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Table of Contents
Year : 2022  |  Volume : 25  |  Issue : 2  |  Page : 196-197
Use of balanced solutions is prudent as the mainstay of fluid management in off pump coronary surgery

1 Consultant Cardiac Anesthesiologist, Kamalnayan Bajaj Hospital, Aurangabad, Maharashtra, India
2 Consultant Cardiac Surgeon, Kamalnayan Bajaj Hospital, Aurangabad, Maharashtra, India

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Date of Submission10-Sep-2020
Date of Decision19-Mar-2021
Date of Acceptance20-May-2021
Date of Web Publication11-Apr-2022

How to cite this article:
Nagre AS, Kabade A, Chaudhari M. Use of balanced solutions is prudent as the mainstay of fluid management in off pump coronary surgery. Ann Card Anaesth 2022;25:196-7

How to cite this URL:
Nagre AS, Kabade A, Chaudhari M. Use of balanced solutions is prudent as the mainstay of fluid management in off pump coronary surgery. Ann Card Anaesth [serial online] 2022 [cited 2022 May 21];25:196-7. Available from:

An impertinent fluid policy can cause repercussions on various systems of the body resulting in renal dysfunction and cardiopulmonary and gastrointestinal complications. Rathore et al.[1] have discussed the importance of meticulous fluid management in the original article “Euvolemic Off Pump Coronary Surgery Further Improves Early Postoperative Outcomes.” The balanced solutions were aptly used in this study, and the amount of fluid administered to the patients was evaluated over various parameters successfully.

By and large, a scrupulous fluid policy tailored to patient's demands and a rational goal-directed fluid therapy should be cultivated to escape the morbidity akin to overzealous fluid therapy.[2] An unintended intraoperative fluid administration is underestimated such as syringe pumps, dilution of drugs which need to be contemplated.

Perioperative euvolemia by goal-directed therapy works on the principle of management of fluid in concordance with inotropes to optimize the perfusion of all the organs in the perioperative period. The goal-directed fluid therapy essentially validates the reduced complication rates and length of stay in the hospital, particularly in cardiac surgery.[3] In a paradigm-shifting review, Malbrain et al.[4] have quoted the concept of four D's of fluid therapy namely drug, dosing, duration, and de-escalation of fluids which can be adapted into practice in cardiac surgery as well. The comprehensive goal-directed therapy is an inevitable part of enhanced recovery after surgery (ERAS) protocol as well. It uses monitoring techniques to reckon the use of inotropes, vasopressors, and fluids according to the patient's needs.

Fluid management is the mainstay of perioperative hemodynamic optimization. The various systems convoluted as a result of defiant fluid conduct need to be closely monitored owing to the grievous outcomes. The cardiovascular manifestations are an increase in central venous pressure and pulmonary artery occlusion pressure, impaired contractility, increase in myocardial edema, diastolic dysfunction, decrease in stroke volume and cardiac output, increase in global end diastolic volume index, decrease in global ejection fraction, and increase in cardio-abdominal-renal syndrome. The respiratory findings in fluid overload are pulmonary edema, altered pulmonary and chest wall elastance, decreased paO2, increased paCO2, decreased PaO2/FiO2 ratio, increase in work of breathing, prolonged ventilation, and difficulty in weaning.[4]

Another system that is notably affected is the renal system. Excess of normal saline results in hyperchloremic acidosis causing renal vasoconstriction, decrease in renal blood flow, and eventually renal dysfunction.[5] Furthermore, hyperchloremia increases renal vascular responsiveness to angiotensin II, and increased osmolality associated with it stimulates secretion of antidiuretic hormone causing fluid retention. Also, one of the mechanisms of perioperative acute kidney injury (AKI) includes fluid overload causing gut edema and intra-abdominal hypertension. Glutatione S-transferase-alpha (GSTA) and neutrophil gelatinase–associated lipocalin (NGAL) is significantly found higher in postoperative cardiac surgery patients receiving normal saline compared to those receiving balanced solutions.[6] The use of chloride-restricted intravenous fluids has been associated with a reduced risk of renal dysfunction in surgical and critically ill patients.[7] The balanced crystalloids and colloids do not cause hyperchloremic acidosis and also increase the mean level of renal cortical perfusion in comparison with saline-based solutions. Thus, balance solutions and limited volume of hydroxyethyl starch (HES) in fact lower persistent AKI and have favorable effects on renal function and clinical outcomes in off-pump coronary artery bypass surgery patients. It also has shorter postoperative extubation time and length of hospital stay.[5]

Another imperative facet of overzealous fluid administration is hypervolemia leading to an increase in intravenous hydrostatic pressure which releases atrial natriuretic peptides that damage the endothelial glycocalyx, a layer of proteoglycans and glycoproteins coating the vascular endothelium. It maintains the vascular permeability hence any damage leads to leakage and consequent interstitial edema. The most common manifestation of excessive fluid administration is edema of the gut wall and prolonged ileus. The goal-directed approach is being mindful of the endothelial glycocalyx alterations caused by cardiac surgery and the tendency toward excessive interstitial volume and tissue edema.[8]

The optimal perioperative fluid management has been severely underappreciated. Miller et al.[9] have stated a study in which change in fluid management alone on the day of surgery has shown to reduce postoperative complications by 50%. To reduce substantial perioperative complications, restrict the overzealous fluid administration and devise tailored fluid management protocols for every patient and strongly abide by them.

   References Top

Rathore K, Boon E, Yussouf R, Newman M,Weightman W. Euvolemic off pump coronary surgery further improves early postoperative outcomes'. Ann Card Anaesth 2022;25:11-18. doi: 10.4103/aca.ACA_139_20.  Back to cited text no. 1
[PUBMED]  [Full text]  
Maes T, Meuwissen A, Diltoer M, Nguyen DN, La Meir M, Wise R, et al. Impact of maintenance, resuscitation and unintended fluid therapy on global fluid load after elective coronary artery bypass surgery. J Crit Care 2019;49:129-35.  Back to cited text no. 2
Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg 2019;154:755-66.  Back to cited text no. 3
Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, 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.  Back to cited text no. 4
Kim J-Y, Joung K-W, Kim K-M, Kim M-J, Kim J-B, Jung S-H, et al. Relationship between a perioperative intravenous fluid administration strategy and acute kidney injury following off-pump coronary artery bypass surgery: An observational study. Crit Care 2015;19:350.  Back to cited text no. 5
Meyer E. A review of renal protection strategies. South Afr J Anaesth Analg 2015;21:5-8.  Back to cited text no. 6
Krajewski ML, Raghunathan K, Paluszkiewicz SM, Schermer CR, Shaw AD. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg 2015;102:24-36.  Back to cited text no. 7
Young R. Perioperative fluid and electrolyte management in cardiac surgery: A review. J Extra Corpor Technol 2012;44:P20-6.  Back to cited text no. 8
Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anesth 2015;62:158-68.  Back to cited text no. 9

Correspondence Address:
Amarja S Nagre
C 3 Row house, Muthiyan Residency, Deepnagar, Aurangabad, Maharashtra 431001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.aca_229_20

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