336: HOW DRY IS TOO DRY TO BREATHE? FLUID RESUSCITATION AND OUTCOMES IN COVID-19 ARDS

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INTRODUCTION: There are differing opinions regarding fluid balance strategies in COVID-ARDS. Excess intravascular volume in the context of an inflammatory process increases lung hydrostatic pressure with subsequent parenchymal edema, alveolar flooding, and worsening gas exchange. Restrictive fluid strategies have been associated with better outcomes in ARDS. COVID-19 represents an extreme inflammatory state, presenting with severe respiratory failure with a high mortality during its first wave in NYC. We review the effects of volume on outcomes. METHODS: Retrospective review of adults admitted for severe COVID-19 infection during the height of the pandemic (March 9-31, 2020) to 2 city hospitals in Queens, NY. Patients surviving at least 5 days were included. Demographic characteristics, fluid administration and development of Acute Kidney Injury (AKI) and respiratory failure requiring Invasive Mechanical Ventilation (MV) were evaluated with respect to mortality. RESULTS: 311 patients were analyzed. Mean age was 50 years and 67% were males. 43% were febrile and symptomatic an average of 6 ± 4 days. Average urine specific gravity was an elevated 1.023 ± 0.01. Overall mortality was 37%. AKI occurred in 39% of patients, was associated with higher mortality (p< 0.01) and older age (p< 0.01). 37% required MV and was associated with higher mortality (p< 0.01). Regression analysis showed age, AKI, and MV were significantly associated with mortality. Use of MV was the strongest predictor of mortality (OR 30.1) compared with AKI (OR 1.9) or age (OR 1.07). Among ventilated patients, higher net fluid input in the first 5 days tended towards improved survival (p=0.07), with mean total fluid received at 5 days: 5.75L in survivors vs 4.19L in deceased. This difference was evident at days 4 (p=0.07) and 5 (p=0.02). There was no significant difference in fluid administration and the risk of developing AKI (p=0.89). CONCLUSIONS: Respiratory failure requiring MV is by far the strongest predictor of mortality in COVID-19 ARDS. Symptomatic days and urinalysis suggest patients were volume depleted. While judicious fluid management is the practice paradigm in ARDS management, the consequences of MV, high PEEP, and low intravascular volume must be considered in COVID-ARDS and individually treated.

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