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      Need for Objective Assessment of Volume Status in Critically Ill Patients with COVID-19: The Tri-POCUS Approach

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          As the coronavirus disease 2019 (COVID-19) continues to spread across the globe, the knowledge of its epidemiology, clinical features, and management is rapidly evolving. Nevertheless, the data on optimal fluid management strategies for those who develop critical illness remain sparse. Adding to the challenge, the fluid volume status of these patients has been found to be dynamic. Some present with several days of malaise, gastrointestinal symptoms, and consequent hypovolemia requiring aggressive fluid resuscitation, while a subset develop acute respiratory distress syndrome with renal dysfunction and lingering congestion necessitating restrictive fluid management. Accurate objective assessment of volume status allows physicians to tailor the fluid management goals throughout this wide spectrum of critical illness. Conventional point-of-care ultrasonography (POCUS) enables the reliable assessment of fluid status and reducing the staff exposure. However, due to specific characteristics of COVID-19 (e.g., rapidly expanding lung lesions), a single imaging method such as lung POCUS will have significant limitations. Herein, we suggest a Tri-POCUS approach that represents concurrent bedside assessment of the lungs, heart, and the venous system. This combinational approach is likely to overcome the limitations of the individual methods and provide a more precise evaluation of the volume status in critically ill patients with COVID-19.

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          Most cited references 13

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          The respiratory variation in inferior vena cava diameter as a guide to fluid therapy.

          To investigate whether the respiratory variation in inferior vena cava diameter (DeltaD(IVC)) could be related to fluid responsiveness in mechanically ventilated patients. Prospective clinical study. Medical ICU of a non-university hospital. Mechanically ventilated patients with septic shock (n=39). Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. Cardiac output and DeltaD(IVC) were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7+/-2.0 to 6.4+/-1.9 L/min (P or =15% (responders). Before volume loading, the DeltaD(IVC) was greater in responders than in non-responders (25+/-15 vs 6+/-4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% DeltaD(IVC) cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. Analysis of DeltaD(IVC) is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.
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            Human Kidney is a Target for Novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection

            BACKGROUND The coronavirus disease 2019 (COVID-19) is a newly emerged infection from the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Apart from the respiratory system, it is unclear whether SARS-CoV-2 can also directly infect other tissues such as the kidney or induce acute renal failure. METHODS We conducted a retrospective analysis of estimated glomerular filtration rate (eGFR), plasma creatinine, and urea concentrations along with other clinical parameters from 85 patients with laboratory-confirmed COVID-19 admitted to a hospital in Wuhan from January 17, 2020 to March 3, 2020. Kidney tissues from six other patients with postmortem examinations were analyzed by Hematoxylin and Eosin (H&E) and in situ expression of viral nucleocaspid protein (NP) antigen was detected by immunohistochemistry. RESULTS Among these 85 COVID-19 cases, 27.06% (23/85) patients exhibited acute renal failure (ARF), and elder patients (≥ 60 years old) are easier to develop ARF (65.22% vs 24.19%, p< 0.001). Comorbidities of disorders like hypertension and heart failure were more common in patients who developed ARF (69.57% vs 11.29%, p< 0.001). Dynamic observation of eGFR revealed that perished cases have a rapid decrease of eGFR but quickly boosting plasma creatinine and urea. On the other hand, enhancement of eGFR and persistence low level of plasma creatinine and urea was observed in recovery patients following diuretic treatment. H&E staining demonstrated kidney tissues from 6 cases of postmortems have severe acute tubular necrosis but no evidence of glomerular pathology or tubulointerstitial lymphocyte infiltration. Immunohistochemistry showed that SARS-CoV-2 NP antigen was accumulated in kidney tubules. CONCLUSIONS The development of ARF during the course of disease is an important negative prognostic indicator for survival with COVID-19. SARS-CoV-2 virus directly infects human kidney tubules by thus induces acute tubular damage, ARF and probably also lead to urine transmission.
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              Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial.

              Physical examination, assessment of central venous pressure (CVP) and chest radiography are diagnostic tools for estimation of volume status in intensive care unit (ICU) patients. Passive leg raising (PLR) is a test to estimate fluid responsiveness. Transpulmonary thermodilution (TPTD) is established for measurement of cardiac index (CI), global end-diastolic volume index (GEDVI), and extravascular lung water index (EVLWI). This study compares the estimation of volume status using physical examination, CVP, chest radiography, PLR, and TPTD. This study was a prospective trial. Seventy-one patients in a medical ICU were studied. Interventions were as follows: physical examination by 2 independent examiners. CVP was measured. TPTD was performed. In 2 patient subgroups PLR and chest radiography was performed. Comparison of clinical and x-ray-based estimation of volume status, CVP, PLR, and TPTD variables was performed. Estimation of volume status based on physical examination showed a poor interobserver agreement between the examiners. There was no significant correlation between physical examination-based estimation of volume status and CVP or TPTD-derived GEDVI. There was no significant correlation between CVP and GEDVI, EVLWI or CI. PLR did not indicate fluid responsiveness. Radiographically estimated and TPTD-GEDVI/EVLWI values were significantly different. In ICU patients, assessment of volume status remains difficult. Physical examination, CVP, and portable radiography do not correlate with TPTD assessment of volume status, preload, or pulmonary hydration. Copyright © 2011 Elsevier Inc. All rights reserved.

                Author and article information

                Cardiorenal Med
                Cardiorenal Med
                Cardiorenal Medicine
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, )
                27 May 2020
                : 1-8
                aDivision of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
                bDepartment of Nephrology, San Bortolo Hospital and International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
                cDepartment of Medicine, University of Padova, Padova, Italy
                dDivision of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida, USA
                Author notes
                *Abhilash Koratala, 8701 W Watertown Plank Road, Division of Nephrology, Room A 7633, Wauwatosa, WI 53226 (USA), akoratala@
                Copyright © 2020 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                Page count
                Figures: 3, References: 25, Pages: 8


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