Fluid Status Assessment and Management During the Perioperative Phase in Adult Cardiac Surgery Patients

PERIOPERATIVE FLUID MANAGEMENT has been studied extensively, especially in noncardiac surgery populations, and hypovolemia and hypervolemia clearly have been identified as major contributors of morbidity and mortality. 1 Silva Jr, J.M. de Oliveira A.M. Nogueira F.A. et al. The effect of excess fluid balance on the mortality rate of surgical patients: A multicenter prospective study. Crit Care. 2013; 17: R288 Crossref PubMed Scopus (103) Google Scholar It has been demonstrated that both hypovolemia, eventually leading to inadequate oxygen delivery (DO2), and hypervolemia, which causes tissue edema, organ dysfunction, and coagulation system alterations, are associated with increased perioperative morbidity risk that has been well-described as a “parabolic-U-shape” relationship. 2 Vincent J.L. Pelosi P. Pearse R. et al. Perioperative cardiovascular monitoring of high-risk patients: A consensus of 12. Crit Care. 2015; 19: 224 Crossref PubMed Scopus (131) Google Scholar Nonetheless, to date, the optimal regimen of fluids administration still is a matter of debate, and great concerns remain about the type (colloids v crystalloids), the ideal composition, and the amount of fluids that should be administered. 3 Della Rocca G. Vetrugno L. Tripi G. et al. Liberal or restricted fluid administration: Are we ready for a proposal of a restricted intraoperative approach?. BMC Anesthesiol. 2014; 14: 62 Crossref PubMed Scopus (47) Google Scholar Whereas in low-risk patients undergoing minor surgery, “liberal” fluid administration (or “nonrestrictive”) seems to improve outcome, reducing complications and length of stay, 4 Doherty M. Buggy D.J. Intraoperative fluids: How much is too much?. Br J Anaesth. 2012; 109: 69-79 Crossref PubMed Scopus (182) Google Scholar , 5 Maharaj C.H. Kallam S.R. Malik A. et al. Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg. 2005; 100: 675-682 Crossref PubMed Scopus (127) Google Scholar but in high-risk and pediatric surgeries, the issue is much more complex and individualized fluid administration (goal-directed therapy [GDT]) seems to be reasonable. 6 Hamilton M.A. Cecconi M. Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg. 2011; 112: 1392-1402 Crossref PubMed Scopus (624) Google Scholar , 7 Arulkumaran N. Corredor C. Hamilton M.A. et al. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: A meta-analysis. Br J Anaesth. 2014; 112: 648-659 Crossref PubMed Scopus (99) Google Scholar In cardiac surgery patients, the distribution of fluids in the intravascular or extravascular spaces depends on a number of intraoperative and postoperative factors that highly influence the pathophysiology of body fluid kinetics, including the patients’ body surface area; cardiopulmonary bypass (CPB) (starting, conducting, and weaning); CPB priming solution (volume and composition); cardioplegic solutions (volume, composition, and temperature); CPB circuits and artificial lungs; thermal management; and vasoactive and inotropic drugs. Patient age is another key factor determining different fluid kinetics during cardiac surgery. This review is the first of 2 concerning fluid management during and after adult and pediatric cardiac surgery, and it addresses evidence on perioperative fluid administration and goal-directed fluid therapies in adult patients.