Fluid choice for resuscitation and perioperative administration.

Fluid Choice for Resuscitation and Perioperative Administration Fluid administration is considered the cornerstone of resuscitative therapy for the treatment of hypotension, hypovolemia, and physical trauma. Isotonic salt (crystalloid) solutions (e.g., lactated Ringer’s solution [LRS]) are the most frequently recommended fluids for this therapy because they are considered to be safe, efficacious, and cost-effective. Seminal studies conducted by Post et al in the late 1940s and early 1950s demonstrated that crystalloid administration reduced mortality in hemorrhaged dogs. Subsequently, Shires et al concluded that the total extracellular fluid volume was decreased independent of blood loss in dogs that were hemorrhaged, thereby suggesting the need for both intravascular and interstitial fluid replacement. These studies, in conjunction with the low incidence of adverse effects associated with the liberal administration of large volumes of isotonic crystalloids to wounded soldiers and surgical candidates during the Korean and Vietnam wars, provided “evidence” that large-volume crystalloid therapy was necessary and well tolerated and could be lifesaving. Subsequently, however, several authors, including Shires, urged careful evaluation of fluid requirements in traumatized patients and moderation in crystalloid administration. Regardless of this caution, the administration of large volumes of crystalloid solutions has become standard for trauma patients, during the perioperative period, and for the treatment of hypotension and hypovolemia. Fluid therapy is not innocuous and should not be so automatic as to preclude consideration of the volume, electrolyte content, osmotic value, oncotic pressure, acid–base characteristics, viscosity, and oxygen-carrying characteristics of the fluid being administered relative to these same values in the patient. This review discusses each of these issues and provides historical and current perspectives based on a diverse set of references and reviews. Fluid therapy should not be formulaic or “recipe-based” (i.e., focused on mL/kg/min or hr) but rather goal directed; that is, designed to address each of the aforementioned issues while attempting to attain a predetermined goal.