Fluid Management in Gastrointestinal Surgery

  • M. G. Mythen
  • M. Hamilton
  • M. Grocott
Conference paper


Major gastrointestinal (GI) surgery is high risk, producing significant physiological disturbance in patients who are often frail prior to surgery. It is associated with considerable morbidity and mortality [1, 2]. Fluid therapy is a fundamental part of the management of the high-risk surgical patient [3]. Detailed knowledge of the pharmacology of the available intravenous solutions should guide their use. It is now clear that differentiation between the properties of the carrier solution and the dissolved colloid is of fundamental importance. Preoperative risk assessment should lead to institution of adequate perioperative monitoring to guide fluid therapy and allocation of an appropriate level of postoperative care, which in many cases will be in a dedicated critical care facility. Fluid therapy should be titrated to rational, physiological endpoints and not dictated by a recipe. Pro-active “optimization” of intravascular volume and organ blood flow has been shown to improve outcome. A “big picture” look at the available literature suggests that the “when” and “how much” of fluid therapy are far more important than the “what”.


Fluid Therapy Fluid Management Colloid Osmotic Pressure Plasma Volume Expansion Organ Blood Flow 
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.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) 1997/1998 (1999) NCEPOD, LondonGoogle Scholar
  2. 2.
    Bennett-Guerrero E, Welsby I, Dunn TJ, et al (1999) The use of post operative morbidity to evaluate patients with prolonged hospitalization after routine. moderate-risk, elective surgery. Anesth Anal 89: 514–519Google Scholar
  3. 3.
    Grocott MPW, Mythen MG (1999) Fluid therapy. In: Ballieres Clin Anaesthesiol; 13: 363–381Google Scholar
  4. 4.
    Mythen MG, Webb AR (1994) The role of gut mucosal hypoperfusion in the pathogenesis of post-operative organ dysfunction. Intensive Care Med 20: 203–209PubMedCrossRefGoogle Scholar
  5. 5.
    Ackland G, Grocott MP, Mythen MG (2000) Understanding gastrointestinal perfusion in critical care: so near, and yet so far. Crit Care 4: 269–281PubMedCrossRefGoogle Scholar
  6. 6.
    Mythen MG, Fink M (1999) The role of gut derived endotoxin in the pathogenesis of multiple organ dysfunction. In: Brade, Morrison, Opal, Vogel (eds) Endotoxin in health and disease, Dekker, New YorkGoogle Scholar
  7. 7.
    Salmon JB, Mythen MG (1993) Pharmacology and physiology of colloids. Blood Rev 7: 114–120PubMedCrossRefGoogle Scholar
  8. 8.
    Haljamae H, Dahlqvist M, Walentin F (1997) Artificial colloids in clinical practise: pros and cons. Baillieres Clin Anaesthesiol 11: 49–79CrossRefGoogle Scholar
  9. 9.
    Lamke LO, Liljedahl SO (1976) Plasma volume changes after infusion of various plasma expanders. Resuscitation 5: 93–102PubMedCrossRefGoogle Scholar
  10. 10.
    Webb AR, Barclay SA, Bennett ED (1989) In vitro colloid osmotic pressure of commonly used plasma expanders and substitutes: a study of the diffusibility of colloid molecules. Intensive Care Med 15: 116–120.PubMedCrossRefGoogle Scholar
  11. 11.
    Webb AR, Moss RF, Tighe D, et al (1992) A narrow range, medium molecular weight pentastarch reduces structural organ damage in a hyperdynamic porcine model of sepsis. Intensive Care Med 18: 348–355.PubMedCrossRefGoogle Scholar
  12. 12.
    Velanovich V (1989) Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality. Surgery 105: 65–71PubMedGoogle Scholar
  13. 13.
    Schierhout G, Roberts I (1998) Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 316: 961–964.PubMedCrossRefGoogle Scholar
  14. 14.
    Anonymous (1998) Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ 317: 235–240.CrossRefGoogle Scholar
  15. 15.
    Bunn F, Alderson P, Hawkins V (2000) Colloid solutions for fluid resuscitation (Cochrane Review). In: The Cochrane Library, issue 4Google Scholar
  16. 16.
  17. 17.
    Gan TJ, Bennett-Guerrero E, Phillips-Bute B, et al (1999) Hextend, a physiological balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Anaesth Anal 88: 992–998Google Scholar
  18. 18.
    Stephens RC, Mythen MG (2000) Saline-based fluids can cause a significant acidosis that may be clinically relevant. Crit Care Med 28: 3375–3377.PubMedCrossRefGoogle Scholar
  19. 19.
    Prough DS, Bidani A (1999) Hyperchloremic metabolic acidosis is a predictable consequence of intraoperative infusion of 0.9% saline. Anesthesiology 90: 1247–1249.PubMedCrossRefGoogle Scholar
  20. 20.
    Scheingraber S, Rehm M, Sehmisch C, Finsterer U (1999) Rapid saline infusion produces hyperchlo-remic acidosis in patients undergoing gynecologic surgery. Anesthesiology 90: 1265–1270PubMedCrossRefGoogle Scholar
  21. 21.
    Reffrom TRICE (2001)Google Scholar
  22. 22.
    Williams EL, Hildebrand KL, McCormick SA, Bedel MJ (1999) The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers. Anesth Analg 88: 999–1003PubMedGoogle Scholar
  23. 23.
    McFarlane C, Lee A (1994) A comparison of Plasmalyte 148 and 0.9% saline for intra-operative fluid replacement. Anaesthesia 49: 779–781PubMedCrossRefGoogle Scholar
  24. 24.
    Healey MA, Davis RE, Liu FC, et al (1998) Lactated Ringer’s is superior to normal saline in a model of massive hemorrhage and resuscitation. J Trauma 45: 894–899PubMedCrossRefGoogle Scholar
  25. 25.
    Kellum JA Schenigel J Venkataraman R 2000 Fluid resuscitation and hyperchloraemic acidosis in experimental sepsis improved survival and acid-base balance with a synthetic colloid in a balanced electrolyte solution compared to saline. Crit Care Med 28 A19Google Scholar
  26. 26.
    Wilkes NJ, Woolf R, Stephens R, et al (2001) The effects of balanced versus saline based intravenous solutions on acid base status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg (in press)Google Scholar
  27. 27.
    Megarbane B, Bruneel F, Bedos J-P, Regnier B (2000) Ammonium chloride poisoning: a misunderstood cause of metabolic acidosis with normal anion gap. Intensive Care Med Online publication 9 November 2000Google Scholar
  28. 28.
    Gan TJ, Mythen MG, Glass PSA (1997) Intraoperative gut hypoperfusion may be a risk factor for postoperative nausea and vomiting. Br J Anaesth 78: 476PubMedCrossRefGoogle Scholar
  29. 28.
    Wilcox CS (1983) Regulation of renal blood flow by plasma chloride. J Clin Invest 71: 726–735PubMedCrossRefGoogle Scholar
  30. 29.
    Tournadre JP, Allaouchiche B, Malbert CH, Chassard D (2000) Metabolic acidosis and respiratory acidosis impair gastro-pyloric motility in anesthetized pigs. Anesth Analg 90: 74–79PubMedCrossRefGoogle Scholar
  31. 30.
    Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78: 355–360.PubMedCrossRefGoogle Scholar
  32. 31.
    Hamilton-Davies C, Mythen MG, Salmon JB, et al (1997) Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry. Intensive Care Med 23: 276–281PubMedCrossRefGoogle Scholar
  33. 32.
    Chapman MV, Mythen MG Webb AR, Vincent JL (2000) Gastrointestinal tonometry: state of the art. Intensive Care Med 26: 613–622PubMedCrossRefGoogle Scholar
  34. 33.
    Webb AR (1997) Fluid management in intensive care—the avoidance of hypovolaemia. Br J Intensive Care 7Google Scholar
  35. 34.
    Shoemaker WC, Appel PL, Kram HB, et al (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94: 1176–1186.PubMedCrossRefGoogle Scholar
  36. 35.
    Boyd O, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270: 2699–2707PubMedCrossRefGoogle Scholar
  37. 36.
    Mythen MG, Webb AR (1995) Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 130: 423–429PubMedCrossRefGoogle Scholar
  38. 37.
    Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ 315: 909–912PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2002

Authors and Affiliations

  • M. G. Mythen
    • 1
  • M. Hamilton
    • 1
  • M. Grocott
    • 2
  1. 1.Centre for AnaesthesiaUniversity CollegeLondonUK
  2. 2.Surgical Outcomes Research CentreUniversity CollegeLondonUK

Personalised recommendations