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

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 

ECMO patient, after aggressive dialysis

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}

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

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.

Reference

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