Current Anesthesiology Reports

, Volume 9, Issue 3, pp 248–256 | Cite as

From the Physiology to the Bedside: Fluid Therapy in Cardiac Surgery and the ICU

  • Marcello Guarnieri
  • Andrea De Gasperi
  • Stefano Gianni
  • Marco Baciarello
  • Valentina Bellini
  • Elena BignamiEmail author
Cardiovascular Anesthesia (J Fassl, Section Editor)
Part of the following topical collections:
  1. Cardiovascular Anesthesia


Purpose of Review

In this review, we summarize the evidence present in the literature about this important field, with particular attention to the peculiarities of cardiac surgery.

Recent Findings

Since water is the main component of human cells and tissue, together with electrolytes and proteins, the manipulation of this element in critical illness is a powerful tool in the hands of the anesthesiologist and intensive care doctor. It can be either extraordinarily effective in the treatment of the patient’s disease and in correcting the hemodynamic instability or it can lead to very dangerous consequences, such as edema or end-organ damage. The potential consequences of this therapy require a proper monitoring system and the possibility to correctly assess the probability of the patient to respond to a fluid bolus in the macro- and microhemodynamics.


Fluid therapy has potentially enormous advantages when the indication is correctly given and balanced to the potential side effects.


Fluid therapy Fluid shift Cardiac surgery Fluid responder Coagulation Kidney injury 


Compliance with Ethical Standards

Conflict of Interest

Marcello Guarnieri declares that he has no conflict of interest.

Andrea De Gasperi has received speaker’s honoraria and reimbursement for travel expenses from Fresenius Kabi and Edwards Lifesciences.

Stefano Gianni declares that he has no conflict of interest.

Marco Baciarello has received reimbursement for travel expenses from Theras Lifetech S.R.L. and Abbott Laboratories.

Valentina Bellini declares that she has no conflict of interest.

Elena Bignami declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Sawka MN, Cheuvront SN, Carter R 3rd. Human water needs. Nutr Rev. 2005;63:S30–9.PubMedGoogle Scholar
  2. 2.
    Rose BD, Post TW, Narins R. Clinical physiology of acid-base and electrolyte disorders. New York: McGraw-Hill; 2001.Google Scholar
  3. 3.
    Bihari S, Peake SL, Prakash S, Saxena M, Campbell V, Bersten A. Sodium balance, not fluid balance, is associated with respiratory dysfunction in mechanically ventilated patients: a prospective, multicentre study. Crit Care Resusc. 2015;17:23–8.PubMedGoogle Scholar
  4. 4.
    Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth. 2012;108:384–94.PubMedGoogle Scholar
  5. 5.
    Bihari S, Taylor S, Bersten AD. Inadvertent sodium loading with renal replacement therapy in critically ill patients. J Nephrol. 2014;27:439–44.PubMedGoogle Scholar
  6. 6.
    Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304–77.PubMedGoogle Scholar
  7. 7.
    Monnet X, Marik PE, Teboul J-L. Prediction of fluid responsiveness: an update. Ann Intensive Care. 2016;6:111.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Jacobs R, Jonckheer J, Malbrain MLNG. Fluid overload FADEs away! Time for fluid stewardship. J Crit Care. 2018;48:458–61.PubMedGoogle Scholar
  9. 9.
    Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal P-J, Joannes-Boyau O, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care. 2018;8:66.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010;87:198–210.PubMedGoogle Scholar
  11. 11.
    Hu G, Minshall RD. Regulation of transendothelial permeability by Src kinase. Microvasc Res. 2009;77:21–5.PubMedGoogle Scholar
  12. 12.
    Rehm M, Bruegger D, Christ F, Conzen P, Thiel M, Jacob M, et al. Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia. Circulation. 2007;116:1896–906.PubMedGoogle Scholar
  13. 13.
    Ellman H. Capillary permeability in septic patients. Crit Care Med. 1984;12:629–33.PubMedGoogle Scholar
  14. 14.
    Nicholson JP, Wolmarans MR, Park GR. The role of albumin in critical illness. Br J Anaesth. 2000;85:599–610.PubMedGoogle Scholar
  15. 15.
    Lee E-H, Chin J-H, Choi D-K, Hwang B-Y, Choo S-J, Song J-G, et al. Postoperative hypoalbuminemia is associated with outcome in patients undergoing off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2011;25:462–8.PubMedGoogle Scholar
  16. 16.
    Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252:325–9.PubMedGoogle Scholar
  17. 17.
    Suding P, Jensen E, Abramson MA, Itani K, Wilson SE. Definitive risk factors for anastomotic leaks in elective open colorectal resection. Arch Surg. 2008;143:907–11 discussion 911–2.PubMedGoogle Scholar
  18. 18.
    Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370:1412–21.PubMedGoogle Scholar
  19. 19.
    Adamson RH, Lenz JF, Zhang X, Adamson GN, Weinbaum S, Curry FE. Oncotic pressures opposing filtration across non-fenestrated rat microvessels. J Physiol Wiley Online Library. 2004;557:889–907.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Iapichino G. Low hemoglobin level with low oncotic pressure in critically ill patients. Is it a safe strategy. Minerva Anestesiol. 2015;81:1047–9.PubMedGoogle Scholar
  21. 21.
    Bignami E, Guarnieri M, Gemma M. Fluid management in cardiac surgery patients: pitfalls, challenges and solutions. Minerva Anestesiol. 2017;83:638–51.PubMedGoogle Scholar
  22. 22.
    Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Miller NH, Hubbard VS, et al. American college of cardiology/American heart association task force on practice guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American college of cardiology/American heart association task force on practice guidelines. Circulation. 2014;129:S76–99.PubMedGoogle Scholar
  23. 23.
    Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, et al. Cumulative fluid balance and mortality in septic patients with or without acute kidney injury and chronic kidney disease. Crit Care Med. 2016;44:1891–900.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Morth JP, Pedersen BP, Toustrup-Jensen MS. Sørensen TL-M, Petersen J, Andersen JP, et al. Crystal structure of the sodium–potassium pump. Nature. Nat Publ Group. 2007;450:1043.Google Scholar
  25. 25.
    Benes J. Cumulative fluid balance: the dark side of the fluid. Crit Care Med. 2016;44:1945–6.PubMedGoogle Scholar
  26. 26.
    Hansell P, Welch WJ, Blantz RC, Palm F. Determinants of kidney oxygen consumption and their relationship to tissue oxygen tension in diabetes and hypertension. Clin Exp Pharmacol Physiol. 2013;40:123–37.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Textor SC, Gloviczki ML, Flessner MF, Calhoun DA, Glockner J, Grande JP, et al. Association of filtered sodium load with medullary volumes and medullary hypoxia in hypertensive African Americans as compared with whites. Am J Kidney Dis. 2012;59:229–37.PubMedGoogle Scholar
  28. 28.
    Neyra JA, Canepa-Escaro F, Li X, Manllo J, Adams-Huet B, Yee J, et al. Association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med. 2015;43:1938–44.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Yunos NM, Bellomo R, Story D, Kellum J. Bench-to-bedside review: chloride in critical illness. Crit Care. 2010;14:226.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Story DA, Morimatsu H, Bellomo R. Strong ions, weak acids and base excess: a simplified Fencl–Stewart approach to clinical acid–base disorders†. Br J Anaesth Oxford University Press. 2004;92:54–60.PubMedGoogle Scholar
  31. 31.
    Gattinoni L, Carlesso E, Maiocchi G, Polli F, Cadringher P. Dilutional acidosis: where do the protons come from? Intensive Care Med. 2009;35:2033–43.PubMedGoogle Scholar
  32. 32.
    Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc Pathol. 2012;21:365–71.PubMedGoogle Scholar
  33. 33.
    Ogawa S, Ohnishi T, Hosokawa K, Szlam F, Chen EP, Tanaka KA. Haemodilution-induced changes in coagulation and effects of haemostatic components under flow conditions. Br J Anaesth. 2013;111:1013–23.PubMedGoogle Scholar
  34. 34.
    Reddy S, McGuinness S, Parke R, Young P. Choice of fluid therapy and bleeding risk after cardiac surgery. J Cardiothorac Vasc Anesth. 2016;30:1094–103.PubMedGoogle Scholar
  35. 35.
    Williams P, Yang K, Kershaw G, Wong G, Dunkley S, Kam PCA. The effects of haemodilution with hydroxyethyl starch 130/0.4 solution on coagulation as assessed by thromboelastography and platelet receptor function studies in vitro. Anaesth Intensive Care. 2015;43:734–9.PubMedGoogle Scholar
  36. 36.
    Ranucci M, Baryshnikova E, Ciotti E, Ranucci M, Silvetti S. Surgical and Clinical Outcome REsearch (SCORE) group. Hemodilution on cardiopulmonary bypass: thromboelastography patterns and coagulation-related outcomes. J Cardiothorac Vasc Anesth. 2017;31:1588–94.PubMedGoogle Scholar
  37. 37.
    Butler J, Rocker GM, Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg. 1993;55:552–9.PubMedGoogle Scholar
  38. 38.
    Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest. 1997;112:676–92.PubMedGoogle Scholar
  39. 39.
    Paparella D, Parolari A, Rotunno C, Vincent J, Myasoedova V, Guida P, et al. The effects of steroids on coagulation dysfunction induced by cardiopulmonary bypass: a Steroids in Cardiac Surgery (SIRS) trial substudy. Semin Thorac Cardiovasc Surg. 2017;29:35–44.PubMedGoogle Scholar
  40. 40.
    Ortmann E, Rubino A, Altemimi B, Collier T, Besser MW, Klein AA. Validation of viscoelastic coagulation tests during cardiopulmonary bypass. J Thromb Haemost. 2015;13:1207–16.PubMedGoogle Scholar
  41. 41.
    Vincent JL, Wan S, Yim AP. Steroids in cardiopulmonary bypass. Crit Care Med. 2000;28:3373–4.PubMedGoogle Scholar
  42. 42.
    Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med. 2012;367:124–34.PubMedGoogle Scholar
  43. 43.
    Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012;367:1901–11.PubMedGoogle Scholar
  44. 44.
    Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declère AD, et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA. 2013;310:1809–17.PubMedGoogle Scholar
  45. 45.
    Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308:1566–72.PubMedGoogle Scholar
  46. 46.
    Bellamy MC. Wet, dry or something else? Br J Anaesth. 2006;97:755–7.PubMedGoogle Scholar
  47. 47.
    Myles PS, Andrews S, Nicholson J, Lobo DN, Mythen M. Contemporary approaches to perioperative IV fluid therapy. World J Surg. 2017;41:2457–63.PubMedGoogle Scholar
  48. 48.
    Ganter MT, Geisen M, Hartnack S, Dzemali O, Hofer CK. Prediction of fluid responsiveness in mechanically ventilated cardiac surgical patients: the performance of seven different functional hemodynamic parameters. BMC Anesthesiol. 2018;18:55.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Jozwiak M, Monnet X, Teboul J-L. Less or more hemodynamic monitoring in critically ill patients. Curr Opin Crit Care. 2018;24:309–15.PubMedGoogle Scholar
  50. 50.
    De Gasperi A. Blood pressure instability, liver transplant surgery and optimization strategies: the Brunelleschi perspective. Minerva Anestesiol. 2013;79:582–4.PubMedGoogle Scholar
  51. 51.
    Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will this Hemodynamically unstable patient respond to a bolus of intravenous fluids? JAMA. 2016;316:1298–309.PubMedGoogle Scholar
  52. 52.
    Hernández G, Teboul J-L. Is the macrocirculation really dissociated from the microcirculation in septic shock? Intensive Care Med. Springer Berlin Heidelberg. 2016;42:1621–4.PubMedGoogle Scholar
  53. 53.
    Ince C. Hemodynamic coherence and the rationale for monitoring the microcirculation. Crit Care. 2015;19(Suppl 3):S8.PubMedPubMedCentralGoogle Scholar
  54. 54.
    •• Ince C, Boerma EC, Cecconi M, De Backer D, Shapiro NI, Duranteau J, et al. Second consensus on the assessment of sublingual microcirculation in critically ill patients: results from a task force of the European Society of Intensive Care Medicine. Intensive Care Med Springer. 2018;44:281–99. This article states the most recent recommendations about the monitoring of microcirculation and tissue perfusion, the key for fluid therapy guidance. PubMedGoogle Scholar
  55. 55.
    Magder S, Potter BJ, Varennes BD, Doucette S, Fergusson D. Canadian Critical Care Trials Group. Fluids after cardiac surgery: a pilot study of the use of colloids versus crystalloids. Crit Care Med. 2010;38:2117–24.PubMedGoogle Scholar
  56. 56.
    Alavi SM, Ahmadi BB, Baharestani B, Babaei T. Comparison of the effects of gelatin, Ringer’s solution and a modern hydroxyl ethyl starch solution after coronary artery bypass graft surgery. Cardiovasc J Afr. 2012;23:428–31.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Schramko A, Suojaranta-Ylinen R, Kuitunen A, Raivio P, Kukkonen S, Niemi T. Hydroxyethylstarch and gelatin solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Br J Anaesth. 2010;104:691–7.PubMedGoogle Scholar
  58. 58.
    Chakravarthy M, Muniraj G, Patil S, Suryaprakash S, Mitra S, Shivalingappa B. A randomized prospective analysis of alteration of hemostatic function in patients receiving tranexamic acid and hydroxyethyl starch (130/0.4) undergoing off pump coronary artery bypass surgery. Ann Card Anaesth. 2012;15:105–10.PubMedGoogle Scholar
  59. 59.
    Bethlehem I, Wierda K, Visser C, Jekel L, Koopmans M, Kuiper MA. Influence of two colloidal extracorporeal primes on coagulation of cardiac surgical patients: a prospectively randomized open-label pilot trial. J Extra Corpor Technol. 2014;46:293–9.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Schramko AA, Suojaranta-Ylinen RT, Kuitunen AH, Raivio PM, Kukkonen SI, Niemi TT. Comparison of the effect of 6% hydroxyethyl starch and gelatine on cardiac and stroke volume index: a randomized, controlled trial after cardiac surgery. Perfusion. 2010;25:283–91.PubMedGoogle Scholar
  61. 61.
    Kimenai DM, Bastianen GW, Daane CR, Megens-Bastiaanse CM, van der Meer NJM, Scohy TV, et al. Effect of the colloids gelatin and HES 130/0.4 on blood coagulation in cardiac surgery patients: a randomized controlled trial. Perfusion. 2013;28:512–9.PubMedGoogle Scholar
  62. 62.
    Tiryakioğlu O, Yildiz G, Vural H, Goncu T, Ozyazicioglu A, Yavuz S. Hydroxyethyl starch versus Ringer solution in cardiopulmonary bypass prime solutions (a randomized controlled trial). J Cardiothorac Surg. 2008;3:45.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg Wiley Online Library. 2016;103:14–26.PubMedGoogle Scholar
  64. 64.
    • Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018;8:CD000567 This article analyzes the current evidence about the comparison between colloids and crystalloids. “Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality”. PubMedGoogle Scholar
  65. 65.
    Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013;369:2462–3.PubMedGoogle Scholar
  66. 66.
    • Zayed YZM, Aburahma AMY, Barbarawi MO, Hamid K, MRN B, Rashdan L, et al. Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis. J Intensive Care Med. 2018;6:51 This article compares the available literature about the comparison between balanced crystalloids and saline, showing no difference on major outcomes. Google Scholar
  67. 67.
    Reddy SK, Bailey MJ, Beasley RW, Bellomo R, Mackle DM, Psirides AJ, et al. Effect of 0.9% Saline or Plasma-Lyte 148 as Crystalloid Fluid Therapy in the Intensive Care Unit on Blood Product Use and Postoperative Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth. 2017;31:1630–8.PubMedGoogle Scholar
  68. 68.
    Raman A, Schoeller DA, Subar AF, Troiano RP, Schatzkin A, Harris T, et al. Water turnover in 458 American adults 40-79 yr of age. Am J Physiol Renal Physiol. 2004;286:F394–401.PubMedGoogle Scholar
  69. 69.
    Geiseler J, Fresenius J, Karg O. Active Versus Passive Humidification: Efficiency Comparison Between the Methods. In: Esquinas AM, editor. Humidification in the Intensive Care Unit: The Essentials. Berlin: Springer Berlin Heidelberg; 2012. p. 41–8.Google Scholar
  70. 70.
    Brattwall M, Warrén-Stomberg M, Hesselvik F, Jakobsson J. Brief review: theory and practice of minimal fresh gas flow anesthesia. Can J Anaesth. 2012;59:785–97.PubMedGoogle Scholar
  71. 71.
    Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M. A rational approach to perioperative fluid management. Anesthesiology. 2008;109:723–40.PubMedGoogle Scholar
  72. 72.
    Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38:48–79.PubMedGoogle Scholar
  73. 73.
    Köster M, Dennhardt S, Jüttner F, Hopf H-B. Cumulative changes in weight but not fluid volume balances reflect fluid accumulation in ICU patients. Acta Anaesthesiol Scand. 2017;61:205–15.PubMedGoogle Scholar
  74. 74.
    Davies H, Leslie G, Morgan D. Effectiveness of daily fluid balance charting in comparison to the measurement of body weight when used in guiding fluid therapy for critically ill adult patients: a systematic review protocol. JBI Database System Rev Implement Rep. 2015;13:111–23.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Marcello Guarnieri
    • 1
  • Andrea De Gasperi
    • 2
  • Stefano Gianni
    • 1
  • Marco Baciarello
    • 3
  • Valentina Bellini
    • 3
  • Elena Bignami
    • 3
    Email author
  1. 1.School of Medicine and SurgeryUniversity of Milan-BicoccaMonzaItaly
  2. 2.Department of Anesthesia and Resuscitation 2ASST Grande Ospedale Metropolitano NiguardaMilanItaly
  3. 3.Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and SurgeryUniversity of ParmaParmaItaly

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