Joosten Alexandre, Coeckelenbergh Sean, Alexander Brenton, Delaporte Amélie, Cannesson Maxime, Duranteau Jacques, Saugel Bernd, Vincent Jean-Louis, Van der Linden Philippe
Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France.
BMC Anesthesiol. 2020 Aug 20;20(1):209. doi: 10.1186/s12871-020-01128-1.
Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate.
The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications.
The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.
围手术期液体管理——包括液体类型、剂量及给药时机——直接影响大手术后的患者预后。液体输注的目的是优化血管内液体状态，以维持充足的组织灌注。关于围手术期使用晶体液与胶体液一直存在争议。遗憾的是，在这场争论中，常常忽略了液体量的重要性，而液体量会显著影响每种所选溶液的效益风险比。
围手术期输注的液体量会影响术后并发症的发生率和严重程度。令人遗憾的是，临床医生在液体输注实践中，无论个体内还是个体间，仍存在巨大差异。目标导向液体治疗（GDFT）旨在优化与血流相关的变量，已被证明具有一定临床益处，并得到多个专业学会的推荐。然而，这种方法尚未得到广泛采用。最近已开发并测试了一种闭环液体输注系统，旨在协助麻醉医生持续应用GDFT策略。这种方法可能会改变晶体液与胶体液的争论。由于胶体溶液对血管内容量有更深远的影响且血浆存留时间更长，在这种更“可控”的情况下使用它们可能会使液体平衡更低，并有可能改善患者预后。此外，大多数评估GDFT策略对高危手术患者预后影响的研究在其方案中使用了羟乙基淀粉（HES）溶液。其中一些研究已证明有有益效果，但均未报告严重并发症。
围手术期管理所用液体的类型和量需要根据患者的血流动力学状态和临床情况进行个体化。给予的液体量应以明确的生理目标为指导。使用计算机系统可优化对预定义血流动力学方案的依从性。液体类型也应个体化，任何药物治疗也应如此，要仔细考虑时机和剂量。我们的观点是，由于HES溶液对血容量的影响及其合理的效益/风险概况，它们在围手术期仍是液体治疗的有效选择。
