Perioperative fluid therapy: defining a clinical algorithm between insufficient and excessive

In the perioperative scenario, adequate fluid and volume therapy is a challenging task. Despite improved knowledge on the physiology of the vascular barrier function and its respective pathophysiologic disturbances during the perioperative process, clear-cut therapeutic principles are difficult to implement. Neglecting the physiologic basis of the vascular barrier and the cardiovascular system, numerous studies proclaiming different approaches to fluid and volume therapy do not provide a rationale, as various surgical and patient risk groups, and different fluid regimens combined with varying hemodynamic measures and variable algorithms led to conflicting results. This review refers to the physiologic basis and answers questions inseparably conjoined to a rational approach to perioperative fluid and volume therapy: Why does fluid get lost from the vasculature perioperatively? Whereto does it get lost? Based on current findings and rationale considerations, which fluid replacement algorithm could be implemented into clinical routine?