Association between early cumulative fluid balance and successful liberation from invasive ventilation in COVID-19 ARDS patients — insights from the PRoVENT-COVID study: a national, multicenter, observational cohort analysis

Abstract

Background Increasing evidence indicates the potential benefits of restricted fluid management in critically ill patients. Evidence lacks on the optimal fluid management strategy for invasively ventilated COVID-19 patients. We hypothesized that the cumulative fluid balance would affect the successful liberation of invasive ventilation in COVID-19 patients with acute respiratory distress syndrome (ARDS). Methods We analyzed data from the multicenter observational ‘PRactice of VENTilation in COVID-19 patients’ study. Patients with confirmed COVID-19 and ARDS who required invasive ventilation during the first 3 months of the international outbreak (March 1, 2020, to June 2020) across 22 hospitals in the Netherlands were included. The primary outcome was successful liberation of invasive ventilation, modeled as a function of day 3 cumulative fluid balance using Cox proportional hazards models, using the crude and the adjusted association. Sensitivity analyses without missing data and modeling ARDS severity were performed. Results Among 650 patients, three groups were identified. Patients in the higher, intermediate, and lower groups had a median cumulative fluid balance of 1.98 L (1.27–7.72 L), 0.78 L (0.26–1.27 L), and − 0.35 L (− 6.52–0.26 L), respectively. Higher day 3 cumulative fluid balance was significantly associated with a lower probability of successful ventilation liberation (adjusted hazard ratio 0.86, 95% CI 0.77–0.95, P = 0.0047). Sensitivity analyses showed similar results. Conclusions In a cohort of invasively ventilated patients with COVID-19 and ARDS, a higher cumulative fluid balance was associated with a longer ventilation duration, indicating that restricted fluid management in these patients may be beneficial. Trial registration Clinicaltrials.gov (NCT04346342); Date of registration: April 15, 2020. Graphical abstract

Effect of restrictive cumulative fluid balance on 28-day survival in invasively ventilated patients with moderate to severe ARDS due to COVID-19

“…There is a logical propensity to prioritize fluid restriction since the pathophysiological mechanism to explain the improvement of hematosis by restricting the fluid input is the reduction of tissue, cellular, interstitial, and alveolar edema caused by the lesion of the alveolar-capillary bed by the inflammatory process 36 , 37 . However, the absence of a clearly defined restrictive fluid management strategy in sepsis 4 , 5 , 9 , 38 in patients with ARDS 33 , 35 , 39 , and now in patients with ARDS caused by SARS-CoV-2 40 , makes it challenging to compare various studies and their findings. This challenge arises from the lack of consensus regarding the specific limits for defining a fluid balance as restrictive and the absence of a universally accepted clinical protocol 34 , 41 .…”

Incidence and Determinants of Acute Kidney Injury after Prone Positioning in Severe COVID-19 Acute Respiratory Distress Syndrome

“…Optimizing volume status and cardiac output may thus improve organ perfusion and provide a protective strategy against kidney damage [2]. In fact, fluid restriction and diuretic drugs are widely used in acute lung injury management, including C-ARDS to prevent further deterioration in lung function [33,34]. Indeed, hypovolemia was a frequent finding in our retrospective cohort, and patients who developed PP-AKI had a significantly lower weight-normalized cumulative fluid balance and a lower CVP before starting their first PP cycle.…”

Fluid intake, fluid output or fluid balance, which one matters in ARDS

“…In a recent trial including 650 COVID-19 patients with acute respiratory distress syndrome (ARDS) [1], Dr. Ahuja et al reported a linear association between cumulative fluid balance and successful liberation from invasive ventilation in the restricted cubic spline function models. This study is well designed, and the conclusions are clear.…”

“…In your journal, we recently showed that a higher cumulative fluid balance has an association with a longer duration of ventilation in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), suggesting that restricted fluid management in these patients may be beneficial [1].…”

“…Author details 1 Department of Intensive Care, Zhejiang Hospital, No. 1229, Gudun Road, Hangzhou 310013, Zhejiang, People's Republic of China.…”