Review Article

Goal‑directed fluid therapy in the perioperative setting

Julia B. Kendrick, Alan David Kaye, Yiru Tong1, Kumar Belani2, Richard D. Urman3,
Christopher Hoffman4, Henry Liu4
Department of Anesthesiology, Lsu Health Sciences Center, New Orleans, LA, 2Department of Anesthesiology, University of Minnesota,
Minneapolis, MN, 3Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, 4Department
of Anesthesiology, Drexel University College of Medicine, Philadelphia, PA, USA, 1Department of Anesthesiology, Shanghai Children’s Hospital,
Shanghai Jiaotong University, Shanghai, China

Abstract
Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The
implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals,
such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging
component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of
goal‑directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid
imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We
evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end‑tidal CO2, central venous
pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non‑invasive
monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid
need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan
and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low‑risk patients
undergoing low‑risk surgery, a “zero‑balance” approach is encouraged. For the majority of patients undergoing major surgery,
GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can
reduce postoperative complications.

Keywords: Arterial contour analysis, bioimpedance, ERAS, goal‑directed therapy, length of hospital stay, volume status

Introduction coordinator, nursing and other staff from units that care
for the surgical patient. The ERAS Society develops,
The Enhanced Recover y After Surger y (ERAS)© promotes, and implements recommended ERAS programs,
protocols are increasingly applied in perioperative which can be modified based on each individual institution’s
ser vices worldwide. [1,2] ERAS adopts a multimodal, conditions. The ERAS Society also regularly publishes
multidisciplinary approach to provide seamless perioperative updated and evidence‑based guidelines for various surgical
care of the surgical patient. ERAS pathways should include procedures. The implementation of ERAS protocols has
a team consisting of surgeons, anesthesiologists, an ERAS resulted in significant benefits to both the patients and
hospitals with a shorter length of hospital stay by 30–50%,
a similar rate of complication decrease, and a significantly
Address for correspondence: Dr. Henry Liu, reduced re‑admissions rate to the hospital.[1-3]
Department of Anesthesiology, Drexel University College of
Medicine, 245 N. 15th Street, Ms 310, Philadelphia, PA 19102, USA.
E‑mail: [email protected] This is an open access journal, and articles are distributed under
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For reprints contact: [email protected]

DOI: How to cite this article: Kendrick JB, Kaye AD, Tong Y, Belani K, Urman RD,
10.4103/joacp.JOACP_26_18 Hoffman C, et al. Goal‑directed fluid therapy in the perioperative setting.
J Anaesthesiol Clin Pharmacol 2019;35:S29-34.

© 2019 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters Kluwer - Medknow S29
 Kendrick, et al.: Goal‑directed fluid therapy perioperative setting

Perioperative fluid management is a key element for the to manage each patient’s fluid therapy in an individualized
success of ERAS protocols. The use of goal‑directed manner.[4-6]
fluid therapy (GDT) is steadily gaining popularity for the
appropriate perioperative fluid/volume management.[4] A Is urine output a valid indicator of perioperative volume
PubMed literature search was performed for articles that status?
included the terms: enhanced recovery and goal‑directed fluid Urine output has traditionally been considered as an indicator
therapy. Key terms that were also included in this search: volume of intravascular volume status, because urine output generally
status assessment, heart rate (HR), blood pressure (BP), reflects adequate renal perfusion that is closely associated with
end‑tidal CO2, central venous pressure (CVP), urine output, systemic intravascular volume. Undoubtedly, preoperative
stroke volume (SV), and cardiac output (CO). All relevant anuria is abnormal and warrants aggressive clinical
information, regardless of publication year, was included investigation. Oliguria is defined as urine output <0.5 ml/kg/h,
although the authors tried to focus on manuscripts that were and caused by various etiologies. Though low urine output
published in the last 5 years. can occur when there is decreased blood flow to the kidney (as
with dehydration or excessive blood loss and hypotension),
This review article will discuss the pertinent aspects of GDT urinary obstruction of outflow of the urine, such as seen in
and its role in the successful implementation of ERAS prostate enlargement can also reduce urine output. Since
protocols. urine output can be affected by multiple factors, it is not a
sensitive indicator of circulating blood volume. On the other
Perioperative Volume Status and hand, urine output has proven to be a sensitive and early
Monitoring marker for acute kidney injury, which can be associated with
adverse outcomes in perioperative patients.[7] Some studies
Factors affecting preoperative intravascular suggest high postoperative urine volume may predict early
volume readiness for discharge among patients undergoing colorectal
Intravenous fluid therapy is an important and integrated surgery.[8] Johnson et al. recommended that isolated low
treatment of patients undergoing surgery. Traditionally, urine output should not trigger fluid therapy and extensive
surgical patients have been required to fast for 8 h. This can diagnostic efforts.[8]
potentially lead to preoperative hypovolemia. The resulting
surgical stress can induce multiple endocrine responses, Monitoring of intravascular volume status
including the release of vasopressin (antidiuretic hormone). The purpose of monitoring intravascular volume status is to
The re‑absorptive actions of vasopressin on the collecting guide fluid administration in order to maintain adequate tissue
duct in the kidneys can cause water retention, which can, to perfusion. Reduced tissue perfusion can be associated with
some extent offset the hypovolemic effect of fasting.[5] The hypovolemia (hemorrhage) or hypervolemia (i.e., a patient
majority of perioperative patients experience a certain degree with severe myocardial dysfunction and compensatory fluid
of preoperative hypovolemia.[6] This has been shown to be retention). Volume status assessment can be achieved with
associated with poorer clinical outcome.[5] The usual etiologies
of preoperative hypovolemia are summarized in Table 1.
Hypovolemia can lead to vasoconstriction and inadequate
perfusion with decreased oxygen delivery to organs and
peripheral tissues causing organ dysfunction. On the other
hand, fluid overload can lead to interstitial edema and local
inflammation and likely impair the regeneration of collagen,
thus negatively affecting tissue healing and increasing the
risk of wound dehiscence, wound infections, and anastomotic
leakage,[5] as illustrated in Figure 1. Therefore, it is imperative

Table 1: Factors affecting preoperative volume status or

preoperative hypovolemia
Factors Notes
Traditional preoperative fasting protocol Usually 8 h nothing by mouth
Unable to have oral intake Due to disease status Figure 1: A depiction of how fluid overload can lead to interstitial edema and
Preoperative hemorrhage Trauma patient local inflammation, impairing the regeneration of collagen, and thus negatively
affecting tissue healing and increasing the risk of wound dehiscence, wound
Other preoperative volume loss Fever, diuresis, diarrhea infections, and anastomotic leakage

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 Kendrick, et al.: Goal‑directed fluid therapy perioperative setting

continuous intraoperative monitoring of factors such as HR, Table 2: Commonly used volume status measurement
BP, end‑tidal CO2, CVP, urine output, SV, CO, and their techniques
derivatives, as summarized in Table 2.[9] However, these are Category Parameters
not reliable measures of volume status.[10] Thus, some invasive, Vital signs Blood pressure
minimally invasive, and non‑invasive monitors of hemodynamic Heart rate
parameters are used to assess volume status and predict Orthostatic changes
Physical Mental status
fluid responsiveness in various surgical procedures.[11-13] examinations Capillary refill
Regardless of the monitoring methods employed, accurate Extremity temperature
intraoperative determination of intravascular volume status Skin turgor
remains challenging because of continuously changing Skin perfusion
cardiovascular responses to anesthetic drugs, variable surgical Urine output
volume losses that are often difficult to quantify, a preoperative Laboratory tests Fractional excretion of sodium, urea
hypovolemia or an unknown preoperative volume status, as Blood lactate level
well as the manifestations of the normal physiological responses Mixed venous oxygen saturation
to surgery.[14] Additionally, not all patients who are fluid Intravascular/cardiac CVP
catheterization PAWP
responders require volume expansion and clinicians often have
SVV
difficulty estimating the preload condition of their patients. LVEDP
The decision to administer fluid should be supported by an Doppler/ LVEDV
apparent need for hemodynamic improvement in the context echocardiography SV
of a likely volume deficit and by the lack of associated risk.[1] CO
CI
Intraoperative fluid management within enhanced recovery Volume status measurement techniques separated into categories and parameters.
after surgery protocols CVP=Central venous pressure, PAWP=Pulmonary artery wedge pressure,
SVV=Stroke volume variation, SV=Stroke volume, LVEDP=Left ventricular
Intraoperative fluid management within ERAS protocols end‑diastolic pressure, LVDEV=Left ventricular end‑diastolic volume, CO=Cardiac
should be viewed as a continuum through the preoperative, output, CI=Cardiac index

intraoperative, and postoperative period.[1] The goal of

preoperative fluid management is for the patient to be in a Table 3: Parameters in early goal‑directed therapy[15]
hydrated and euvolemic state when arriving in the operating Parameters Range to target Interventions
room. This is usually achieved by avoidance of prolonged CVP 8-12 cmH2O Early use of mechanical ventilation
fasting and mechanical bowel preparation and encouraging MAP 65-90 mmHg Fluid resuscitation
patients to ingest a clear carbohydrate drink approximately 2 h SvO2 ˃70% Use of vasoactive agents
prior to surgery. The goals of intraoperative fluid management ScvO2 ˃65% Noradrenaline
Urine output >0.5 ml/kg/h Dobutamine
are to avoid excess salt and water and to maintain central
Hematocrit >30% Transfusion
euvolemia. As such, patients undergoing surgery within Parameters, range to target, and interventions in goal‑directed fluid therapy.
an ERAS protocol should have an individualized fluid CVP=Central venous pressure, MAP=Men arterial pressure, SvO2=Mixed venous
management plan. Excess crystalloid should be avoided oxygen saturation, ScvO2=Central venous oxygen saturation

for all the patients. In some low‑risk patients undergoing

low‑risk surgery, a “zero‑balance” approach is encouraged. investigated, Table 4 summarizes the reported “Goals” and
For the majority of patients undergoing major surgery, GDT reported outcomes in the literature.
is recommended. Optimal perioperative fluid management is
an important component of the ERAS protocol. In one study, Fluid responsiveness
a change in fluid management alone on the day of surgery GDT extrapolates a patient’s fluid responsiveness from
was shown to reduce perioperative complications by 50%.[1] measurable hemodynamic changes according to the
Frank–Starling curve. Fluid responders will generally
Goal‑Directed Fluid Therapy demonstrate an increase in their SV by  ≥10–15% after a
fluid challenge. The exact definition of a “fluid challenge”
What is the goal in the “goal‑directed fluid varies, yet in most sources it typically refers to a certain volume
therapy”? of fluid administered over a short period of time, for example,
There is no consensus reported in the literature in terms of the a bolus of 500 ml or more, administered in 10 min or less.
goals in the “Goal‑directed fluid therapy”. For many years, the A fluid challenge can simultaneously identify and treat volume
parameters originally used in critical care medicine for septic depletion while avoiding deleterious consequence of large fluid
patients are listed in Table 3. Various parameters have been overload. However, it is important to realize that being a fluid

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 Kendrick, et al.: Goal‑directed fluid therapy perioperative setting

Table 4: Key techniques of goal‑directed fluid therapy[16-22]

Parameters Technique Surgical procedures
GDT results Year reported
CI, SVV, SvO2, SVR EV1000 (Edwards Life Science, USA) Off‑pump CABG LOHS ↓ ICU stay ↓ 2017[16]
SV Transesophageal Doppler (Deltex, UK) Colorectal surgery
Postoperative ileus: Not better 2017[17]
SVV Vigileo/Flotrac (Edwards Life Science, USA) Spine surgery EBL/transfusion ↓ ICU stay ↓ 2016[18]
Bowel function ↑
SVV LidCO (UK) Bariatric surgery IVF ↓ 2010[19]
SV, SVV Flotrac (Edwards Life Science) Major abdominal Complications ↓ 2017[20]
ScvO2 PreSep Oximetry (Edwards Life Science, USA) Sepsis Mortality ↓ 2014[21]
PVI Masimo (USA) Roux‑en‑Y gastric bypass IVF ↓ 2017[22]
↓= Decrease; ↑= Increase. CI=cardiac index, SVV=stroke volume variation, SvO2=Mixed venous oxygen saturation, SVR=Systemic vascular resistance, CABG=Coronary
artery bypass graft, LOHS=Length of hospital stay, EBL=Estimated blood loss, IVF=Intravenous fluid, ScvO2=Central venous oxygen saturation, PVI=Plethysmography
variability index, ICU=Intensive Care Unit, GDT=Goal‑directed fluid therapy

responder is not equal to being hypovolemic. For example, when b. The CNAP is relatively new, but its basic theory “the
a fluid challenge is given on clinical grounds, only 50% of those Peñáz principle” was described by Dr. Saugel as early
hemodynamically unstable patients will prove to be volume as 1973 as a method to generate arterial waveform.[23]
responders.[1] Due to the risks associated with excessive fluid This system offers continuous non‑invasive beat‑by‑beat
administration and the challenge in identifying hypovolemic recording of the arterial pressure waveform, CNAP
patients, it is important to be able to predict whether a patient system also uses an inflatable finger cuff, so the patient’s
will be fluid responsive without actually giving fluid. One such finger artery’s diameter is measured by an integrated
method is to see the response to a 30° Trendlenburg position. photo‑plethysmograph. The pressure needed to keep
the blood volume constant corresponds to the arterial
Commonly used techniques in goal‑directed blood pressure waveform. The new CNAP algorithm
fluid therapy also analyzes the arterial blood pressure waveforms and
Transesophageal echocardiography it can respond to any deviations from the set point.[23]
Transesophageal echocardiography can measure SV, CO,
CVP, thus it can be used intraoperatively to provide parameters Esophageal Doppler
for GDT.[12] The less invasive transthoracic echocardiography Transesophageal Doppler is basically measuring the thoracic
can be used preoperatively and postoperatively; however, it aortic blood velocity to calculate SV, CO, and other
is often not convenient to use transthoracic echocardiography hemodynamic parameters. It is relatively easy to perform and
intraoperatively. the required training is significantly less than transesophageal
echocardiography.
Pulmonary artery catheterization
Pulmonar y arter y catheterization was used initially Bioimpedance‑based technologies
perioperative when early GDT was proposed to guide a. Thoracic Electrical Bioimpedance (TEB): TEB determines
intensive care unit (ICU) management of septic patients. the change of impedance via delivering a low‑amplitude high
Pulmonar y arter y catheterization can provide those frequency electrical current across the thorax. The TEB
hemodynamic parameters needed for GDT, which include electrodes are placed on the upper and lower thorax. TEB
CVP, mixed venous oxygen saturation (SvO2), left ventricular provided hemodynamic parameters are based on changes
end‑diastolic pressure (LVEDP), left ventricular end‑diastolic in the thoracic electrical conductivity to changes of thoracic
volume (LVEDV), SV, CO, cardiac index (CI), and systemic aortic blood flow during the cardiac cycle. TEB is an
vascular resistance (SVR).[12] alternative technique to measure SV, CO, and CI[24]
b. Electrical Bioreactance‑based Technology: Electric
Arterial waveform analysis‑based techniques bioreactance (EB) analysis is also based on alterations
There are different technologies that can be used to measure in frequency of electrical resistivity across the thorax. EB
the parameters for GDT‑guided management. Examples is significantly less susceptible to interference from chest
include: wall movement, lung edema, and pleural effusion.[25]
a. ClearSight/EV and 1000/Vigileo/Flotrac by Edwards EB measures CO centrally. When an alternative current
Life Science are series of products introduced over a two is applied to the thorax, the pulsatile blood flow in the
decades’ span. Clearsight is completely non‑invasive and large thoracic arteries induces phase shifts or time delays
it can continuously monitor BP, CO, SV, CVV, PPV, between the measured thoracic voltage and the applied
SVR by using a digital sensor and wrist cuff[23] alternative current. By continuously measuring these

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 Kendrick, et al.: Goal‑directed fluid therapy perioperative setting

phase shifts, EB can determine SV and other derivative daily basis.[27] The theory of GDT encourages clinicians
parameters such as CO, CI, SVI, and SVRI.[25] to manage fluid/volume administration based on objective
goals of hemodynamic parameters that are evidence based.
Application of goal‑directed fluid therapy and The principle behind GDT is to maximize tissue oxygen
clinical outcomes delivery without fluid overload by achieving measurable
GDT has been associated with improved clinical outcomes optimal hemodynamic indices. CO will usually increase
based on some clinical investigations. Hamilton et al. in response to a fluid challenge, which is in contrast to the
conducted a meta‑analysis that included 29 studies, 23 of historical method of predicting fluid losses based on fasting
which reported the incidence of surgical complications. The duration and insensible losses that may occur during surgery,
total 4805 patients enrolled in the 29 studies suffered an in addition to titrating fluid administration based on static
overall mortality of 7.6%. The use of preemptive hemodynamic parameters such as urine output, HR, and BP. It is well
intervention guided by GDT significantly decreased mortality established that both hypovolemia and hypervolemia are
and surgical complications.[26] They also found that subgroup associated with postoperative morbidity.[28] Maintenance of
analysis further showed significant reductions in mortality for intravascular euvolemia throughout the perioperative period is
investigations using a pulmonary artery catheter, supra‑normal ideal. Assessment of volume status can be achieved by various
resuscitation targets, and studies using CI or oxygen delivery as techniques, including traditional measures (HR, BP, laboratory
goals in GDT, and the combined use of fluids and inotropes test), invasive methods like pulmonary artery catheterization,
versus fluids alone. Thus, they concluded that the use of a minimally invasive approaches namely, arterial waveform‑based
preemptive strategy of hemodynamic monitoring and coupled analysis, thoracic bioimpedance‑based technologies, and
GDT can reduce surgical mortality and morbidity.[26] However, echocardiography. ERAS Society publishes evidence‑based
there are also reports that indicated no clinical benefits from guidelines regularly. Individual institutions can establish their
GDT. Gómez‑Izquierdo et al. performed a randomized and own ERAS protocols based on these guidelines.
assessor‑blind controlled clinical trial (GDT vs traditional)
in adult patients undergoing laparoscopic colorectal surgery. Financial support and sponsorship
Postoperative ileus was used as the primary outcome. Nil.
128 patients were included and analyzed (both GDT group
and control group enrolled 64 patients each). The incidence Conflicts of interest
of primary postoperative ileus was 22% in the GDT group There are no conflicts of interest.
and 22% in the control group. Intraoperatively, patients in
the GDT group received less intravenous fluids (mainly less References
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