EVALUATION OF INTRAVASCULAR VOLUME Clinical evaluation and assessment of intravascular volume must generally be relied upon, because measurements

of fluid compartment volumes are not readily available. Intravascular volume can be assessed using physical or laboratory examinations or with the aid of sophisticated hemodynamic monitoring techniques. Regardless of the method employed, serial evaluations are necessary to confirm initial impressions and guide fluid therapy. Moreover, modalities should complement one another because all parameters are indirect, nonspecific measures ofvolume; reliance on any one parameter may be eroneous and, therefore, hazardous. Physical Examination Physical examination is most reliable preoperatively.Invaluable clues tohypovolemia include skin turgor, the hydration of mucous membranes, fullness of a peripheral pulse,the resting heart rate and blood pressure and the (orthostatic) changes from the supine to sitting or standing positions, and urinary flow rate. Unfortunately, many drugs used during anesthesia, as well as phusiological effects of surgical stress, alter these signs and render them unreliable in the immediat postoperative period. Intraoperatively,the fullness of a peripherl pulse (radial or dorsalis pedis) , urinsry flow rate, and indirect signs,such as the response of blood pressure to positive-pressure ventilation and the vasodilating or negative inotropic effects of anesthetics, are most often used. Laboratory Evaluation Several laboratory measurements maybe used assurrogates of intravascular volume and adequacy of tissue perfusion. These measurement are only indirect indices of intravascular volume and often cannot be relid upon intraoperatively because they are affected by many ther variables and results are often delayed. Laboratory signs of dehydration include a rising hematocrit, a progressivemetabolic acidosis, a urinary sodium less than 10mEq/L, a urinary osmolality greater than 10:1. Only radiographic signs of increased pulmonary vascular and intersitial markings (Kerly B lines) or diffuse alveolar infiltrates are reliable measures of volume overload. Hemodynamic Measurements Central venous pressure monitoring is indicated in patients with normal cardiac and pulmonary function when volume status is difficult to assess by other means or when rapid ormajor alterations are expected. Central venous pressure readings must be interpreted in view of the clinical setting. Low values (< 5 mmHg) may be normal unless associated with other signs of hypovolemia.Moreover, the response to a fluid bolus (250 mL) is equallyas important:a small elevation (1-2 mmHg)may indicate the need for more fluid, whereas a large increase > 5mmHg) suggest the need for a slower rate of administration and a reevaluation of volume status. Central venous pressure readings greater than 12 mmHg are considered elevated and imply hypervolemia in the absence of right ventricular dysfunction, increased intrathoracic pressure, or restrictive pericardial disease. Pulmonary artery pressure monitoring is necessary if central venous pressure do not correlate with the clinical assessment or if the patient has primary or secondary right ventricular disfunction; the latter is usually due to pulmonary or left ventricular disease, respectively. Pulmonary artery occlusion pressure *PAOP) readings of less than 8 mmHg indicate hypovolemia inthe presence. Of confirmatory clinical signs; however, values less than 15 mmHg may be associated with relative

hypovolemia in patients with poor ventricular compliance. PAOP measurements greater than 18 mmHg are elevated and generally imply left ventricular volume overload. The presence of mitral valve disease (particularly stenosis), severe aortic stenosis, or a left atrial myxoma or thrombus alters the normal relationship between PAOP and left ventricular end-diastolic volume. Increased thoracic and pulmonary airway pressure also introduce errors; consequently, all pressure measurements should always be obtained at end expiration and interpreted in the context of the clinical setting. Newer techniques of measuring ventricular volumeswith transesophageal echocardioghrapy or by radioisotopes are more accurate but are not as widely available.