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

Abstract

As the coronavirus disease 2019 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.

Cohort Study of Outpatient Hemodialysis Management Strategies for COVID-19 in North-West London

“…Fluid balance management of COVID-19 patients has attracted debate. 13,14 Although causality cannot be inferred, our data indicate maintained ultrafiltration volumes associate with better clinical outcomes in COVID-19 dialysis patients.…”

“…Progressive decreases in ultrafiltration volume at consecutive dialysis sessions corresponded with SaO 2 patterns. Fluid balance management of COVID-19 patients has attracted debate 13 , 14 . Although causality cannot be inferred, our data indicate maintained ultrafiltration volumes associate with better clinical outcomes in COVID-19 dialysis patients.…”

Point of Care Ultrasonography for Objective Assessment of Heart Failure: Integration of Cardiac, Vascular, and Extravascular Determinants of Volume Status

“…Moreover, it has proven to significantly increase the sensitivity of auscultation, particularly for the diagnosis of left ventricular dysfunction and common valvular abnormalities [16]. FoCUS assists in the evaluation of fluid status by rapidly providing the answers to the so-called “5 Es,” that is, qualitative estimation of left ventricular Ejection, presence or absence of pericardial Effusion, Equality (relative right ventricular size), Entrance (IVC size and collapsibility), and the Exit (stroke volume measurement at the left ventricular outflow tract [LVOT]) [17, 18]. While fluid overload is the main concern in HF, a subset of patients aggressively treated with diuretics may develop reduced cardiac output and consequent tissue hypoperfusion due to relative volume depletion.…”

A.B.C. approach proposal for POCUS in COVID-19 critically ill patients

“…Especially, fluid overload has negative effects on multiple organs' function with a poor outcome, acute respiratory distress syndromes patients with high vascular permeability, interstitial and tissue edema being at risk for respiratory aggravation. Ultrasound is easy to use for intravascular volume status monitoring and allows therapeutic interventions in real time together with response monitoring to fluid challenges [33,34]. Inferior vena cava diameter is measured with the transducer placed in sagital position and inspiratory and expiratory variation in response to respiration is measured, obtaining the distensibility or the collapsibility index, depending on the type of breathing: spontaneous or mechanical [24,34].…”