Perioperative Fluid Therapy: From Restrictive/Liberal Labels to Physiology-Guided Individualization
Perioperative Fluid Therapy
Abstract
Perioperative fluid therapy has evolved from fixed replacement of fasting and presumed third-space losses toward restrictive, zero-balance, and increasingly individualized strategies. The therapeutic window is narrow: inadequate circulating volume may impair organ perfusion and contribute to acute kidney injury (AKI), whereas excessive fluid can cause interstitial oedema, pulmonary complications, gastrointestinal dysfunction, and delayed recovery. Enhanced Recovery After Surgery (ERAS) pathways have reduced unnecessary intravenous fluid administration, but the optimal balance remains uncertain. The RELIEF randomized trial found no disability-free survival benefit from a restrictive strategy and reported more postoperative AKI than with liberal therapy. [1] Contemporary PeriOperative Quality Initiative (POQI) recommendations emphasize individualized management according to surgical factors, intravascular volume status, arterial pressure, and comorbidities. [2,3] This narrative review synthesizes evidence on restrictive versus liberal strategies, goal-directed haemodynamic therapy (GDHT), fluid responsiveness, AKI, fluid accumulation, fluid composition, vasopressors, and ERAS integration. The emerging paradigm is not simply restrictive or liberal therapy, but dynamic physiology-guided treatment that seeks adequate organ perfusion while avoiding unnecessary fluid accumulation.
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References
2. Ostermann M, Auzinger G, Grocott MPW, Morton-Bailey V, Raphael J, Shaw AD, et al. Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative. Br J Anaesth. 2024;133(6):1263-1275.
3. Edwards MR, Kunst G, Forni LG, Chappell D, Miller TE, et al; POQI-11 Group. Perioperative Quality Initiative consensus statement on goal-directed haemodynamic therapy. Br J Anaesth. 2025;135(3):547-560.
4. Thiele RH, Raghunathan K, Brudney CS, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Anesth Analg. 2016;123(5):1206-1219.
5. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292-298.
6. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid management in fast-track surgery. Br J Anaesth. 2002;89(6):912-920.
7. Pearse RM, Harrison DA, MacDonald N, Gillies MA, Blunt M, Ackland G, et al; OPTIMISE Study Group. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery. JAMA. 2014;311(21):2181-2190.
8. OPTIMISE II Trial Group (Edwards MR, Pearse RM, Kahan BC, et al). Cardiac output-guided haemodynamic therapy for patients undergoing major gastrointestinal surgery: OPTIMISE II randomised clinical trial. BMJ. 2024;387:e080439.
9. Gameiro J, et al. Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative. Nat Rev Nephrol. 2021;17:605-618.
10. McIlroy DR, Feng X, Shotwell M, Wallace S, Bellomo R, Garg AX, et al. Candidate kidney protective strategies for patients undergoing major abdominal surgery: a secondary analysis of the RELIEF trial cohort. Anesthesiology. 2024;140(6):1111-1125.
11. McIlroy DR, Wallace SK, Forbes A, Peyton P, Story DA, Corcoran T, et al. Perioperative intravenous fluid and chronic kidney disease: long-term follow-up of the RELIEF randomised trial. Br J Anaesth. 2026;137(2):479-489.
12. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018;378(9):829-839.
13. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al. Balanced crystalloids versus saline in noncritically ill adults. N Engl J Med. 2018;378(9):819-828.
14. Cao Q, Pang QY, Sun SF, Jiang Y, Liu HL. The safety and efficacy of balanced crystalloid vs normal saline in non-cardiac surgeries: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2024;28(10):3927-3940.
15. Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI, et al. PeriOperative Quality Initiative international consensus statement on perioperative arterial pressure management. Br J Anaesth. 2024;133(2):264-276.
16. Gustafsson UO, Rockall TA, Wexner SD, et al. Enhanced Recovery After Surgery (ERAS) Society 2025 guidelines for perioperative care in elective colorectal surgery. Surgery. 2025;184:109397.
17. Chong MA, Wang Y, Berbenetz NM, McGloughlin S. Does goal-directed haemodynamic and fluid therapy improve outcome in high-risk surgical patients? A systematic review and meta-analysis. Eur J Anaesthesiol. 2018;35(7):469-483.
18. Salzwedel C, Puig J, Carstens A, et al. Perioperative goal-directed hemodynamic therapy for adults undergoing surgery: a systematic review and meta-analysis. Crit Care. 2013;17:R191.
19. Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in high-risk surgical patients. Anesth Analg. 2011;112(6):1392-1402.
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