Int r aoperative F luid

Management
Judy Thompson, CRNA, DNAP, APRN

KEYWORDS
! Body fluid compartments ! Fluid management ! Crystalloids and colloids
! Blood and blood products ! The third space ! Goal-directed fluid therapy

KEY POINTS
! The amount of fluid in an average adult is approximately 60% of their total body weight.
! The “4-2-1 Rule” is still used as a formula that gives a basic number for calculating require-
ments for fluid maintenance.
! Newer nil per os guidelines developed in 1999 should be used when calculating a fluid
deficit.
! Data from randomized controlled trials do not support resuscitation with colloids
(compared with crystalloids) as being associated with lower mortality.
! “The Third Space” is now deemed “a myth.”
! Goal-directed fluid therapy is the current best practice recommendation for the manage-
ment of high-acuity patients and/or complex or prolonged surgical procedures.

INTRODUCTION

A core element in the practice of anesthesia is the administration of intravenous (IV)

fluids to maintain homeostasis. Clinical outcome data and evidence-based medicine
direct best practice. Knowledge and understanding of the effects of fluid management
choices should guide the clinical management of all patients and all procedures. The
appropriate administration of IV fluids and blood products is equal in importance to the
maintenance of sleep, the relief of pain, surgical muscle relaxation, and the monitoring
of vital signs. This article explores currently available IV fluids, discusses current rec-
ommendations for their use, and cites recent studies that challenge some of the long
established tenets of intraoperative fluid therapy. Goal-directed fluid therapy for select
patients has been frequently studied and highly supported in the recent literature. This
supportive evidence is examined, the monitoring modalities used and recommended
criteria for patient and case selection are explained, and anticipated outcomes are

Disclosure Statement: The author has nothing to disclose.

Nurse Anesthesia Program, School of Nursing, Quinnipiac University, 275 Mount Carmel
Avenue NH-HSC, Hamden, CT 06518, USA
E-mail address: judy.thompson@quinnipiac.edu

Crit Care Nurs Clin N Am 27 (2015) 67–77

http://dx.doi.org/10.1016/j.cnc.2014.10.012 ccnursing.theclinics.com
0899-5885/15/$ – see front matter ! 2015 Elsevier Inc. All rights reserved.
68 Thompson

defined. Current evidence-supported recommendations for colloid and blood admin-

istration are also reviewed.

BODY FLUID COMPARTMENTS

Before intraoperative fluid management and replacement can be completely under-

stood, it is important to review body fluid compartments, fluid distribution, and fluid
composition. The body is in large part composed of fluid, ranging between 46%
and 80%, depending on the age and gender of the individual and the body’s compo-
sition of fat relative to muscle.1(p382) Pound for pound (or kilogram for kilogram), fat
contains less fluid than muscle. Infants have the greatest percentage of total body fluid
(70%–80% of their body weight), whereas the elderly have the least (50% of their body
weight). Using an average amount of fluid at approximately 60% of the body weight,
the hypothetical 70-kg (154-lb) adult (if one were to lose all of their bodily fluid) would
weigh 42 kg (61.6 lb). As you can see, we are mostly water. The other tissues are “light
weights” compared with total body water (TBW).
TBW is divided between 2 compartments within the body, the intracellular (ICF) and
extracellular (ECF) fluids. The intracellular compartment contains most of the body wa-
ter, comprising about two-thirds of the total fluid volume. The ECF compartment
therefore contains the other one-third of the total fluid volume. The ECF compartment
is further divided into the intravascular fluid (ICF or plasma) that makes up approxi-
mately one-quarter of the ECF and the interstitial fluid (ISF) that makes up the rest.
ICF is high in potassium and magnesium and low in sodium and chloride ions. The
ECF composition is the opposite of that of the ICF, low in potassium and magnesium
and high in sodium and chloride ions.
Semipermeable cell and capillary membranes separate the fluid compartments. The
ICF compartment is separated from the ECF compartment by a cell membrane, and
the ICF is separated from the ISF by a capillary membrane. The properties of the mem-
brane that separates the fluid compartment as well as the relative concentration of the
osmotically active substances within each compartment are the factors primarily
responsible for the movement of fluid (water and electrolytes) among compartments
in the body.1(p382) This movement is governed by Starling forces. Starling forces main-
tain the balance between hydrostatic pressure of the blood in the capillaries and the
osmotic attraction of the blood for the surrounding fluid. Starling forces are made
up of ISF pressure, ISF colloid osmotic pressure, capillary pressure, and plasma
colloid osmotic pressures, respectively.2
Preoperatively, one can attempt to assess the fluid status of patients by several
indices, such as skin turgor, mucus membrane hydration, heart rate, blood pressure
and pulses, urinary output, and laboratory findings, such as specific gravity and
osmolality of the urine, serial hematocrit (HCT), blood urea nitrogen (BUN), creatinine,
and BUN/creatinine ratio, serum sodium, arterial blood gases, and base deficits. All
of these measures are indirect indices. None of them in isolation or together are
definitive. If the patient was known to have had vomiting and/or diarrhea preopera-
tively or a fever, or had been actively bleeding before surgery, this deficit could be
attempted to be calculated as well and a plan devised for fluid replacement and
maintenance therapy. Again, this is not definitive and in certain circumstances may
be all that there is to use as a guide. At the time anesthesia is induced and
throughout the intraoperative period, yet another set of variables exist that can be
used to measure directly, such as response to anesthetics, pulses, and urinary
output if a Foley catheter is in place. In addition to urinary output, blood and fluid
loss can be estimated by measuring suction from the surgical site or from oral/
 Intraoperative Fluid Management 69

nasogastric tube drainage, chest tube drainage, sponges, and gauzes (depending on
their level of saturation).

FLUID COMPOSITION

IV fluids may be broadly classified into colloid and crystalloid solutions. They each
have very different physical, chemical, and physiologic characteristics. Crystalloids
are solutions of inorganic ions and small organic molecules dissolved in water. They
are the most common fluids administered intraoperatively to patients. Infused crystal-
loids are free of colloid osmotic force and are therefore not retained at the vascular
wall. Accordingly, they distribute within the whole extracellular space for physiologic
reasons.3
Crystalloids have as wide a range of uses as they have compositions (Table 1). The
main solute is either glucose or sodium chloride (saline) and the solutions may be
isotonic, hypotonic, or hypertonic with respect to plasma.4 Crystalloids that most
closely compare to the composition of plasma are also referred to as “balanced.”
When glucose is added to an isotonic solution, it is quickly metabolized, which allows
the water in the solution to be freely distributed throughout the TBW. For this reason,
the addition of glucose to a crystalloid provides water replacement and is used to treat
simple dehydration. The most common balanced salt solutions used during surgery
are 0.9% sodium chloride (normal saline, NS) and lactated Ringer’s solution (LR).
Isotonic solutions such as NS and LR are commonly used to correct the hypovolemia
resulting from surgery and anesthesia because the bulk of fluid lost is isotonic.1(p392)
Crystalloids have an intravascular half-life of approximately 20 to 30 minutes.
Colloids are large molecular weight solutions that do not easily pass the endothelial
wall.5 Colloid molecules are most commonly dissolved in isotonic saline, but they may
also be dissolved in isotonic glucose, hypertonic saline, and isotonic “balanced” elec-
trolyte solutions. Colloids expand plasma volume by 1:1. Colloid solutions are divided
into semisynthetic and naturally occurring human plasma derivatives. Blood deriva-
tives include fresh frozen plasma (FFP) and plasma protein fraction (PPF) and albumin.
Albumin comes in 5% and 25% solutions and is purified from human plasma. The half-
life in human plasma is approximately 16 hours. PPF comes in a 5% solution and con-
tains a-globulins and b-globulins plus albumin. These blood derivatives are heated to
60" C for 10 minutes to minimize the risk of transmitting hepatitis and other virally trans-
mitted diseases as well as bacterial contamination.

Table 1
Commonly used crystalloids

Fluid Management
Solution Tonicity NaD ClL KD CaDD Glucose Lactate
D5W Hypo 50
NS Iso 154 154
D51/4 NS Iso 38.5 38.5 50
D51/2 NS Hyper 77 77 50
D5NS Hyper 154 154 50
LR Iso 130 109 4 3 28
PL Iso 140 98 5
D5LR Hyper 130 109 4 3 50 28
1
/2 NS Hypo 77 77
70 Thompson

Semisynthetic colloids include gelatins, dextrans, and hydroxyethyl starches.

Dextran is a polysaccharide made of many glucose molecules. Dextran 70 (Macrodex)
is the most widely used plasma expander, which yields the same volume as the
infused amount or a 1:1 ratio. The solution resides in the plasma for about 3 to 4 hours.6
Dextran 40 (Rheomacrodex) is used in vascular surgery because it decreases blood
viscosity and improves blood flow through the microcirculation. These synthetic prod-
ucts are not without several associated problems. They have been implicated in both
anaphylactic and anaphylactoid reactions. The administration of a low-molecular-
weight dextran (dextran-1 Promit, Hapten) before starting the infusion can consider-
ably reduce the possibility of these serious reactions. Dextran can interfere with blood
typing, can prolong bleeding time, can exhibit antiplatelet effects, and has been asso-
ciated with renal failure as well. The alterations in platelet function, thus increasing the
potential for blood loss, are the basis for the maximum dose recommendations of 1.5
to 2 g/kg for such solutions.7
Hydroxyethyl starch (Hetastarch) is a 6% solution. The molecules are smaller and
therefore more easily eliminated by the kidneys. Hetastarch is a highly effective
plasma expander, is less expensive than albumin, is nonantigenic, and does not affect
bleeding times and coagulation to the extent that the dextrans do.
Much controversy regarding the use of crystalloids versus colloids has been present
in recent literature. According to an analysis of the literature in the Cochrane Database,
“there is no evidence from randomized controlled trials that resuscitation with colloids
reduces the risk of death, compared to resuscitation with crystalloids, in patients with
trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might
increase mortality. As colloids are not associated with an improvement in survival and
are considerably more expensive than crystalloids, it is hard to see how their
continued use in clinical practice can be justified.”8

THE CALCULATION OF FLUID MAINTENANCE

The calculation of maintenance fluid requirements is of particular use in the estimation

of electrolyte and water deficits in preoperative surgical patients. Commonly, these
patients have been restricted from eating and drinking for a prolonged period of
time. In healthy adults, sufficient water is required to balance gastrointestinal losses
of 100 to 200 mL/d, insensible losses of 500 to 1000 mL/d (half of which is respiratory
and half is cutaneous), and urinary losses of 1000 mL/d.9
It might be hard to believe, but the widely used formula for calculating fluid mainte-
nance requirements came from the work of Holliday and Segar10 in 1957. In their pub-
lication, they advocated for the use of hourly fluid maintenance based on caloric
expenditure calculated by weight (Fig. 1). Their work was directed at the pediatric pa-
tient initially. Anesthesia providers have widely used this formula in their calculation of
intraoperative fluid maintenance. This commonly used formula is the “4-2-1 Rule,”
which has been the basis for fluid calculations since its adoption (Fig. 1). Holliday
and Segar formulated this simple rule from the following:

Hourly volume (V1) 5 Maintenance (M) 1 Fasting deficit (nil per os [NPO])
1 Estimated Blood Loss (EBL) 1 Third Space Losses (TS).11

The practitioners has used the “4-2-1 Rule” in practice, taught it to new practi-
tioners, and relied on it to give initial calculations for many years. This equation has
been the basis from which many additional fluid calculations have been derived. A
simple example follows.
 Intraoperative Fluid Management 71

Fig. 1. Commonly used formula for fluid maintenance requirements (Holliday and Segar)
“4-2-1 Rule.” (Data from Holliday MA, Segar WE. The maintenance need for water in paren-
teral fluid therapy. Pediatrics 1957;19(5):823–32.)

! The hypothetical 70-kg adult: 4 mL per kilogram for the first 10 kg (40 mL), 2 mL
for the next 10 kg (20 mL), and 1 mL for each kilogram greater than 21 kg
(50 mL) 5 40 1 20 1 50 5 110 mL/h for maintenance.
Eighteen years later, expanded recommendations were published that became
widely adopted as well.12 These recommendations were used to correct for the
NPO deficit, which was commonly calculated from midnight to the time of surgery
(at least 8 hours after fast) the following day. Although the current recommendations
published in 1999 do not support these past NPO guidelines,13 this practice is still
commonly used in many settings (Table 2).
If calculations are based on the “4-2-1 Rule” and the NPO deficit is added for each
hour that the patient has fasted (liquid and solid), the result will be roughly this formula:
Maintenance # Hours fasted 5 Deficit.
! The hypothetical patient of 70 kg: Maintenance (110 mL) # 8 hours 5 880 (fluid
deficit).
Replacing this has been traditionally broken into set amounts and added to the
hourly maintenance. The most commonly used method by clinicians is to divide this

Table 2
Current NPO guidelines

The NPO Requirement

Clear liquids 2h
Breast milk 4h
Formula/milk 6h
Light meal (clear liquid/toast) 6h
Solid food 8h

Guidelines prefer relatively health patients without risk factors for delayed gastric emptying. Pa-
tients undergoing emergency surgery or patients with predisposing factors for delayed gastric
emptying (diabetics, morbidly obese, pregnant, gastroesophageal reflux disease, difficult airway)
should follow the NPO guidelines (nothing by mouth for 8 h).
Data from Practice guidelines for preoperative fasting and the use of pharmacologic agents to
reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective pro-
cedures: a report by the American Society of Anesthesiologists Task Force on Preoperative Fasting.
Anesthesiology 1999;90(3):896–905.
72 Thompson

amount by 1/2 and give it back to the patient in the first hour of surgery. This amount,
of course, is plus the maintenance. The second hour, one-quarter of the deficit plus
the maintenance is replaced, and in the third hour, the final one-quarter of the deficit
is replaced, making the calculated total, which would look like this:
! 110 mL (calculated maintenance) 1 880 (calculated deficit)/2 or 440 mL 5
550 mL (total) given in the first hour.
! 110 mL (maintenance) 1 (880/4) 220 mL (1/4 of the calculated deficit) 5 330 mL
for the second hour.
! 110 mL 1 (880/4) (5220) 5 330 for the third hour.
Therefore, in 3 hours, the patient would receive a total of (550 mL 1 330 mL 1
330 mL) or 1210 mL of fluid. This amount, provided all variables stay the same, should
replace the patient’s deficit from fasting.
If the fast were to follow the newer guidelines, only an 8-hour deficit would be seen in
a patient with solid food intake preoperatively or in a patient with certain comorbidities
(see Table 2). In other patients, the current NPO guidelines would be followed and the
hours actually fasted used to calculate the deficit. This amount might be a deficit that is
so insignificant that it is not realty worth including in the calculations.
In this example, a toddler coming for surgery nursed 4 hours previously.
! Example: 13-kg toddler, NPO for 4 hours
" 46 mL # 4 hours 5 184 mL (deficit)
" 1st hour, 92 mL 1 46 5 138 mL (138 mL)
" 2nd hour, 46 mL 1 46 mL 5 92 mL (230 mL)
" 3rd hour, 46 mL 1 46 mL 5 92 mL (322 mL)

THE THIRD SPACE

Until recently, calculating surgical fluid replacement was normally based on 4 param-
eter: maintenance, deficits, surgical wound losses, and “third space” losses. The
notion of a “third space” was originally postulated by Shires and colleagues14 in
1961 around the time of the Vietnam Conflict when mass casualties were being treated
in the field. The third space, according to Shires, consisted of fluid that was seques-
tered into a compartment that was no longer functional due most often to tissue
trauma. Examples of a “third space” might be ascites or fluid in the peritoneal cavity
or bowel or from traumatized tissues. In the past, these calculations were added to the
fluids that were transfused into the patients, depending on an estimation of the degree
of trauma produced by a particular procedure. Table 3 gives an example of these cal-
culations. If the surgery caused minimal tissue trauma such as one might expect from
a small incision such as an appendectomy, an additional fluid requirement of between
1 and 4 mL/kg/h would be added to the maintenance for each hour of surgery. Larger

Table 3
The hypothetical “third space” requirements

Fluid Management
Degree of Tissue Trauma Additional Fluid Requirement
Minimal (eg, herniorrhaphy) 0–4 mL/kg/h
Moderate (eg, cholecystectomy) 4–6 mL/kg/h
Severe (eg, bowel resection) 6–8 mL/kg/h
 Intraoperative Fluid Management 73

procedures that were more invasive and caused more severe tissue trauma required
larger fluid requirements of as much as 8 mL/kg/h of surgery. Classic third space fluid
losses have never been measured directly, and the actual location of the lost fluid re-
mains unclear.15 It is now known that the shift of fluid to the interstitial space is
returned to the circulation via the lymphatics and is thus not lost to the circulation at
all. Such shifting is related to a destruction of the endothelial glycocalyx, a key struc-
ture of the vascular barrier, by traumatic inflammation and iatrogenic hypervolemia.3
The glycocalyx is the inner lining of the endothelial wall visible through electron micro-
scopy. It consists of a variety of transmembrane and membrane-bound molecules.
The glycocalyx is approximately 1 mm in thickness. Surgical stress is responsible for
causing the release of several inflammatory mediators, atrial natriuretic peptide
(ANP) among them. ANP release is triggered by acute hypervolemia that is often
induced by iatrogenic administration of IV fluids. A degradation of the glycocalyx leads
inevitably to an increase of capillary leakage and interstitial edema, which is strongly
corelated to a decrease in tissue oxygenation.16 Recent evidence now recommends
that the arbitrary third space is no longer included in fluid calculations.

GOAL-DIRECTED FLUID THERAPY

Multiple studies done within the last 20 years have looked at fluid therapy based on a
balance between inadequate fluid resuscitation and decreased tissue perfusion and
excess fluid with edema formation. These studies have been casting doubt on the
traditional management of fluid in favor of a more individualized fluid therapy based
not only on the types of surgery but also on the individual characteristics of the pa-
tients. Studies have shown that patients undergoing major procedures can gain an
average of between 3 and 10 kg of weight due to traditional methods of fluid therapy.17
Tissue edema has been associated with altered oxygen tensions, and this directly af-
fects surgical wound healing. Other studies have shown that mortality is higher in pa-
tients with further weight increases.18 With the benefits of more sophisticated
technology, fluid therapy may be more easily individualized today than ever before
and is the basis for individualized fluid therapy, or goal-directed fluid therapy. Goal-
directed fluid therapy is based on a specific endpoint.
One of the hallmark studies in fluid therapy and administration techniques was the
study done by Brandstrup and colleagues19 in 2003. Standard fluid therapy versus
restricted fluid replacement was compared in patients undergoing colorectal surgery.
In this study, researchers looked at 141 patients in 8 hospital trials. The findings indi-
cated that patients in the restrictive group had a significantly lower incidence of car-
diac and wound-healing complications compared with the patients in the standard
group.
Technologies used to predict fluid responsiveness and to guide management for
goal-directed fluid therapy in the intraoperative setting are not readily available in all
settings and are costly to obtain. Esophageal Doppler monitoring is a minimally inva-
sive method using ultrasound technology to assess the blood flow in the descending
aorta, thereby guiding goal-directed fluid therapy in the operating room. A disposable
probe is placed in the esophagus following induction of anesthesia.
The use of pulmonary artery catheters to assess fluid status has declined signifi-
cantly because of inconsistencies in the data obtained and the complication rate
associated with their use. Arterial pulse waveforms, while also invasive, can be
used to predict fluid responsiveness through the measurement of pulse contour
and pulse power analysis. The lithium dilution CO monitor and transesophageal
echocardiography have been successfully used to guide goal-directed fluid therapy
74 Thompson

as well. Newer monitors available measure plethysmographic variability in both the

pulse oximeter and the arterial waveforms and produce a plethysmographic vari-
ability index (PVI). Studies have shown this measurement to be reliant in patients
in normal sinus rhythm and mechanically ventilated with tidal volumes and a heart
rate to respiratory rate ratio within an acceptable range.7 Monitors are commercially
available that measure PVI among other parameters. This technology may become
routine in the future and more readily available. Using new technology with goal-
directed fluid therapy allows one to more carefully and accurately maintain the fluid
requirements throughout the surgical procedure for the sickest patients and for the
most critical procedures.

BLOOD COMPONENT THERAPY

Volume replacement due to intraoperative blood loss initially can be achieved with
both crystalloids and colloids. If blood loss due to hemorrhage is significant enough
that the danger of anemia outweighs the risk of transfusion and/or a decreased
oxygen-carrying capacity is present, then the administration of blood may be required.
Traditional therapy suggests that crystalloid replacement for blood volume lost is in a
1:3 ratio (for every measurable amount of blood lost, 3 times the amount of crystalloid
needs to be administered). This ratio is for volume replacement lost only and for initial
and noncritical blood loss. For colloids, the ratio is 1:1.
Decisions to administer blood must take into account several factors including not
only the amount of blood lost, the clinical condition of the patient, and the availability of
the proper type of blood, but also, on occasion, factors that are unrelated to the clin-
ical picture, such as religious beliefs. Estimation of blood loss, patient-specific blood
volume, and calculation of allowable blood loss can be done before transfusion is
considered. There are several formulas that allow a reasonable estimate. To do this,
one must first be able to calculate the patient’s estimated blood volume. Table 4
list the average blood volumes for men, women, and children. When calculating a po-
tential allowable blood loss, it might be prudent to consider monitoring for hemoglobin
concentration using a point-of-care monitor or the laboratory if one is not available.
Healthy patients with hemoglobin values greater than 10 g/dL rarely require transfu-
sion and those with hemoglobin values less than 6 g/dL almost always require trans-
fusion. In patients with intermediate hemoglobin concentrations of between 10 and
6 g/dL, the decision should be based on the patient and/or the procedure. One of

Table 4
Average blood volumes

Blood Therapy
Average blood volumes
Age Blood volume
Neonates
Preemies 95 mL/kg
Full term 85 mL/kg
Infants 80 mL/kg
Adults
Men 75 mL/kg
Women 65 mL/kg
 Intraoperative Fluid Management 75

Box 1
Example: allowable blood loss to a hematocrit of 30%

Blood therapy
Blood
Calculation of blood loss for HCT to decrease to 30%
EBV
Estimate RCV at the preoperative HCT (ERCVpreop)
Estimate RBCV at HCT of 30% (ERCV30%)
Assuming that fluid volume is maintained
Calculate the RCV lost when the HCT is 30
RBCV lost 5 RBCVpreop $ RBCV30%
Allowable blood loss 5 RBCVlost # 3

the formulas used for calculating allowable blood loss is found in Box 1 with an
example found in Box 2. The following more simplified formula may also be used:

Maximal allowable blood loss (MABL) 5 Estimated blood volume (EBV) # (Starting
HCT $ Target HCT)1(p392) Starting HCT

The major goal of the administration of red blood cells (RBCs) is to treat anemia and
thus to increase O2 carrying capacity. The use of packed RBCs is the most common
form of transfusion therapy for the treatment of anemia. Packed RBCs are reconsti-
tuted with between 50 and 100 mL of 0.9% NaCl (NS). Glucose solutions should never
be used because they can cause hemolysis of the red cell. LR contains calcium and
may cause clotting of the cells to occur because of the preservative citrate phosphate
dextrose-adenine in the blood. One unit of RBCs will increase the hemoglobin concen-
tration by 1 g/dL and the hemocrit by 2% to 3% in adults. A transfusion of 10 mL/kg of
RBCs will increase the hemoglobin concentration by 3 g/dL and the hemocrit by 10%.
The administration of blood is not without associated hazards. Bacterial contamina-
tion is rare because the blood supply is carefully screened and tested. The number 1

Box 2
Example of allowable blood loss/65-kg woman to a hematocrit of 30%

Blood therapy
Example
A 65-kg woman has a preoperative HCT of 34%.
How much blood loss will decrease her HCT to 30%?
EBV 5 65 mL/kg # 65 kg 5 4225 mL
RBCV34% 5 4225 # 34% 5 1436.5 mL
RBCV30% 5 4225 # 30% 5 1267.5 mL
Red cell loss at 30% 5 1436.5–1267.5 5 169 mL
Allowable blood loss 5 3 # 169 5 507 mL
76 Thompson

cause of transfusion-related fatalities is transfusion-related acute lung injury (TRALI).

TRALI occurs approximately 6 hours following the transfusion of blood or FFP. It is
characterized by dyspnea and arterial hypoxemia secondary to noncardiogenic
pulmonary edema fluid with a high protein content.
Other associated complications include transfusion reactions, febrile, allergic, and
hemolytic, which can cause injury to the kidneys as well as death.

SUMMARY

In the past, direct and indirect indices were used to determine the fluid status of
patients. Calculating preoperative deficits and planning for intraoperative mainte-
nance have not significantly changed for many years. In practice, the “4-2-1 Rule”
is still partially relied on for guidance. More evidence-based literature now challenges
practices. The “third space” and its inclusion in the calculations have been proven to
be the source of hypervolemia in many surgical patients. Newer and more sophisti-
cated monitoring modalities allow more precise guidance and are being used more
commonly with the sicker patients. Not only is intraoperative fluid maintenance being
challenged, but more questions are arising about the best uses of these fluids. New
evidence comparing colloids with crystalloids is supporting the latter in volume expan-
sion and safety.
Health care providers need to individualize fluid administration based on many
factors. Staying current on the latest evidence is needed to guide them in this impor-
tant goal in the future.

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