Authors: Longrois D.
Source: European Journal of Anaesthesiology. 2026;43(6):473-475.
Summary:
This editorial discusses an important controversy in perioperative hemodynamic management: whether clinicians should proactively optimize stroke volume with repeated fluid boluses or reserve fluids only for patients who show signs of hypoperfusion.
The article compares two different approaches. The French perspective supports early, systematic preload optimization after induction of anesthesia, using stroke volume response to guide small fluid boluses. The German perspective emphasizes a more individualized and reactive approach, arguing that fluid responsiveness alone does not mean the patient actually needs fluid.
The author explains that both sides agree on several key principles. Both agree that adequate organ perfusion is the goal, that real-time hemodynamic monitoring can be useful in high-risk patients, that vasopressors have an important role, and that fluid overload can cause harm. The main disagreement is timing and interpretation. The proactive approach treats preload reserve early, while the reactive approach waits for clinical or metabolic evidence of hypoperfusion.
A major practical point is that “fluid responsive” does not automatically mean “fluid requiring.” A patient may increase stroke volume after a fluid bolus, but that does not prove the patient is hypoperfused or that additional fluid will improve outcome. The author recommends using the full clinical picture, including blood pressure, lactate, capillary refill, ScvO2, urine output, cardiac function, pulmonary status, renal status, and surgical phase.
The article proposes a balanced framework. Stroke volume optimization may be more useful in patients with preserved left ventricular function, high-risk surgery, expected blood loss, prolonged procedures, dehydration, hypotension with low stroke volume, elevated lactate, or other signs of inadequate perfusion. It may be harmful in patients with heart failure, right ventricular dysfunction, pulmonary edema, advanced kidney disease, elevated venous pressures, or clear anesthesia-induced vasodilation with normal or high cardiac output.
Clinical importance:
This article is useful because it moves the discussion away from a rigid “give fluid” versus “avoid fluid” argument. In anesthesia practice, post-induction hypotension is often caused by vasodilation and decreased venous return rather than true hypovolemia. In those cases, vasopressors may be more appropriate than repeated fluid boluses.
The practical message is to assess before giving fluid. If volume expansion is chosen, the author recommends small crystalloid boluses of about 200 to 250 mL followed by reassessment. Fluids should be stopped when stroke volume no longer improves or when signs of congestion appear.
Bottom line:
The best approach is individualized hemodynamic management rather than routine stroke volume maximization or strict fluid avoidance. Clinicians should use patient comorbidities, surgical context, hemodynamic monitoring, and perfusion markers to decide whether fluid, vasopressors, or both are needed.
Thank you to the European Journal of Anaesthesiology for publishing this practical editorial on preload optimization and individualized fluid management in high-risk noncardiac surgery.