INNOVATIVE IRRIGATION Evidence is increasing that perioperative fluid therapy can affect important longer-term post-operative outcomes.

Are you making precise perioperative management of fluids and electrolytes a fundamental part of your patients' overall treatment? Both too little and excessive fluid during the intraoperative period can adversely affect patient outcomes. In the low-risk patient undergoing gynecology, urology and orthopedic procedures, intraoperative fluid therapy improves such ambulatory anesthesia outcomes as pain, nausea and dizziness. It also increases discharge readiness.

Today's fluid management systems that provide real-time temperature, pressure, volume and deficit readings make it easy to monitor the input and output of fluid during a procedure. This is particularly important for procedures such as hysteroscopy, where fluid absorption can have a dire impact on patient outcomes, says Mary C. Wilson, BSN, RN, CNOR, clinical preceptor at West Virginia University Hospitals in Morgantown, W.Va.

"When you are doing a hysteroscopy, you must keep in mind that the uterus is very vascular, particularly if you're taking out polyps and exposing those vessels," says Ms. Wilson. "Once you have those vessels exposed, then your body's going to start absorbing that fluid."

Also consider the overall health of your patient, says Ms. Wilson. A young, healthy patient can tolerate and absorb extra fluid more so than a patient with compromised kidney function or congestive heart failure. "You have a smaller margin of error with these patients because they can't tolerate absorbing more fluids," she says.

Features to look for
The clinical aim of intraoperative fluid therapy is to maintain an adequate circulating volume to ensure end-organ perfusion and oxygen delivery to the tissues. Here are some features to look for in a system.

• On-demand fluid warming. The ability to control the temperature of fluids infused during procedures that use large volumes has a significant impact on the ability to maintain normothermia during those procedures and consequently avoid the complications of hypothermia. "The ability to heat your fluids can be significant," says Ms. Wilson. "If you're doing an extensive procedure like removing a bladder tumor, you can significantly cool down a patient by pumping that much room-temperature fluid into them."

• Real-time fluid deficit monitoring. This means the system can measure fluid inflow against collected fluid. Ms. Wilson points out that "just because a bag of saline says it contains 3,000 cc doesn't mean it's exactly 3,000 cc. "Just as with suction canisters, there's an acceptable range of variation," she says. To decipher the difference in what the suction canister and what the fluid bag hold, you can measure the weight of the fluid or refer to the markings on the container, says Ms. Wilson. Automatic flow rate adjustment provides constant pressure for even distention.
• Clear intraoperative visibility. Surgeons appreciate a clear display of real-time monitoring and fluid-deficit readings throughout the procedure.
• Simple touch-screen setup and operation. "As with all technology, some systems are easier to use than others," says Ms. Wilson. "Set-up time, ease of use and accuracy of the system are important to the successful use of a fluid management system."
• Continual irrigation capacity. This lets you change fluid bags and canisters without interrupting the surgical procedure. "The ability to easily add bags of fluid and change collection canisters without stopping the procedure is vital for both nurses and surgeons to use the system consistently," says Ms. Wilson.
• Alarms. It's a good safety feature to have configurable alarms for perforation, deficit and pressure.

Under- and over-hydration
There is continuing debate with regard to the volume and the type of fluid you should administer. Too little fluid is associated with hypotension, impaired tissue oxygenation and inadequate organ profusion. Fluid overload, on the other hand, is associated with interstitial edema and cardiopulmonary complications. A probable reason for such variability is that evidence regarding best fluid management with respect to clinically important outcomes is limited and of low quality, says anesthesiologist Girish P. Joshi, MB, BS, MD, FFARCSI, of the department of anesthesiology and pain management at the University of Texas Southwestern Medical Center in Dallas, Texas.

What's the optimal perioperative fluid management strategy? One study found that both "goal-directed" fluid therapy and liberal use of fluid without using hemodynamic goals used a large amount of perioperative fluid, but the perioperative outcomes after such therapies differed significantly, favoring the use of specific hemodynamic goals to titrate fluid therapy. Some researchers say moderation might be the wisest course — that restraint in fluid administration correlates with better outcomes.