation, moderate-quality evidence).
• Use of Ultrafiltration: Excessive ultrafiltration (>30 ml/kg) during cardiopulmonary bypass is not recommended (weak recommendation, moderate-quality evidence).

3. Thoracic Surgery

• Postoperative Fluid Management: A positive fluid balance in the first 24 hours following lung resection surgery is not recommended (weak recommendation, very low-quality evidence).

4. Neurosurgery

• Use of Albumin: The use of albumin in neurosurgical patients is not recommended (strong recommendation, moderate-quality evidence).
• Use of Hypotonic Solutions: The use of hypotonic solutions in neurosurgical patients is not recommended (strong recommendation, moderate-quality evidence).
• Fluid Management in Traumatic Brain Injury: The use of 0.9% saline as first-line fluid therapy in patients with traumatic brain injury is recommended (weak recommendation, moderate-quality evidence).

5. Minor Noncardiac Surgery

• Prevention of Postoperative Nausea and Vomiting: A mildly positive fluid balance is recommended to reduce the incidence of postoperative nausea and vomiting in minor noncardiac surgery (weak recommendation, low-quality evidence).

6. Critical Illness

• Use of Buffered Crystalloids: In the absence of hypochloraemia, the use of buffered crystalloid solutions is recommended (strong recommendation, high-quality evidence).
• Use of Synthetic Colloids: The use of synthetic colloids is not recommended (strong recommendation, high-quality evidence).
• Use of Albumin: Routine use of albumin is not recommended (strong recommendation, high-quality evidence).
• Minimizing Fluid Accumulation: Strategies that minimize the risk of fluid accumulation and promote maintenance of intravascular normovolaemia are recommended (weak recommendation, moderate-quality evidence).
• Fluid Management in Subarachnoid Hemorrhage: Hypervolaemia in patients with subarachnoid hemorrhage is not recommended (weak recommendation, moderate-quality evidence).

Conclusions and Significance

This article provides evidence-based recommendations for perioperative fluid management through a multidisciplinary expert consensus, covering all stages from preoperative to postoperative care and offering specific fluid management strategies for different surgical types and patient populations. These recommendations aim to assist clinicians in making more informed fluid management decisions during the perioperative period, reducing postoperative complications and improving patient outcomes.

However, the article also highlights that many unresolved issues remain in the field of perioperative fluid management, and further research is needed to address these knowledge gaps. For example, the role of albumin in major surgery, the impact of synthetic colloids on renal function, and parameters for individualized fluid management are important areas for future research.

Research Highlights

1. Multidisciplinary Consensus: This article was developed by international experts from multiple fields, including anesthesiology, critical care, and perioperative medicine, ensuring the comprehensiveness and authority of the recommendations.
2. Evidence-Based Recommendations: All recommendations are based on the latest clinical trials and observational studies, ensuring scientific rigor and practical applicability.
3. Individualized Management: Emphasis is placed on tailoring perioperative fluid management to the type of surgery and individual patient factors, particularly for patients with chronic conditions.
4. Future Research Directions: In addition to providing current recommendations, the article identifies key areas for future research, guiding further advancements in perioperative fluid management.

Other Valuable Information

The article also discusses the potential risks and benefits of fluid management in detail, particularly the impact of fluid overload or insufficiency on patient outcomes. Furthermore, it highlights the differences in fluid management across various surgical types, such as the special considerations for cardiopulmonary bypass and neurosurgery.

This article provides comprehensive evidence-based recommendations for perioperative fluid management, offering significant clinical guidance and pointing the way for future research.