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Portex Institute of Anaesthesia and Critical Care, University College London, Portex Unit, Institute of Child Health, London, UK, g.ackland{at}medsch.ucl.ac.uk
To the Editor:
Joshi's (1) assertion that intraoperative fluid restriction improves outcome in major gastrointestinal surgery cannot be supported. Several trials demonstrate outcome benefits when robust hemodynamic variables have been targeted to guide supplemental colloid administration (2–5) rather than cardiovascular end-points that are poor markers of intravascular volume status (6). The use of inaccurate markers of intravascular volume brings into sharp focus the importance attached by Joshi to the Brandstrup et al. article (7). The patients in this study were administered "liberal" volumes of fluid IV in a physiologically imprecise, prescriptive manner and hence may well have received inadequate volumes or volumes in excess of those guided by appropriate measures of intravascular volume. Indeed, similar studies have had to resort to bolus IV fluid administration in the "restrictive" group (8). Furthermore, failure to control for the type of fluid administered introduces important confounding factors associated with pathophysiological changes (e.g., hyperchloremic metabolic acidosis) that may affect several surrogate outcome measures (9).
Administration of fluid in a prescriptive fashion, based on unsubstantiated assumptions of perioperative fluid requirements, is unacceptable when both invasive and noninvasive technology facilitates clinicians to administer fluid in a dynamic, hemodynamically monitored manner.
References
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