Lung Injury in COVID-19 Has Pulmonary Edema as an Important Component and Treatment with Furosemide and Negative Fluid Balance (NEGBAL) Decreases Mortality.

The SARS-CoV2 promotes dysregulation of Renin-Angiotensin-Aldosterone. The result is excessive retention of water, producing a state of noxious hypervolemia. Consequently, in COVID-19 injury lung is pulmonary edema. Our report is a case-control study, retrospective. We included 116 patients with moderate-severe COVID-19 lung injury. A total of 58 patients received standard care (Control group). A total of 58 patients received a standard treatment with a more negative fluid balance (NEGBAL group), consisting of hydric restriction and diuretics. Analyzing the mortality of the population studied, it was observed that the NEGBAL group had lower mortality than the Control group, p = 0.001. Compared with Controls, the NEGBAL group had significantly fewer days of hospital stay (p < 0.001), fewer days of ICU stay (p < 0.001), and fewer days of IMV (p < 0.001). The regressive analysis between PaO2/FiO2BAL and NEGBAL demonstrated correlation (p = 0.04). Compared with Controls, the NEGBAL group showed significant progressive improvement in PaO2/FiO2 (p < 0.001), CT score (p < 0.001). The multivariate model, the vaccination variables, and linear trends resulted in p = 0.671 and quadratic trends p = 0.723, whilst the accumulated fluid balance is p < 0.001. Although the study has limitations, the promising results encourage more research on this different therapeutic approach, since in our research it decreases mortality.

Pulmonary Edema in COVID-19 Treated with Furosemide and Negative Fluid Balance (NEGBAL): A Different and Promising Approach.

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.

Síndrome del ligamento arcuato medio / Median arcuate ligament syndrome

Se presenta el caso de una paciente mujer de 63 años de edad, que por epigastralgia severa acompañada de náuseas y sudoración, cursa internaciones en noviembre de 2017 y en febrero de 2018. Como antecedentes de enfermedad cercana, en 2015 presentó un infarto agudo de miocardio (IAM) inferolaterodorsal por disección de la arteria circunfleja. Los estudios post IAM mostraron buena performance miocárdica. En ambas internaciones, la paciente fue evaluada en Unidad Coronaria (UCO) y en Clínica Médica detectándose leve aumento de transaminasas con fosfatasa alcalina (FAL), electrocardiograma (ECG) y Troponina T dentro de parámetros normales. En la primera internación, la ecografía abdominal y la ecoendoscopia biliar descartaron síndrome de la vía biliar y afección pancreática; las transaminasas hepáticas se normalizaron espontáneamente. Durante la segunda internación, y ante reiteración de la sintomatología, se sospechó afección vascular abdominal alta debido al antecedente de disección coronaria; por lo que se le solicitó Angiotomografía de tórax y de abdomen que confirmaron el diagnóstico de Síndrome del Ligamento Arcuato Medio diafragmático. Conclusiones: Los nuevos métodos complementarios de diagnóstico por imágenes permitieron realizar el diagnóstico de esta entidad poco sospechada. (AU)

The case of a 63-year-old female patient is presented, who -due to severe epigastric pain accompanied by nausea and sweating- was admitted to hospital in November 2017 and February 2018. In her medical history of recent disease, she had presented an acute myocardial infarction (AMI) inferolaterodorsal by circumflex artery dissection in 2015. Post-AMI studies showed good myocardial performance. In both hospitalizations, the patient was evaluated in the Coronary Unit (CU) and in the Medical Clinic, showing a slight increase in transaminases with alkaline phosphatase (AF); electrocardiogram (ECG) and Troponin T were within normal parameters. In her first hospitalization, abdominal ultrasound and echoendoscopy of the biliary system ruled out bile duct syndrome and pancreatic disease; liver transaminases normalized spontaneously. During the second hospitalization, and due to repeated symptoms, an upper abdominal vascular condition was suspected due to her history of coronary dissection. Therefore, chest and abdomen CT angiography were indicated which confirmed the diagnosis of diaphragmatic median arcuate ligament syndrome. Conclusions: The new complementary methods of diagnostic imaging allowed the diagnosis of this scarcely suspected syndrome. (AU)