Conservative fluid therapy was the strategy used in Wuhan 18

The cause of death from COVID-19 is most often ARDS and subsequent complications, which may be exacerbated by fluid administration20

“We believe the Maltron device plays a pivotal role in the day to day assessment and monitoring of Covid-19 patients and should be made available in all ICU departments as a matter of urgency. Assessing fluid volume status of these patients on an ongoing basis is essential and should be performed using the BioScan touch i8” Prof. Dr. Manu Malbrain

Intensive Care Director, Brussels

In COVID-19, Sepsis and Septic shock (ARDS) ICU patients, optimal ventilation and effective treatment may be achieved when patients are at their most stable state.18 One of the most important principles to understand in the management of these complex patients is the need for a detailed initial assessment and ongoing evaluation of the response to treatment.19

It is recommend following initial fluid resuscitation, that additional fluids be guided by frequent reassessment of hemodynamic status.19

It is appropriate to be conservative with intravenous fluids in patients with severe lung injury if there are no signs of tissue hypoperfusion.19

Whilst using the BioScan touch i8 one of many significant findings reported was that patients that were fluid overloaded did not respond as effectively to the treatment resulting in mortality.

Prof. Dr. Manu Malbrain 

  • Fluid overload is associated with increased morbidity and mortality in critically ill patients
  • Aggressive fluid resuscitation increases the risk of excessive fluid administration and fluid overload
  • Fluid responsiveness should be assessed prior to fluid administration to reduce the risk of excessive fluid administration
  • Fluid resuscitation strategies should include clear limits and individualised end-points to reduce the risk of excessive fluid administration
  • Interventions aimed at achieving a negative fluid balance should be considered after adequately resuscitating patients with shock.17

Assessment of fluid accumulation inside the torso

Fluid accumulation is one of the significant and early-stage manifestations of fatal diseases,
such as lung-cancer, liver-failure and congestive heart-failure

Early stage assessment or monitoring of the Torso is a key to timely medical intervention in order to help prevent complication and worsening of patients which could lead to mortality.

Accumulation of fluid in the torso area (inside or around the lungs), prevents the lungs from exchanging gases causing fatal consequences if not treated properly and timely.

According to the World Health Organization (WHO) cardiovascular diseases (CVD’s) are the leading cause of death in the world. World Health Care Fact Sheet on Cardiovascular diseases (CVDs).22

Although, CT – Scan are commonly used for the detection of thoracic fluid, it cannot be used frequently due to ionizing radiation, the high cost, lack of mobility and on these types of patients.

BioScan touch i8 is a safe, accurate, non-invasive and low-cost device that can be used for the assessment and monitoring of the torso of patient with acute respiratory distress syndrome (ARDS)

Results show data of Normal Patient vs Clinical patient

We believe the BioScan touch i8 plays a pivotal role in the day to day assessment and monitoring of Covid-19 patients and should be made available in all ICU departments as a matter of urgency

Prof. Dr. Manu Malbrain

 

BioScan touch i8 is a non-invasive monitor used in hospital departments such as ICU, Renal, Cardiology, Cancer and many more to assess and monitor Covid-19 patients and others in order to help physicians understand the impact of the virus.

The BioScan touch i8, has shown to be of significant importance and benefit in the assessment and monitoring of patients diagnosed with COVID-19. As a result they have been able to make supportive clinical decisions in the treatment of patient care.

BioScan touch i8 should be used in ASSESSMENT & MONITORING CORONAVIRUS (COVID-19). This non-invasive device provides vital and valuable information of the patient’s fluid status along with other important parameters to the clinician in order to guide therapy.

ECMO patient, after aggressive dialysis

The screens are assessments of a clinical patient, showing evolution of Intravascular, Extravascular fluid volume and Hematocrit assessments.

Fluid overload patients require accurate management to optimise fluid balance

Numerous recent studies have shown fluid overload to have adverse outcomes on patients. These studies have shown a correlation between fluid overload and increased mortality along with several complications like pulmonary edema, cardiac failure, impaired bowel function, delayed wound healing and tissue breakdown.1

In the management of critically ill patients accurate evaluation of volume status is crucial in the early management of these patients. Knowing the volume status is vital for appropriate therapy, errors could lead to either a lack of essential treatment or unnecessary fluid administration, and both scenarios are associated with increased mortality.1

Successful fluid overload treatments depend on precise assessment of individual volume status, understanding the principles of fluid management with ultrafiltration, and clear treatment goals.

Several observational studies have demonstrated a correlation between fluid overload and mortality in critically ill patients with acute respiratory distress syndrome, acute lung injury, sepsis, and AKI. Bouchard et al., have shown that patients with fluid overload defined as an increase in body weight of over 10% had significantly more respiratory failure, need of mechanical ventilation, and more sepsis. After adjusting for severity of illness, AKI patients with fluid overload had increased 30 day and 60 day mortality. Among survivors, AKI patients who required renal replacement therapy had a significantly lower level of fluid accumulation at initiation of dialysis and at dialysis cessation than non-survivors. Renal recovery was significantly lower in patients with fluid overload.1, 7

In children, a multicenter prospective study found that the percentage of fluid accumulation at initiation of CRRT was significantly lower in the survivors (14.2 % ±15.9 % vs. 25.4 % ±32.9 %, P = 0.03).1, 8

It was also suggested the use of BioScan touch i8 on the frontline in A & E settings or in the inpatient or outpatient departments monitoring of these patients with the Maltron device could be vital we know mild cases of Covid-19 in itself are not dangerous. However, in some cases more commonly in older people and in people with underlying chronic medical conditions can progress to a moderate case that could require some supportive care such as fluids for dehydration, typically in hospitals that are overwhelmed by the most acute cases. Prof. Dr. Manu Malbrain

A study undertaken at Icahn School of Medicine recently showed more than half the patients with early stage of the coronavirus disease in China had normal CT scans. As the disease progressed scans showed hazy parts of the lungs

 

Unenhanced CT images in a 33-year-old woman. A, Image shows multiple ground-glass opacities in bilateral lungs. Ground-glass opacities are seen in the posterior segment of right upper lobe and apical posterior segment of left superior lobe. B, Image obtained 3 days after follow-up shows progressive ground-glass opacities in the posterior segment of right upper lobe and apical posterior segment of left superior lobe. The bilateralism of the peripheral lung opacities, without subpleural sparing, are common CT findings of the 2019 novel coronavirus pneumonia.
Patients admitted to an intensive care unit are prone to cumulated fluid overload and receive intravenous volumes through the aggressive resuscitation recommended for septic shock treatment, as well as other fluid sources related to medications and nutritional support. The liberal liquid supply strategy has been associated with higher morbidity and mortality. During systemic inflammatory response syndrome, the endothelial glycocalyx is damaged, favoring fluid extravasation and resulting in interstitial edema. Extravasation to the third space results in longer mechanical ventilation, a greater need for renal replacement therapy, and longer intensive care unit and hospital stays, among other changes. Proper monitoring, as well as cautious infusion of fluids, can minimize these damages.16

Lungs are one of the organs in which adverse effects of fluid overload are most evident, which can lead to acute pulmonary edema or acute respiratory distress syndrome. 1, 9 Several studies have provided evidence associating positive fluid balances with poorer respiratory outcomes. In one of these studies, septic shock patients with acute lung injury who received conservative fluid management after initial fluid resuscitation had lower in-hospital mortality.1, 10

In another study, Wiedemann et al. randomized 1000 patients to either a conservative or to a liberal strategy of fluid management. Patients randomized to the conservative fluid strategy had lower cumulative fluid balance, improved oxygenation index and lung injury score, increased number of ventilator-free days, and reduction in the length of ICU stay. It is worth mentioning that the conservative fluid management strategy did not increase the incidence or prevalence of shock during the study or the need for renal replacement therapies.1, 11

Finally, in the Vasopressin in Septic Shock Trial (VASST) study authors found that higher positive fluid balance correlated significantly with increased mortality with the highest mortality rate observed in those with central venous pressure >12 mmHg.1, 12

The ultimate goal is to preserve tissue perfusion, optimizing fluid balance by effectively removing fluid without compromising the effective circulating fluid volume; therefore, meticulous monitoring of fluid balance is critical for all patients.1, 13

Another consideration is Malnutrition which can decrease Muscle function.14 Loss of Muscle Mass is linked to an increased risk of infection and increased risk of mortality15

 

Recent ESPEN expert statements and practical guidance for nutritional management of individuals with SARS-CoV-2 infection highlighted the importance of assessment in Prevention and treatment of malnutrition.

It was suggested Impedance analysis as one of the methods to assess Muscle mass.23

Ayse Baccioglu et.al although Malnutrition has been associated with impaired health status in patients with chronic obstructive pulmonary disease (COPD), the effects of body composition (body fat and protein percentage) in patients with COPD have not been demonstrated. A total of 180 stable patients with COPD and 50 healthy subjects were included in this prospective study. It was found stable patients with COPD showed frequent alterations in body composition besides malnutrition. Malnutrition and body decomposition were both related to impairment in respiratory muscle strength, and diffusing capacity of the lung. These results indicate that body composition should be a part of nutritional assessment besides BMI.

Dekker MJE et.al study looked at Malnutrition and its association with outcome. Pre dialysis fluid overload (FO) in haemodialysis (HD) patients is associated with an increased risk of death, further increased by the presence of inflammation. The study looked at the associations of Fluid overload, malnutrition, and inflammation with outcome. The presence of malnutrition found to be associated with higher levels of Fluid overload, which amounted to further increase when inflammation was present. It was shown that Malnutrition as singular risk factor was not associated with increased mortality risk. The highest mortality observed in patients with the presence of all 3 risk factors.

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Reference

  1. Fluid overload in the ICU: evaluation and management Rolando Claure-Del Granado; Ravindra L. Mehta – BMC Nephrology volume 17, Article number: 109 (2016).
  2. WHO Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected – Interim guidance 13 March 2020 – second edition (version 1.2).
  3. Piccoli A. Patterns of bioelectrical impedance vector analysis: learning from electrocardiography and forgetting electric circuit models. Nutrition. 2002;18(6):520–1.
  4. Piccoli A, Pittoni G, Facco E, Favaro E, Pillon L. Relationship between central venous pressure and bioimpedance vector analysis in critically ill patients. Crit Care Med. 2000;28(1):132–7.
  5. Piccoli A. Bioelectric impedance measurement for fluid status assessment. Contrib Nephrol. 2010;164:143–52.
  6. Bioelectrical impedance phase angle in clinical practice: implications for prognosis in stage IIIB and IV non-small cell lung cancer Digant Gupta, Carolyn A Lammersfeld, Pankaj G Vashi, Jessica King, Sadie L Dahlk, James F Grutsch and Christopher G Lis.
  7. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009;76(4):422–7.
  8. Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int. 2005;67(2):653–8.
  9. Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004;351(2):159–69.
  10. Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, et al. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136(1):102–9.
  11. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–75.
  12. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259–65.
  13. Bouchard J, Mehta RL. Volume management in continuous renal replacement therapy. Semin Dial. 2009;22(2):146–50.
  14. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Nicolaas E.Deutz, Eric M.Matheson, Laura E. Matarese, MenghuaLuo, Geraldine E.Baggs, Jeffrey L.Nelson, Refaat A.Hegazi, Kelly A.Tappenden, Thomas R.Ziegler.
  15. Nutrition, anabolism, and the wound healing process: an overview. Demling RH.
  16. Fluid overload in children undergoing mechanical ventilation. Clarice Laroque Sinott Lopes and Jefferson Pedro Piva.
  17. How to Avoid Fluid Overload. Ogbonna C. Ogbu, MD, David J. Murphy, MD, PhD, and Greg S. Martin, MD, MSc.
  18. Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience. Lingzhong Meng, M.D.; Haibo Qiu, M.D.; Li Wan, M.D.; Yuhang Ai, M.D.; Zhanggang Xue, M.D.; et al Qulian Guo, M.D.; Ranjit Deshpande, M.D.; Lina Zhang, M.D., Ph.D.; Jie Meng, M.D., Ph.D.; Chuanyao Tong, M.D.; Hong Liu, M.D.; Lize Xiong, M.D., Ph.D.- Anesthesiology.
  19. Rhodes, A, Evans, LE, Alhazzani, W, Levy, MM, Antonelli, M, Ferrer, R, Kumar, A, Sevransky, JE, Sprung, CL, Nunnally, ME, Rochwerg, B, Rubenfeld, GD, Angus, DC, Annane, D, Beale, RJ, Bellinghan, GJ, Bernard, GR, Chiche, JD, Coopersmith, C, De Backer, DP, French, CJ, Fujishima, S, Gerlach, H, Hidalgo, JL, Hollenberg, SM, Jones, AE, Karnad, DR, Kleinpell, RM, Koh, Y, Lisboa, TC, Machado, FR, Marini, JJ, Marshall, JC, Mazuski, JE, McIntyre, LA, McLean, AS, Mehta, S, Moreno, RP, Myburgh, J, Navalesi, P, Nishida, O, Osborn, TM, Perner, A, Plunkett, CM, Ranieri, M, Schorr, CA, Seckel, MA, Seymour, CW, Shieh, L, Shukri, KA, Simpson, SQ, Singer, M, Thompson, BT, Townsend, SR, Van der Poll, T, Vincent, JL, Wiersinga, WJ, Zimmerman, JL, Dellinger, RP . Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304–77
  20. DoD COVID-19 PRACTICE MANAGEMENT GUIDE. Clinical Management of COVID-19 Leads Lt Col Renee I. Matos and COL Kevin K. Chung 3-23-2020
  21. Clinical management of persons admitted to hospital with suspected COVID-19 infection. Specialty guides for patient management during the coronavirus pandemic. Publications approval reference: 001559. NHS England and NHS Improvement
  22. Available at: www.who.int/mediacentre/factsheets/fs317/ en/. (Accessed: 15th June 2016) (2015).
  23. Espen expert statements and practical guidance for nutritional management of individuals with sars-cov-2 infection: Rocco Barazzoni, Stephan C. Bischoff, Zeljko Krznaric, Matthias Pirlich, Pierre Singer, endorsed by the ESPEN Council

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