key: cord-351597-bdazrbsz
authors: Thalappillil, Richard; White, Robert S.; Tam, Christopher W.
title: POCUS to guide fluid-therapy in COVID-19
date: 2020-05-06
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.04.049
sha: 
doc_id: 351597
cord_uid: bdazrbsz

nan

We propose that a focused lung and heart ultrasound may help follow progression of pneumonia, pulmonary edema, and characterize volume status.

As anesthesiologists are being tasked to provide critical care, it is necessary to take the lessons of judicious fluid use from our operating rooms to the ICUs. Indeed, daily weights and fluid balance help guide diuretic and fluid therapy. However, the inflammatory state in COVID-19 patients may contribute to vascular permeability and intravascular depletion despite increased total body water. Periodic vasoplegia, high positive end-expiratory pressure, and cardiac dysfunction also confuse typical hemodynamic estimations of total body water such as blood pressure and central venous pressure. 4 Utilizing an apical four-chamber view and a parasternal short-axis view, a quick estimation of left and right ventricular function and fluid status can be obtained (Figure 1 ). These findings could then be interpreted in the context of hemodynamics and fluid balance to guide treatment.

Lung ultrasound can help characterize normal and abnormal lung regions. In addition to ventilatory settings, partial pressure of oxygen, and pulse oximetry, a scoring of diseased to normal lung regions may add to patient assessment. Placing patients with severe ARDS in the prone position is employed as high settings or limits of mechanical ventilation are reached. 5 Posterior lung ultrasound, if identifying significant areas of normal lung parenchyma, may identify patients in whom early proning may reduce precipitous increases in ventilator settings, 3 escalation of vasopressors, and need for neuromuscular paralysis. We depict a COVID-19 patient pre-and post-proning demonstrating improved lung aeration and reduced consolidation (Figure 2 ).

In a time where there is an increase in telemedicine, limited physical exams, and limited provider-patient direct contact, it is difficult to recommend the use of personnel and personal protective equipment to perform specialized and technical tasks. However, the potential benefit of possible reduced end-stage lung failure, reduced ventilator days, and reduced critical care resource utilization needs to be carefully weighed. As non-critical care trained physicians are called to provide critical care, the utility of a curriculum of very focused POCUS may also assist in patient management. 

Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome

National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network

Utility of Point-of-Care Lung Ultrasound for Initial Assessment of Acute Respiratory Distress Syndrome Patients in the Emergency Department

Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis

Prone Positioning in Severe Acute Respiratory Distress Syndrome

Lung ultrasound after placing patient in prone position demonstrates significant "B lines" (arrows) consistent with acute respiratory distress syndrome, however with improved aeration. Clinically, the patient's oxygenation improved as well after proning

C) Linear probe demonstrates a thickened pleural line (arrows)