We thank Dr. Navarro-Martinez and colleagues for their letter concerning our review on perioperative fluid management. In general, we would like to point out that our article was targeted on perioperative fluid therapy in patients who primarily have a steady state concerning their fluid compartments.1In these patients an intact vascular barrier function ensures that, despite a positive pressure within the circulatory space, plasma constituents are not distributed evenly across the whole extracellular compartment.2,3Rather, under normal physiologic conditions, they are predominantly retained where they are needed to maintain a sufficient cardiac preload. A small residual flow towards the interstitial space is managed by an intact lymphatic system.1In this situation, requirement-adapted fluid handling might limit tissue edema by considering physiologic and pathologic shifting, provided that the vascular barrier is primarily fully functioning.1
The septic patient, undergoing surgery or not, does not present such a steady state.4The normally accompanying capillary leakage syndrome, as a result of an insufficient vascular barrier, leads to a barely calculable shift of fluid and macromolecules (such as proteins and colloids) towards the interstitial space, representing a primary problem during sepsis.5Recent evidence suggested a deterioration of the endothelial glycocalyx by inflammatory mediators to be an important part of the underlying pathomechanism.6,7Therefore, a careful differential indication between crystalloids and colloids as suggested for the perioperative steady state might not only be insufficient in this context, but in vain.1Until today, we only know that we have to give enough, irrespective of the kind of fluid, to improve outcome of patients suffering from severe sepsis and septic shock.8
We support most of the interesting considerations by Dr. Navarro-Martinez and colleagues. However, septic patients were not the focus of our rational approach.
*Ludwig-Maximilians University, Munich, Germany. email@example.com