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Saturday, April 4, 2020

Allowing Kidney Injury in the Setting of Ventilator Need

Patients who have coronavirus are at risk for fluid overload. Please be cautious using too much during the Covid-19 crisis.
Please note: these suggestions are just that, suggestions, which are  based on the current situation.  It is important to tailor your situation accordingly and collaborate via a team-based approach.

I had a great discussion with my critical care colleagues the other day.  We were discussing the paradigm shifting approach to treating Covid-19 which is very different from the current sepsis guidelines. The goal is to avoid the need to intubate a patient.

When a person is infected with the novel coronavirus, the patient appears to be at high risk for fluid overload and the need for intubation -- which by definition requires a ventilator. As we all know, there is a ventilator shortage. We need to do everything possible to avoid using ventilators while saving lives. Can kidney doctors (nephrologists) work with their critical care colleagues and emergency room physicians to facilitate? Yes, we can!

Caring for these patients, we physicians are normally asked to provide the patient with intravenous fluid -- lots of it. In fact, hospitals can get "into trouble" if they don't give patients who present with severe infection several liters of fluid. Note: there are 33 ounces in 1 liter.

It is turning out that if we avoid this approach (use less fluid) we can avoid ventilator use and keep more people alive, especially when there is a ventilator need. There is a shortage of ventilators.

Consider that as of April 1st, it is projected that Nebraska is going to have a ventilator deficit of 169.

Learn more: Covid-19 projections. Click to find the projected ventilator need in your state.

Invasive ventilators needed in the state of Nebraska: 169 ventilators (projected).
A fascinating abstract in emergency medicine news has suggested that we keep patients relatively volume down (dehydrated) despite a faster heart rate and worsening kidney function (acute kidney injury).

Learn more about the recommendation to allow kidney injury, keeping patients dry to avoid the need to use ventilators and keep patients alive.

The recommendations are constantly changing. The above link provides updated information.

So, how to maintain blood pressure in the patients we serve if we aren't going to give them lots of intravenous fluid?

Again, try to avoid fluid overloading these patients.

Consider the early use of low dose pressors to support the blood pressure.  If the patient appears to be severely dehydrated, consider a small bolus of intravenous fluid. 500 ml of normal saline has been suggested. In contrast, it is usually suggested to give patients with suspected shock caused by a severe sepsis viral infection up to 2000 milliliters of fluid over thirty to sixty minutes, with additional fluid challenges given as required.

500 ml of normal saline as an initial bolus is suggested if the patient appears to be dehydrated and in kidney failure.

Also, avoid maintenance intravenous fluids, especially if the patient's oxygen status is low. Moreover, if the patient is low on oxygen and has normal blood pressure, it has been suggested that a dose of furosemide (also called Lasix) be given. Some have suggested that this will delay the need to use a ventilator for days. This may be a way to mitigate the above ventilators required curve.

So in the short term, while we weather the Covid-19 storm, we need to allow some kidney failure. We need to be patient and treat accordingly as we wait for the coronavirus vaccine.

I know this is paradigm shifting, but I do think this approach will save lives.

I am not a dog on a chain, I use my own brain -- Morrissey on YouTube
That said,  I would suggest following the surviving sepsis campaign as much as possible.

Read more:  Dr. Aaronson Back on the Chain Gang. Stay Healthy and Exercise at Home as We Wait for the Covid-19 Vaccine.

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis