Fluid Physiology – the paper back edition is here.

Delighted to say the type setter has done her job and you should soon be able to get a more affordable edition of my book from Cambridge Scholars Publishing .

I’d like to take this opportunity to Thank CSP for making this project happen. The big publishing companies (we know who they are) have an eye-watering profit margin and offer zero £ € $ to Authors. When I offered them a Proposal for this monograph I did not even receive the courtesy of a response, in spite of the fact that I am an Author for chapters they had invited me to write. Academic readers are understandably concerned about the Reputation of smaller publishers, but I can fully endorse the comments of this man who has his own Wikipedia page.

After CSP Board agreed to publish, it was up to me to deliver a text that was type-set ready; there was no Editor or Proof Reader, no Graphics team to help. Many of the staff seem to be part time, and communication was sometimes hit-or-miss, but we got there. The first copies are very expensive (and no discount for the e-pub) as the publisher has to make a profit on small sales numbers. I therefore pay tribute to my followers who dug deep to read my efforts. The reward of their investment is that CSP now anticipate a market out there for the more affordable paperback edition.

I am delighted to report that no significant revisions to the original text are needed to date. Despite widespread acceptance, misconceptions about the revised or steady-state or extended Starling principle persist in 2021. Physiologists Charles Michel and Roy Curry offered some clarifications to one of the Journals in question [1]. Three main causes of confusion amongst clinicians were identified. Firstly, that it is impossible for body fluid compartments to exist in a state of no-flow equilibrium; fluids must cross the vascular endothelium and then be returned to the plasma. Starling physiology explains (a) an essential and continuous steady state flow of salts and water between compartments, and (b) transient disturbances to that steady state when a Starling force is abruptly changed. Transient change of plasma colloid osmotic pressure has been used in clinical experiments to justify biophysical osmotic pressure therapy, but such experiments tell us little of the ensuing steady state. Secondly, some clinicians seem not to appreciate that proteins like albumin continuously leave the plasma to enter the interstitial fluid, mostly via large pore permeability mechanisms that are quite separate from the glycocalyx’s small pore filtration. Finally, clinicians seem to underestimate the importance of local hydrostatic pressure differences within the body. These may account for the phenomenon that has been called context sensitivity; that the observed consequences of therapeutic infusions depend upon the clinical situation.

More recently it was reported (incorrectly) that “the Revised Starling mechanism” (sic) holds that interstitial fluid cannot be recruited by raising the plasma oncotic pressure [2].  What I had actually written in 2012 was “when albumin is used for normovolaemic haemodilution, keeping capillary pressure normal, the transendothelial solvent filtration rate is not increased and so most of the infused volume remains intravascular.” The experimental results confirmed my explanation [3].

In an invited commentary for Jean-Louis Vincent’s Annual Update in Intensive Care and Emergency Medicine, Professor Robert Hahn of the Karolinska Institute posed the very pragmatic question “Do Intensivists Need to Care About the Revised Starling Principle?”  I believe that most clinicians would aspire to understand the underlying physiological principles that make our best judgments on fluid therapy rational. What do you think?

  1. Michel CC, Woodcock TE, Curry FE. Understanding and extending the Starling principle. Acta Anaesthesiol Scand. 2020;64:1032-1037.
  2. Löffel LM, Hahn RG, Engel D, Wuethrich PY. Intraoperative Intravascular Effect of Lactated Ringer’s Solution and Hyperoncotic Albumin During Hemorrhage in Cystectomy Patients. Anesth Analg. 2021;133:413-422.
  3. Woodcock TE. Misconceptions About the Starling Principle as Applied to Fluid Therapy, Anesth  Analg: 2021;133: e19
  4. Hahn R.G. (2020) Do Intensivists Need to Care About the Revised Starling Principle? In: Vincent JL. (eds) Annual Update in Intensive Care and Emergency Medicine 2020. Annual Update in Intensive Care and Emergency Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-37323-8_11

By admin

after more than a quarter of a century of intensive care medicine consultancy in one of the UK's largest teaching hospitals Dr Woodcock is on a mission to ensure the steady state Starling principle is known and understood by every student and every practitioner.

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