MANAGEMENT & PRACTICE INTENSIVE CARE - EMERGENCY MEDICINE - ANAESTHESIOLOGY Challenges and Management in Italy and Lessons Learned, M. Cecconi The Calm Before the Storm, K. Naidoo, D. Kloeck, L. Mathivha From Hydroxychloroquine and Remdesivir to Plasma Administration, JL Vincent Masks in Intensive Care Units, A. Cornejo, A. Cunha Adaptive Strategies for Intensive Care: The Brussels Experience, E. De Waele et al. What COVID-19 Has Taught Me, A. Wong History of Pandemics, J. Poole Tracheal Intubation in the ICU, A. Higgs, M. Udberg, G. Hopkin Intensive Care in the Coronavirus Era: Collective Intelligence, H. Ksouri, S. Doll, G. Carrel, L. Hergafi, G. Sridharan An Adaptive Response, J. Nosta Thoughts on COVID-19, M. Malbrain, S. Ho, A. Wong Ultrasound in Times of COVID-19, A. Wong, O. Olusanya, J. Wilkinson, C. McDermott Overview of Nurse Assessment, C. Nicole Personal Experience: 66 days in Wuhan, C. Wang Immersive Virtual Reality in the Intensive Care Unit, C. Lynch, G. Jones Nutrition for Critically Ill Patients with COVID-19, L. Chapple, K. Fetterplace, E. Ridley icu-management.org

80 COVER STORY: COVID-19 CHALLENGES Manu L.N.G. Malbrain Intensive Care Unit University Hospital Brussel (UZB) Jette, Belgium Faculty of Medicine and Pharmacy Vrije Universiteit Brussel (VUB) Brussels, Belgium [email protected] @manu_malbrain Serene Ho Cavendish Clinic London, UK Thoughts on COVID-19 from the International Fluid Academy An overview of what has been published on fluid strategies in COVID-19, guidelines available and reflections on personal practice. Adrian Wong Consultant Intensive Care Medicine and Anaesthesia King’s College Hospital London, UK [email protected] by frontline...

81 COVER STORY: COVID-19 CHALLENGES these guidelines with emphasis on fluid management is summarised below. Surviving Sepsis Campaign The Surviving Sepsis Campaign group has suggested the following in their COVID-19 specific guidelines for acute resuscitation of adults with shock: • Measuring dynamic parameters to assess fluid responsiveness (weak recommendation; low quality of evidence [QE]), • Using a conservative fluid administration strategy (weak recommendation; very low QE), • Using crystalloids in preference to colloids (strong recommendation; moderate QE), • Balanced crystalloids preferred...

82 COVER STORY: COVID-19 CHALLENGES Identifiable structures Measurable parameters Tracheal rings Cricothyroid membrane Thyroid cartilage Hyoid bone Distance to structures Diameter of trachea Presence of oedema or external compression Plan for difficult intubation and extubation A-lines B-lines Consolidation Collapse Effusion Diaphragm Number of B-lines Volume of effusion, depth to effusion Extent of pneumothorax (lung sliding, lung-point) Diaphragmatic function Assess degree of lung involvement Diagnose any concurrent conditions Right atrium and ventricle Left atrium and ventricle AV valves Pulmonary...

83 COVER STORY: COVID-19 CHALLENGES When to start IV fluids? When to stop IV fluids? When to start removing fluids? When to stop removing fluids? Resuscitation Maintenance Replacement Nutrition Drug Dose Duration De-escalation Resuscitation Optimisation Stabilisation Evacuation (de-escalation) 1st HIT: initial insult (e.g. COVID with sepsis) 2nd HIT: ischaemia and reperfusion 3rd HIT: fluid accumulation and GIPS (global increased permeability syndrome) 4th HIT: hypoperfusion during de-resuscitation Table 2. Rules of Fours patients too dry’ in an effort to spare the lungs, as there are increased...

84 COVER STORY: COVID-19 CHALLENGES basic maintenance need of 1ml/kg/ hr e.g. nutrition and fluid creep (see below). Fluid creep • All sources of fluids administered need to be detailed: crystalloids, colloids, blood products, enteral and parenteral nutritional products, intravenous medication and oral intake (water, tea, soup, etc.) • Precise data on the concentrated electrolytes added to these fluids or administered separately need to be documented. • Fluid creep is defined as the sum of the volumes of these electrolytes, the small volumes to keep venous lines open (saline or glucose 5%) and...

85 COVER STORY: COVID-19 CHALLENGES technology and the ability to swiftly disseminate information on our side. Whether we handle it ‘the old way’ or embrace all the tools and collaborative opportunities available to us may well decide how this pandemic goes down in history. We firmly believe in the latter approach. Key Points • The general principles of fluid management in critical care provides the foundation for fluid therapy in COVID-19. • During the early stages of the COVID-19 pandemic, it was common advice to aim for a negative fluid balance but more recently there have been calls for a...