Fluid Management

  • Jessica Miller
  • Lee A. Fleisher
  • Jeffrey L. Carson


It is imperative that anesthesiologists are well versed in modifications to fluid management for the elderly patient.1 This chapter discusses the guiding principles in fluid management and the important alterations in kidney function and fluid homeostasis in the elderly patient. These concepts are built upon to provide recommendations for the perioperative period. Preoperative evaluation, assessment, and decision making in the intraoperative period are discussed below, including methods of monitoring intraoperatively, types of fluids to administer, and the use of blood transfusions. Special anesthetic challenges such as spinal anesthesia and fluid management are also included.


Atrial Natriuretic Peptide Spinal Anesthesia Total Body Water Acute Tubular Necrosis Intravascular Volume 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Liu LL, Leung JM. Perioperative complications in the elderly patient. Available at: http://www.asahq.org/clinical/geriatrics/perio_comp.htm. Accessed May, 2003.Google Scholar
  2. 2.
    Luckey A, Parsa C. Fluid and electrolytes in the aged. Arch Surg 2003;138:1055–1060.PubMedCrossRefGoogle Scholar
  3. 3.
    Vander AJ, Sherman JH, Luciano DS. Human Physiology: The Mechanisms of Body Function. 6th ed. New York: McGraw-Hill; 1994:539.Google Scholar
  4. 4.
    Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anesth 2002;89(4):622–632.CrossRefGoogle Scholar
  5. 5.
    Wei JY. Age and cardiovascular system. N Engl J Med 1992;327:1735–1739.PubMedGoogle Scholar
  6. 6.
    Epstein M. Aging and the kidney. J Am Soc Nephrol 1996;7:1106–1122.PubMedGoogle Scholar
  7. 7.
    Rowe JW. Clinical research on aging; strategies and directions. N Engl J Med 1977;297:1332–1336.PubMedGoogle Scholar
  8. 8.
    Epstein M, Hollenberg NK. Age as a determinant of renal sodium conservation in normal man. J Lab Clin Med 1976; 87:411–417.PubMedGoogle Scholar
  9. 9.
    Hollenberg NK, Adams DF, Solomon HS, Rashid A, Abrams HL, Merrill JP. Senescence and the renal vasculature in normal man. Circ Res 1974;34:309–316.PubMedGoogle Scholar
  10. 10.
    Rowe JW, Andres R, Tobin JD, Norris AH, Shock NW. The effect of age on creatinine clearance in man: a cross sectional and longitudinal study. J Gerontol 1976;31:155–163.PubMedGoogle Scholar
  11. 11.
    Fliser D, Aeier M, Nowack R, Ritz E. Renal functional reserve in healthy elderly subjects. J Am Soc Nephrol 1993; 3:1371–1377.PubMedGoogle Scholar
  12. 12.
    Faulstick D, Yeingst MJ, Oussler DA, Shock NW. Glomerular permeability in young and old subjects. J Gerontol 1962; 17:40–44.PubMedGoogle Scholar
  13. 13.
    McDonald RK, Solomon DH, Shock NW. Aging is a factor in the renal hemodynamic changes induced by a standard pyrogen. J Clin Invest 1951;30:457–462.PubMedCrossRefGoogle Scholar
  14. 14.
    Wesson LG. Renal hemodynamics in physiological states. In: Physiology of the Human Kidney. New York: Grune and Stratton; 1969:96–108.Google Scholar
  15. 15.
    Lindeman RD, Tobin JD, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985;33:278–285.PubMedGoogle Scholar
  16. 16.
    Crockroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31–41.Google Scholar
  17. 17.
    Goldberg TH, Finkelstein MS. Difficulties in estimating glomerular filtration rate in the elderly. Arch Intern Med 1987;147:1430–1433.PubMedCrossRefGoogle Scholar
  18. 18.
    Malmrose LC, Gray SL, Peiper CF, et al. Measured versus estimated creatinine clearance in a high functioning elderly sample: MacArthur Foundation study of successful aging. J Am Geriatr Soc 1988;36:437–441.Google Scholar
  19. 19.
    Crane MG, Harris JJ. Effect of aging on renin activity and aldosterone excretion. J Lab Clin Med 1976;87:947–959.PubMedGoogle Scholar
  20. 20.
    Weidmann P, Demyttenaere-Bursztein S, Maxwell MH, DeLima J. Effect of aging on plasma renin and aldosterone in normal man. Kidney Int 1975;8:325–333.PubMedCrossRefGoogle Scholar
  21. 21.
    Shannon RP, Wei JY, Rosa RM, Epstein FH, Rowe JH. The effect of age and sodium depletion on cardiovascular response to orthostasis. Hypertension 1986;8:438–443.PubMedGoogle Scholar
  22. 22.
    Sunderam SG, Mankikar GD. Hyponatremia in the elderly. Age Aging 1983;12:77–80.CrossRefGoogle Scholar
  23. 23.
    Snyder NA, Feigal DW, Ariff AI. Hypernatremia in elderly patients: a heterogenous, morbid and iatrogenic entity. Ann Intern Med 1987;107:309–319.PubMedGoogle Scholar
  24. 24.
    Beck LH. Changes in renal function with aging. Clin Geriatr Med 1998;14(2):199–209.PubMedGoogle Scholar
  25. 25.
    Rowe JW, Shock NW, DeFronzo RA. The influence of age on the renal response to water deprivation in man. Nephron 1976;17:270–278.PubMedGoogle Scholar
  26. 26.
    Helderman JH, Vestal RE, Rowe JW, Tobin JD, Andres R, Robertson GL. The response of arginine vasopressin to intravenous ethanol and hypertonic saline in man: the impact of aging. J Gerontol 1978;33:39–47.PubMedGoogle Scholar
  27. 27.
    Rowe JW, Minaker KL, Sparrow D, Robertson GL. Agerelated failure of volume-pressure-mediated vasopressin release. J Clin Endocrinol Metab 1982;54:661–664.PubMedCrossRefGoogle Scholar
  28. 28.
    Duggan J, Kilfeather S, Lightman SL. The association of age with plasma arginine vasopressin and plasma osmolality. Age Ageing 1993;22:332–336.PubMedCrossRefGoogle Scholar
  29. 29.
    Frolkis VV, Golovchenko SF, Medved VI, Frolkis RA. Vasopressin and cardiovascular system in aging. Gerontology 1982;28:290–302.PubMedGoogle Scholar
  30. 30.
    Kirkland J, Lye M, Goddard C, Vargas E, Davies I. Plasma arginine vasopressin in dehydrated elderly patients. Clin Endocrinol 1984;20:451–456.CrossRefGoogle Scholar
  31. 31.
    Phillips PA, Rolls BY, Ledingham JG, Forsling ML, Morton JJ, Crowe MJ. Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 1984;311:753–759.PubMedGoogle Scholar
  32. 32.
    Howard L, Ashley C. Nutrition in the perioperative patient. Ann Rev Nutr 2003;23:263–282.CrossRefGoogle Scholar
  33. 33.
    Flynn MB, Leightty FF. Preoperative outpatient nutritional support of patients with squamous cancer of the upper aerodigestive tract. Am J Surg 1987;154(4):359–362.PubMedCrossRefGoogle Scholar
  34. 34.
    Foschi D, Cavagna G, Callioni F, Morandi E, Rovati V. Hyperalimentation of jaundiced patients on percutaneous trans hepatic biliary drainage. Br J Surg 196;73(9):716–719.Google Scholar
  35. 35.
    Shukla HS, Rao RR, Banu N, Gupta RM, Yaday RC. Enteral hyperalimentation in malnourished surgical patients. Ind J Med Res 1984;80:339–346.Google Scholar
  36. 36.
    Von Meyenfeldt MF, Meijerink WJHJ, Rouflart MMJ, Builmaassen MTHJ, Soeters PB. Perioperative nutritional support: a randomized clinical trial. Clin Nutr 1992;11:180–186.CrossRefGoogle Scholar
  37. 37.
    Sandstom R, Drott C, Hytlander A, et al. The effect of postoperative intravenous feeding (TPN) on outcome following major surgery evaluated in a randomized study. Ann Surg 1993;217:185–195.Google Scholar
  38. 38.
    Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1990;335(8698):1013–1016.PubMedCrossRefGoogle Scholar
  39. 39.
    Lavizzo-Mourey R, Johnson J, Stolley P. Risk factors for dehydration among elderly nursing home residents. J Am Geriatr Soc 1988;36:213–218.PubMedGoogle Scholar
  40. 40.
    Barlow I. Perioperative renal insufficiency and failure in elderly patients. Available at: www.asahq.org/clinical/ geriatrics. Accessed 5/2003.Google Scholar
  41. 41.
    Mcgee S, Abernethy WB, Simel DL. Is this patient hypovolemic? JAMA 1999;281(11):1022–1029.PubMedCrossRefGoogle Scholar
  42. 42.
    Beck LH. Perioperative renal, fluid, and electrolyte management. Clin Geriatr Med 1990;6(3):557–569.PubMedGoogle Scholar
  43. 43.
    Alpert RA, Roizen MF, Hamilton WK, et al. Intraoperative urinary output does not predict postoperative renal function in patients undergoing abdominal aortic revascularization. Surgery 1984;95:707–711.PubMedGoogle Scholar
  44. 44.
    Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduced length of hospital stay after major surgery. Anesthesiology 2002;97(4):820–826.PubMedCrossRefGoogle Scholar
  45. 45.
    Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture. Br Med J 1997;315(7113): 909–912.Google Scholar
  46. 46.
    Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P. Randomized controlled trial to investigate the influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anesth 2002;88:65–71.CrossRefGoogle Scholar
  47. 47.
    Price JD, Sear JW, Venn RM. Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database Syst Rev 2004;(1):CD003004.Google Scholar
  48. 48.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high risk surgical patients. Chest 1988; 94:1176–1186.PubMedCrossRefGoogle Scholar
  49. 49.
    Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990;30(2):129–134.PubMedGoogle Scholar
  50. 50.
    Velanovich V. Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality. Surgery 1989;105(1):65–71.PubMedGoogle Scholar
  51. 51.
    Alderson P, Schierhout G, Roberts I, Bunn F. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2000;(2):CD000567.Google Scholar
  52. 52.
    Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev 2003;(1): CD001319.Google Scholar
  53. 53.
    Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. NEJM 2004;350:2247–2256.PubMedCrossRefGoogle Scholar
  54. 54.
    Rooke GA. Cardiovascular response to spinal anesthesia in the elderly. Available at: www.asahq.org/clinical/ geriatrics. Accessed May 2003.Google Scholar
  55. 55.
    Rooke GA, Freund PR, Jacobson AF. Hemodynamic response and change in organ blood volume during spinal anesthesia in elderly men with cardiac disease. Anesth Analg 1997;85:99–105.PubMedCrossRefGoogle Scholar
  56. 56.
    Coe AJ, Revanas B. Is crystalloid preloading useful in spinal anesthesia in the elderly? Anaesthesia 1990;45:241–243.PubMedCrossRefGoogle Scholar
  57. 57.
    Nutall GA, Brost BC, Connis RT, et al. Practice Guidelines for Blood Component Therapy: a report by the American Society of Anesthesiologist Task Force on Blood Component Therapy. Anesthesiology 1996;84(3):732–747.CrossRefGoogle Scholar
  58. 58.
    Perioperative red cell transfusion. Natl Inst Health Consens Dev Conf Consens Statement 1988;7(4):1–19.Google Scholar
  59. 59.
    American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support Course Manual. Chicago: American College of Surgeons; 1989.Google Scholar
  60. 60.
    Carson JL, Duff A, Poses RM, et al. Effect of anemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996;348:1055–1060.PubMedCrossRefGoogle Scholar
  61. 61.
    Herbert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340(6):409–417.CrossRefGoogle Scholar
  62. 62.
    Ely EW, Bernard GR. Transfusions in critically ill patients. N Engl J Med 1999;340(6):467–468.PubMedCrossRefGoogle Scholar
  63. 63.
    Hogue CW, Goudnough LR, Monk TG. Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion 1998;38:924–931.PubMedCrossRefGoogle Scholar
  64. 64.
    Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high-risk vascular patients in the intensive care unit. Crit Care Med 1993;21:860–866.PubMedCrossRefGoogle Scholar
  65. 65.
    Wei-Chih W, Rathore S, Wang Y, Radford M, Krumholz H. Blood transfusions in elderly patients with acute myocardial infarction. N Engl J Med 2001;345(17):1230–1236.CrossRefGoogle Scholar
  66. 66.
    Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004;292(13):1555–1562.PubMedCrossRefGoogle Scholar
  67. 67.
    Carson JL, Duff A, Berlin JA, et al. Perioperative blood transfusion and postoperative mortality. JAMA 1998; 279(3):199–205.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Jessica Miller
    • 1
  • Lee A. Fleisher
    • 2
  • Jeffrey L. Carson
    • 3
  1. 1.Fellow Department of Pediatric Anesthesiology and Critical CareChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Department of Anesthesiology and Critical Care Chair of Anesthesiology and Critical CareHospital of the University of PennsylvaniaPhiladelphiaUSA
  3. 3.Division of General Internal Medicine Department of MedicineUMDNJ—Robert Wood Johnson Medical SchoolNew BrunswickUSA

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