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Emergency Preparedness Considerations: COVID-19 Fluid Resuscitation Guidelines

By Mark Piehl MD MPH | Apr 15, 2020 |

 

WHO recommendations for suspected COVID-19 patients with septic shock:
  • Adults: 250–500 mL crystalloid fluid and reassess after each bolus
  • Children: 10–20 mL/kg crystalloid fluid and reassess after each bolus

Recent reports on hospitalized COVID-19 patients have indicated that many develop shock.1-4  In the first U.S. case series of COVID patients, recently published in New England Journal of Medicine, a majority of patients presented with shock and hypotension requiring vasopressors.4  Given the severity of lung disease in these patients, a careful approach to fluid resuscitation is required. Newly updated Surviving Sepsis Campaign guidelines, along with those from the NIH, World Health Organization and reporting COVID-19 centers, recommend a controlled fluid strategy using crystalloid fluid boluses of 250-500mL, preferably Lactated Ringer’s. Frequent bedside monitoring of patient response after each bolus is advised, along with early use of vasopressors targeted at a MAP > 65 and a conservative post-resuscitation fluid strategy. 3,6-9

LifeFlow is a single-use, hand-powered, and portable fluid infuser that can be an ideal tool in managing critically ill patients in multiple settings. LifeFlow allows the user to carefully titrate the volume of fluid administered, enabling providers to rapidly resuscitate with continuous assessment while reducing the risk of fluid overload for patients with severe respiratory illness. LifeFlow offers quick setup and the ability to deliver a 250ml bolus in <1 minute, leading to rapid reversal of shock and hypotension, and providing immediate feedback on fluid responsiveness with less total volume infused, allowing earlier identification of patients who need vasopressors.

Early and targeted fluid resuscitation for septic shock can reduce the risk of endotracheal intubation, shorten duration of mechanical ventilation, decrease organ injury and hospital length of stay, and save lives.10-12 In fact, patients with septic shock who receive their fluid bolus early in their course of treatment have shown the lowest likelihood of requiring endotracheal intubation, even among patients with pneumonia, heart failure, and end stage renal disease.13  This could be particularly important during the COVID-19 pandemic, where up to half of hospitalized patients develop respiratory failure.1 In hospitals experiencing a sudden influx of critically ill patients, immediate response to those with hypovolemic shock or suspected sepsis may be a key factor in stabilizing these patients and reducing subsequent complications, including death.

As hospitals prepare for the COVID-19 pandemic, LifeFlow can be a tool for managing and treating large numbers of patients in contact and droplet isolation rooms and emergency triage facilities needing rapid and measured fluid delivery for septic shock.

Interested in learning more about LifeFlow? Contact us.


References

  1.  Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 9 March 2020. doi: 10.1016/S0140-6736(20)30566-3.
  2. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. February 2020. doi: 10.1001/jama.2020.1585.
  3. Alhazzani W, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020. https://www.sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf?lang=en-US.
  4. Bhatraju PK, et al. Covid-19 in Critically Ill Patients in the Seattle Region — Case Series. NEJM. 30 Mar 2020. DOI: 10.1056/NEJMoa2004500.
  5. Arentz M, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. Research Letter. Published online March 19, 2020. doi:10.1001/jama.2020.4326.
  6. Treatment Guide for Critically Ill Patients with COVID-19. Massachusetts General Hospital. 5 April 2020.
  7. Bohula E, et al. Shock: Septic, Cardiogenic, and Cytokine. Brigham and Women’s Hospital COVID-19 Guidelines. 30 March 2020. https://covidprotocols.org/protocols/07-shock-septic-cardiogenic-and-cytokine.
  8. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim Guidance. World Health Organization. 13 March 2020. Pg. 9. WHO/2019-nCoV/clinical/2020.4. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-issuspected.
  9. COVID -19 Treatment Guidelines. NIH. Site update 21 April 2020. https://www.covid19treatmentguidelines.nih.gov/critical-care/hemodynamics/.
  10. Lee SJ, et al. (2014). Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest. 2014 Oct;146(4): 908-915. DOI: 10.1378/chest.13-2702. https://www.ncbi.nlm.nih.gov/pubmed/24853382.
  11. Leisman D, et al. Association of Fluid Resuscitation Initiation Within 30 Minutes of Severe Sepsis and Septic Shock Recognition With Reduced Mortality and Length of Stay. Ann Emerg Med. 2016 Sep;68(3):298-311. DOI: 10.1016/j.annemergmed.2016.02.044. https://www.ncbi.nlm.nih.gov/pubmed/27085369.
  12. Williams JM, et al. “Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study.” Eur J Emerg Med. 2018 Apr; 25(2): 97-104. DOI: 10.1097/MEJ.0000000000000419. https://www.ncbi.nlm.nih.gov/pubmed/27547885.
  13. Kuttab HI, Lykins JD, Hughes MD, et al. Evaluation and predictors of fluid resuscitation in patients with severe sepsis and septic shock. Crit Care Med. 2019;47(11):1582-1590. doi:10.1097/CCM.0000000000003960.

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