Hemodynamic Monitoring in Critical COVID-19 Patients: One Constant in a Changing Picture

- 9 April, 2020

In times to come, COVID-19 may well have proven to be an invaluable, however unwelcome, source of therapeutic certainty. Today’s scenario is one of unprecedented demand and often trial-and-error pioneering. At the front line of critical care the world’s finest practitioners are striving to do their best for every single patient. They are learning as they do so. Yet still they find themselves scratching their heads when similar patients presenting in similar condition can have dramatically different outcomes. In the jigsaw of therapeutic options we’re still clearly missing a few pieces.

What follows here is a short editorial, because it has to be. There’s barely time for ultra-nuanced care, let alone lengthy discussion or a heavy read. Find evidence in the unedited publication of COVID-19 “Surviving Sepsis” treatment guidelines as an accepted proof in Intensive Care Medicine. This is the journal of the European Society of Intensive Care Medicine and the Society of Critical Care Medicine. The peer-reviewed document aims to “provide recommendations to support hospital clinicians managing critically ill adults with COVID-19 in ICU.”

Importantly it represents a combination of direct and indirect evidence from all available sources, graded according to quality and estimated effect.

Of the 50 key questions addressed by the panel of 36 experts from 12 countries, 14 pertained directly to hemodynamics. Why? Because it’s an important subject, particularly in ventilated COVID-19 patients. The clinical challenge is, in effect to keep the lungs dry, while protecting the kidneys. This tightrope is an extremely difficult one to walk, especially in very unstable patients. It demands a precision approach to fluid management. And while the finer points of finding the right balance might seem incompatible with the frantic plate-spinning ICU “war zone”, a simple solution is at hand. In daily use across many top facilities, Deltex’s TrueVue with esophageal Doppler monitoring (EDM+) offers a quick procedure that sees a probe inserted in the esophagus. The probe yields directly-acquired, real-time cardiac output (ie circulating blood volume) data from the patient’s aorta. It also provides valuable information on heart function.

Pneumonia or Renal Failure? Can we minimize both?

The traditional approach in these very sick patients may be instinctively to give fluids. But here’s what looks like a “Catch 22” situation: The current perceived wisdom is to fluid-restrict patients to prevent pneumonia. This is causing a significant number (reportedly up to 30%) to develop renal problems. Patients are not getting the correct fluid treatment as doctors are understandably reluctant to give volume to patients with lung problems, ignoring the fact that this is leading to kidney problems.

It seems therefore (as supported by the Intensive Care Medicine guidance), the answer to avoiding or at least minimizing the addition of acute kidney injury and renal failure to the list of poor COVID-19 outcomes lies in expertly controlling their fluids.

Hemodynamic Stability Key

With the clinically proven EDM+, clinicians can aspire to achieving hemodynamic stability while minimizing fluid interventions. All from a system that combines accuracy with user-friendliness. EDM+ is relatively non-invasive in “asleep” patients and the TrueVue device helpfully features non-invasive modes for awake patients.
Furthermore it:

doesn’t require invasive “lines”
isn’t affected by patient position
isn’t affected by arrhythmias
is used within lung protective protocols
is uniquely supported by clinical evidence
is reliable across all patient groups
isn’t affected by big changes in vascular tone, for example when patients are vasodilated for pathophysiological or clinically-induced reasons (sepsis, vasoactive agents etc)
was originally designed for the critical care setting and does not interfere with ventilation

Deltex CEO Andy Mears states; “Our unique technology and hemodynamic management experience are extremely well-suited to helping clinicians treat these very complicated COVID-19 patients in critical care.”