What Happens with the Fluid Replacement in the Septic Surgical Patient?

Abstract

We have read the interesting review of Chappell et al. 1about the rational approach to preoperative fluid management, and we would like to add several aspects related to the surgical patient with sepsis coming to the operation room.In 2004, the first guidelines2of the management of the septic patient were published. In these guidelines, fluids were essentiality given to reach the objectives in terms of blood pressure. At the beginning of 2008 these guidelines were updated,3and one of the most important items was still fluid replacement. If you follow the guidelines, as you should, you will find yourself giving a huge amount of volume in the first 24 h.These guidelines did not differentiate the surgical and the medical patient. As we all know, our surgical patient has many differences in terms of fluid management.For example, if you are on duty and the surgeon calls us because he has a patient in septic shock because of peritonitis, then we follow the guidelines using different monitors that show us the fluids the patient needs (central venous saturation, systolic pressure variation, lifting the legs up, etc .); what we really obtain is a very liberal fluid strategy.As Chappell et al. 1analyze, there are many studies that show us that the liberal strategy increases the anastomotic leaks, pulmonary edema, and wound infection after colorectal surgery. So what do we do?To try and answer this question, we have to first find studies that discuss this specific topic, but it is really difficult to find. So what we really do is extrapolate the studies of the surgical scheduled patient and the septic patient, and we put them all together.In the majority of patients, the septic surgical patient reaches the operation room with a high negative fluid balance, hypoproteinemic (hypoalbuminemic), and hypotensive. At that moment we start to administer fluids, but what type of fluids? The septic patient guidelines indicate that there is no difference in terms of mortality in using colloids or crystalloids.If we give only crystalloids it would provoke different complications,4but a big third space would be created in our patient, and this is related to higher morbidity,5including anastomotic leaks.6If we give only colloids, it could aggravate the septic kidney failure.7In the end we try and balance the guidelines for the surgical and medical patient; colloid nephrotoxicity versus tissue edema of crystalloids, rapid fluid replacement versus slow fluid replacement with vasopressor.The liberal strategy is beneficial for the septic patient but is deleterious for the surgical one. Trying to counterbalance the risks and benefits of the correct fluid replacement strategy is at times difficult because of the lack of studies and guidelines in the septic surgical patient.*Hospital General Universitario de Alicante, Alicante, Spain. jnavarro.martinez@gmail.com