For the acute resuscitation of adults with COVID-19 and shock, the current recommendations are suggesting, using buffered/balanced crystalloids over unbalanced crystalloids.
The purpose of this discussion is address the need for guidance on fluid resuscitation among severe COVID-19 patients and shock management in resource-limited settings
Well, the BaSICS study was negative, so why not use 0.9%, especially in resource-limited settings? Best, Corstiaan.
Fluid management is a very complex issue.
There are many confounding factors including co-morbidities such as heart failure, liver disease and renal impairment.
It is important that management is individualised on a case by case basis.
By the time most of our patients come to the ICU they will have been on the wards for a few days. If their oral intake has been poor they will likely already be in a negative fluid balance. Other patients with early shock may have developed quite a positive balance. I don't think it makes a huge difference 0.9% NaCl vs other crystalloids. I think the main thing is to assess each patient individually for fluid responsiveness and not allow patients with ARDS to become too fluid overloaded. In the resource limited setting the passive leg raise is the best bedside tool for assessing this in my opinion.
I have yet to see any evidence that intravenous fluids are beneficial. All the evidence I have seen indicates that they are harmful. 100 years ago George Washington Crile demonstrated that crystalloids rapidly leave the vascular space via lymph flow and wind up in the intestine, causing the intestine to swell like a sausage. This gut swelling can press upon the diaphragm from below and undermine breathing. Secondly, they dilute blood elements and undermine coagulability, which can aggravate surgical blood loss. Thirdly, they damage the delicate glycocalyx that lines all the blood vessels. Finally, they cause the lung to become “wet”, which promotes atelectasis and inhibits gas exchange. It is best to restrict intravenous fluids in all types of pulmonary disease.
Today’s physicians are taught to believe that each disease or syndrome is a specific entity that must be treated with specialized treatments. In reality, there is a “stress mechanism” that repairs tissues and regulates physiology. Normally it operates unobtrusively and efficiently, but when it becomes hyper activated by combinations of environmental stresses, it begins to waste and deplete body resources and induce harmful inflammatory effects and increased blood coagulability that disrupts organ function and promotes infarction. These effects actually promote the viral invasion. The virus triggers this reaction by attacking the pulmonary vascular endothelium, which causes inflammation that releases tissue factor into systemic circulation, activates factor VII, and initiates systemic inflammation. The lung is heavily innervated, and pulmonary inflammation induces harmful nociception that exaggerates sympathetic nervous activity and releases von Willebrand Factor into systemic circulation, which activates factor VIII and increases blood coagulability.
The key to treating COVID and other forms of critical illnesses is to control stress mechanism hyperactivity, decrease inflammation, and restore tissue perfusion, tissue oxygenation, and organ function, and thereby prevent viral propagation and further damage. I would recommend the following measures:
1. fluid restriction
2. elective endotracheal intubation to confine the virus, protect health care workers, and facilitate control and measurement of inhaled gas mixtures
3. deliberate hypoventilation to maintain hypercarbia in the range of end-tidal CO2 50-100 torr to optimize cardiorespiratory function, tissue oxygenation, and organ safety
4. fentanyl with stress control dosage beginning with 10 micrograms/kg and supplementation to prevent harmful nociception
5. Magnesium sulphate using established dosage protocols for eclampsia
6. Antibiotics as necessary to control secondary bacterial infestation
7. Sedation to prevent harmful fear and anxiety that exaggerates harmful sympathetic nervous activity. The best means of sedation is 1/2 MAC isoflurane to minimize toxicity.
I have recently published a book called “50 Years Lost in Medical Advance” that is available via Amazon. It describes the discovery of the mammalian stress mechanism and details its revolutionary implications for medicine and biology.
As most COVID-19 patients may experience often AKI or are in a state of acidosis maybe, balanced crystalloids be the best option, considering the harm that 0,9% NS may pose in kidney function, with a frequent dynamic and static evaluation of volume status. Neither NS nor other balanced crystalloids are proved to be superior over another. In my practice i use balanced crystalloids with often evaluation of fluid status mostly using CRT, MAP, ECHO, leg raise , or more advanced parameters in the case of ICU admitted COVID patients.