Optimizing intraoperative fluid therapy.
OBJECTIVE
Correcting the fluid status of the surgical patient is an integral part of good anaesthetic practice. There have been few areas in anaesthesia and perioperative medicine as controversial as fluid resuscitation. Uncertainties still exist as to what the best solution to give is, whether it be a colloid or a crystalloid, and how and when to give it. As well as increasing awareness of the different properties of various colloids, there has been interest in the nature of the carrier solutions, essentially a choice between saline or Ringer's lactate (compound sodium lactate or Hartmann's solution). In this article we review recent studies involving crystalloids, the 'new colloids', and on the amount and timing of fluid therapy.


RESULTS
Saline based fluids (including most colloids) are associated with a hyperchloremic metabolic acidosis, and a hypocoagulable state, although these may not necessarily harm the patient. Saline may have deleterious effects on renal function. Colloids in solutions similar to Ringer's lactate ('balanced solutions') may avoid these effects although few are currently available. Several studies that have used fluids (along with other therapies) to improve organ perfusion around the time of surgery have been associated with a better outcome.


CONCLUSIONS
Compared with Ringer's lactate, saline, and saline-based colloids are associated with a hyperchloremic metabolic acidosis, and a hypocoagulable state although they may not be associated with adverse patient outcomes. Increasing awareness of the 'Stewart hypothesis' has led to new ways of managing hyperchloremic metabolic acidosis. The 'crystalloid-colloid debate' continues, and has led to an awareness that these different fluids, along with their carrier solutions are drugs with different effects. Several studies, in which patients have received more fluid in the protocol group, have found better clinical outcomes in the 'optimized' patients.
Stephens
Robert
R
Portex Anaesthesia, Intensive Therapy and Respiratory Medicine Unit, Institute of Child Health, London, UK. R.Stephens@ich.ucl.ac.uk
Mythen
Monty
M