Fluid Management Strategies in Major Surgery: Restrictive vs. Liberal Approaches
Peter Aduvie Josiah
*
Department of Medicine and Surgery, College of Health Sciences, Niger Delta University, Bayelsa State, Nigeria.
Benjamin Chidera Aghaonu
Department of Medicine and Surgery, College of Medicine, Virgen Milagrosa University Foundation, Pangasinan, Philippines.
Blessing Edidiong Dickson
Department of Nursing, Washtenaw Community College, Ann Arbor, Michigan, United States.
Oforbuike Samuel Odo
Department of Emergency Medicine, King Saud Hospital, Unayzah, Al Qasim, Saudi Arabia.
Victor Temilola Adibi
Department of Internal Medicine, Kwara State University Teaching Hospital, Kwara State, Nigeria.
*Author to whom correspondence should be addressed.
Abstract
During major surgery, perioperative intravenous fluid therapy is a very important component of anesthetic and surgical care owing to its profound implications for patient morbidity, mortality, and healthcare utilization. Both fluid overload and hypovolemia have been associated with various organ-specific complications as well as impaired wound healing and delayed gastrointestinal recovery. Liberal fluid administration was the main practice in the past due to concerns about fasting deficits and presumed third space losses. However, mounting evidence has demonstrated the detrimental effects of excessive fluid therapy, triggering a shift towards more restrictive approaches. Despite this development, consensus on approach still hasn't been achieved due to inconsistent definitions, heterogeneity of study designs, and variability of clinical practices.
This narrative review searched PubMed, ResearchGate, and Google Scholar for studies such as randomized controlled trials, observational studies, and systematic reviews that critically evaluate evidence on the outcomes of liberal and restrictive perioperative fluid management strategies during major surgery. One particularly large randomized controlled trial—the RELIEF trial—has significantly shaped contemporary fluid management approaches. The review also explores the physiological principles governing fluid balance in the surgical patient and assesses organ-specific outcomes, including renal, pulmonary, gastrointestinal, and cardiovascular effects. The limitations of rigid fluid protocols are given particular attention, as well as the emerging role of individualized, goal-directed therapy that follows a physiology-guided approach.
The available evidence suggests that excessively restrictive approaches risk hypotension and renal injury while overly liberal approaches have been associated with increased postoperative complications. Current perioperative care therefore favours a patient-centered approach aimed at maintaining near zero fluid balance. To optimize outcomes in major surgery, a pragmatic strategy of integrating an individualized fluid management approach within enhanced recovery after surgery pathways is advocated.
Keywords: Perioperative fluid therapy, near-zero fluid balance, goal-directed fluid therapy, major surgery, enhanced recovery after surgery (ERAS)