Poor outcomes have been reported on Non-protocolized fluid administration in critically ill patients. It is even true for those with acute respiratory distress syndrome (ARDS), thus fluid administration in Coronavirus disease (COVID-19) patient’s demands proper guidance. 

A challenge in establishing a Choice of an index to guide fluid management lies during a pandemic as mass patient admissions are seen besides relatively limited resources. 

An ideal test for assessment of fluid responsiveness during the COVID-19 pandemic should fulfill the following criteria-

It should be accurate in ARDS patients, 

Should be economic, 

Should be easy to interpret by junior staff, 

Should be valid in patients in the prone position and 

Can be performed with minimal contact with the patient to avoid the spread of infection. 

COVID-19 ARDS patients are categorized into two phenotypes according to their lung compliance-

L phenotype 

H phenotype 

This patient phenotype directs for the Selection of the proper index for fluid responsiveness. Like Heart-lung interaction methods can be utilized only in patients with L phenotype ARDS. 

Real-time measures like pulse pressure variation observe greater utility during this pandemic than the ultrasound-derived measures, as the contamination of the ultrasound machine can spread infection.

Preload challenge tests can be utilized in every COVID-19 patient. The passive leg raising test remains superior to the mini-fluid challenge test since it can be repeated without overloading the patient with fluids. Moreover, the Trendelenburg maneuvers serves as a good alternative to the passive leg raising test in patients with prone positions. 

In the absence of cardiac output monitor, the response to the passive leg raising test could be traced by measuring the pulse pressure or the perfusion index. 

Further, Preload modifying maneuvers like tidal volume challenge have also shown great usage in COVID-19 patients, particularly when the patient remains in the grey zone of other dynamic tests. However, the preload modifying manoeuvres have not seen extensive evaluation outside the operating room. 

Thus the selection of the proper test greatly depends on the level of healthcare of the country and the number of admissions. A comprehensive evaluation of the volume status should be carried out including the presence of signs of volume overload like lower limb edema, lung edema, and severe hypoxemia, along with the usual indices for fluid responsiveness.

Source: Hasanin A, Mostafa M. Evaluation of fluid responsiveness during COVID-19 pandemic: what are the remaining choices?. J Anesth. 2020;34(5):758-764. doi:10.1007/s00540-020-02801-y