Can I administer Intravenous Fluids (IVF) to a patient with COVID-19 and Acute Kidney Injury (AKI)?

Management of Intravenous Fluids in COVID-19 Patients with Acute Kidney Injury

Yes, intravenous fluids (IVF) should be administered to COVID-19 patients with AKI who are hypovolemic, as maintaining optimal fluid status (euvolemia) is critical in reducing the incidence and progression of AKI. 1

Assessment Before IVF Administration

Before administering IVF to a COVID-19 patient with AKI, perform a thorough evaluation of:

1. Fluid status assessment:

   • Clinical examination for signs of hypovolemia: peripheral perfusion, capillary refill, pulse rate, blood pressure, postural hypotension, jugular venous pressure 1
   • Fluid balance monitoring: intake, output, and weight 1

2. Laboratory evaluation:

   • Serum urea, creatinine, and electrolytes (sodium, potassium, bicarbonate)
   • Full blood count
   • Urinalysis for hematuria and proteinuria (which may indicate COVID-19-induced kidney damage) 1

IVF Administration Guidelines

When to Administer IVF:

• When clinical assessment indicates hypovolemia
• When dehydration is present (common on admission and may develop later) 1
• When fever and increased respiratory rate have increased insensible fluid losses 1

Choice of IVF:

• For resuscitation: balanced crystalloids like Hartmann's or Lactated Ringer's solution are preferred over 0.9% sodium chloride 1
• For maintenance: solutions with appropriate electrolyte composition based on patient needs 1

Cautions and Monitoring:

• Monitor fluid balance daily with clinical examination 1
• Measure serum urea, creatinine, and electrolytes at least every 48 hours or more frequently if clinically indicated 1
• Be vigilant for electrolyte disturbances, particularly hyponatremia, hypernatremia, hypokalemia, and hypocalcemia, which are common in COVID-19 patients 2

Special Considerations in COVID-19

• COVID-19 patients with AKI have significantly higher mortality rates (52.4% vs 26.3% in those without AKI) 3
• Maintaining euvolemia is particularly challenging in COVID-19 patients but is critical for kidney protection 1
• Be aware that COVID-19 treatments may increase AKI risk (e.g., diuretics causing volume depletion) 1
• COVID-19 increases risk of coagulopathy, which may complicate management 1

When to Seek Specialist Advice

Refer for specialist nephrology advice if:

• Fluid management needs are complex
• AKI is worsening despite initial management
• AKI has not resolved after 48 hours
• There is diagnostic uncertainty about the cause of AKI
• Abnormal urinalysis results are present
• The patient has indications for renal replacement therapy 1

Monitoring Response to IVF

• Use early warning scores (e.g., NEWS2) for patients whose clinical condition is deteriorating 1
• Reassess fluid status regularly after IVF administration
• Adjust fluid management based on clinical response and laboratory parameters

Remember that while addressing hypovolemia with IVF is important, the ultimate goal is to achieve and maintain euvolemia, as both hypovolemia and hypervolemia can worsen outcomes in COVID-19 patients with AKI.