Abstract
In COVID-19, pulmonary edema has been attributed to “cytokine storm”. However, it is known that SARS-CoV2 promotes angiotensin-converting enzyme 2 deficit, increases angiotensin II, and this triggers volume overload. Our report is based on COVID-19 patients with tomographic evidence of pulmonary edema and volume overload to whom established a standard treatment with diuretic (furosemide) guided by objectives: Negative Fluid Balance (NEGBAL approach). Retrospective observational study. We reviewed data from medical records: demographic, clinical, laboratory, blood gas, and chest tomography (CT) before and while undergoing NEGBAL, from 20 critically ill patients. Once the NEGBAL strategy was started, no patient required mechanical ventilation. All cases reverted to respiratory failure with NEGBAL, but subsequently two patients died from sepsis and acute myocardial infarction (AMI). The regressive analysis between PaO2/FiO2BAL and NEGBAL demonstrated correlation (p < 0.032). The results comparing the Pao2Fio2 between admission to NEGBAL to NEGBAL day 4, were statistically significant (p < 0.001). We noted between admission to NEGBAL and day 4 improvement in CT score (p < 0.001), decrease in the superior vena cava diameter (p < 0.001) and the decrease of cardiac axis (p < 0.001). Though our study has several limitations, we believe the promising results encourage further investigation of this different pathophysiological approach.
Highlights
IntroductionIn December 2019, a new coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China [1] and spread throughout the world [2,3]
In December 2019, a new coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China [1] and spread throughout the world [2,3].In COVID-19, pulmonary edema is described [4,5,6,7]; the dominant paradigm is focused on cytokine storm [8,9,10,11,12] as responsible for lung injury and subsequent acute respiratory distress syndrome (ARDS) [5,13]
We reviewed tomographies performed before admission to our center, at the emergency room or as an inpatient, if any, during the first days of the course of COVID-19 and distanced at least two days before admission to Negative Fluid Balance (NEGBAL) (CT score prior to NEGBAL) with the purpose of observing the natural evolutionary trend of COVID-19 before NEGBAL
Summary
In December 2019, a new coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China [1] and spread throughout the world [2,3]. In COVID-19, pulmonary edema is described [4,5,6,7]; the dominant paradigm is focused on cytokine storm [8,9,10,11,12] as responsible for lung injury and subsequent acute respiratory distress syndrome (ARDS) [5,13]. Sinha et al [14] challenged the role of this cytokine storm given that median IL-6 levels in non-COVID patients ARDS are up to 200 times higher than in patients with severe.
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