COVID-19 And Erythrocyte Aggregates: An Intensivists Experience When Being Affected

COVID-19 pandemic has killed over 310,000 individuals as of 17 May 2020. Healthcare providers are profoundly vulnerable to be contaminated instead of taking every single careful step. Although the respiratory tract and the lungs are the target organs some complications may develop even at the introductory phase of this sickness course. Hemoconcentration with raised serum ferritin levels is one of the dangerous conditions that may occur from chronic hypoxia and severe dehydration because of increased insensible loss due to continuous excessive perspirations. Recent posthumous pulmonary tissue studies revealed that the viral infective mechanism, as well as the miniaturized erythrocyte aggregates, are additionally a significant contributing phenomenon to create acute respiratory distress syndrome (ARDS). Hematological issues require to deal proactively alongside other vital organ protection protocols for better outcomes. This article will depict the disease sequence of an intensivist working in a corona unit after being infected by COVID-19.

COVID-19 And Erythrocyte Aggregates: An Intensivists Experience When Being Affected

COVID-19 pandemic has killed over 310,000 individuals as of 17 May 2020. Healthcare providers are profoundly vulnerable to be contaminated instead of taking every single careful step. Although the respiratory tract and the lungs are the target organs some complications may develop even at the introductory phase of this sickness course. Hemoconcentration with raised serum ferritin levels is one of the dangerous conditions that may occur from chronic hypoxia and severe dehydration because of increased insensible loss due to continuous excessive perspirations. Recent posthumous pulmonary tissue studies revealed that the viral infective mechanism, as well as the miniaturized erythrocyte aggregates, are additionally a significant contributing phenomenon to create acute respiratory distress syndrome (ARDS). Hematological issues require to deal proactively alongside other vital organ protection protocols for better outcomes. This article will depict the disease sequence of an intensivist working in a corona unit after being infected by COVID-19.

The Maintenance Need for Water in Parenteral Fluid Therapy, by Malcolm A. Holliday, MD, and William E. Segar, MD,Pediatrics, 1957;19:823–832

One of the major objectives of parenteral fluid therapy is provision of water to meet physiologic losses. These losses, the insensible and urinary losses, have been extensively studied and defined for infants and adults. It is established from these studies that both insensible loss of water and urinary water loss roughly parallel energy metabolism and do not parallel body mass (weight). Therefore, any values that are applicable to all ages must be derived from some function of energy metabolism. Initially, and to a large extent even today, needs for water have been determined on the basis of weight in infants and on the basis of total amounts in adults. Although this serves well for infants and adults, the hapless individual between these two groups receives, at best, a rough estimate of his requirement for water. Crawford and his associates have referred needs for water, and a variety of drug dosages as well, to a unit of surface area (SA) because SA closely parallels basal energy metabolism. In this system SA is computed from a height-weight nomogram. It is generally agreed that the maintenance requirements for water of individuals is determined by their caloric expenditure. By means of the following formulae, the caloric expenditure of hospitalized patients can be determined from weight alone. For weights ranging from 0 to 10 kg, the caloric expenditure is 100 cal/kg/day; for weights ranging from 10 to 20 kg the caloric expenditure is 1000 cal plus 50 cal/kg for each kilogram of body weight >10; for weight >20 kg the caloric expenditure is 1500 cal plus 20 cal/kg for each kilogram >20. Maintenance requirements for water depend on insensible loss of water and renal loss. An allowance of 50 mL/100 cal/day will replace insensible loss of water, and 66.7 mL/100 cal/day will replace renal losses. As water of oxidation will supply approximately 16.7 mL/100 cal/day, the remaining 100 mL/100 cal/day must be supplied to meet the remaining water losses of patients on parenteral fluid therapy. Possible exceptions to this figure are discussed. Maintenance requirements of sodium, chloride, and potassium are 3.0, 2.0, and 2.0 mEq/100/cal/day, respectively.

Computational Model for Insensible Water Loss From the Newborn

A mathematical model for predicting insensible water loss from the newborn infant has been developed, and its adjustable parameters have been evaluated using existing data for respiratory and transepidermal water loss components. Subsequently, the model was verified by using an independent set of available data on total insensible loss from naked infants who were not mechanically ventilated and who did not sweat. Under these conditions, the model was capable of correctly predicting the influence of ambient humidity, gestational age, and postnatal age, and in general, the predictions had a precision of ± 14%, but they tended to underestimate insensible water loss by –16%. The straightforward algebraic form of the model makes it suitable for computerized calculations, which can be readily available at the bedside and quickly updated to account for changes in infant or environmental variables. The model is useful both for anticipating the abnormally large insensible water loss of the premature infant early in life and for computing expected changes in insensible water loss as a result of intentional manipulation of environmental factors, such as incubator temperature or supplemental humidification.

CONSERVATIVE MANAGEMENT OF ACUTE RENAL FAILURE

The observations during treatment of three children with acute renal failure by a conservative regimen of therapy are presented. One patient died. The regimen has also been applied to six adults with renal failure; one died. The urine in the early stages of renal failure may be iso-osmotic with plasma and may represent unmodified fluid from the proximal tubules. Cardiac failure associated with hyperkalemia or administration of excessive quantities of fluids is the most frequent cause of death in this disorder. A regimen of therapy is described which embodies the following principles: a) Limitation of daily fluid intake to insensible loss plus the urine volume of the previous day. b) Restriction of sodium intake from the beginning to anticipate the development of acidosis. c) Use of cation exchange resins to prevent excessive increase in the concentration of potassium in the serum. d) Provision of adequate caloric intake through the administration of emulsified fat intravenously. e) Treatment of hyperphosphatemia and hypocalcemia when they occur. f) Continuation of careful supervision and therapy, even after the diuretic phase begins, since renal function continues to be severely restricted for several days afterwards.

THE EFFECT OF MERCUROUS CHLORIDE (CALOMEL) AND EPINEPHRINE (SYMPATHETIC STIMULATION) ON RATS

It has been found that calomel will produce retardation of growth and loss of sodium and chloride from tissue with or without associated functional renal insufficiency. The findings are compared with data obtained by injecting a mercurial diuretic, Mercuhydrin®, into rats. In young rats given 10 mg of calomel, no renal structural change is seen 1 to 4 days after ingestion but the concentration of urea nitrogen in the blood is slightly elevated. If one injection of epinephrine (0.5 mg) is given to the young rat treated with calomel, hemoconcentration, hypertension, 16% loss of total content of chloride from the body and reduction in volume of the chloride space, increased insensible water loss, moderate rise in concentration of urea nitrogen in the blood and a renal lesion in the outer area of the renal medulla (upper portion of Henle's loop) are all found within 24 hours. The animals developed a weak, scrawny appearance, and in some instances distinct coldness to palpation and blueness of the extremities. Epinephrine, when injected into normal rats, produced a lesser increase in insensible loss of water and only 6% loss of content of chloride from the body. Hypertension was not sustained. The changes demonstrated in the current experiments with rats resemble many of the findings in acrodynia. In acrodynia, sweating, hypertension, tachycardia, vasospasm, increased insensible loss of water, raised venous pressure, and increased excretion of steroids all support the concept of sympathetic preponderance. Increased adrenal cortical function also exists but to a lesser extent. Hence, acrodynia must represent "failure of adaptation" or failure to withstand stress. It is suggested that mercury potentiates directly or indirectly the action of epinephrine in the body and that the coexistence of sympathetic stress plus calomel can give rise to acrodynia. Loss of extracellular volume resulting from mercurial diuretic effects, and from loss of water from the skin potentiates sympathetic and adrenal activity. Adrenal hormones are ineffective in conserving sodium chloride at the renal level in the presence of mercury. Augmented sympathetic activity leads to renal anoxia, vasospasm, and renal pressor effects. Renal damage may result and augment the vasospasm and hypertension.

THE MAINTENANCE NEED FOR WATER IN PARENTERAL FLUID THERAPY

It is generally agreed that the maintenance requirements for water of individuals is determined by their caloric expenditure. By means of the following formulae, the caloric expenditure of hospitalized patients can be determined from weight alone. For weights ranging from 0 to 10 kg, the caloric expenditure is 100 cal/kg/day; from 10 to 20 kg the caloric expenditure is 1000 cal plus 50 cal/kg for each kilogram of body weight more than 10; over 20 kg the caloric expenditure is 1500 cal plus 20 cal/kg for each kilogram more than 20. Maintenance requirements for water depend upon insensible loss of water and renal loss. An allowance of 50 ml/100 cal/day will replace insensible loss of water, and 66.7 ml/100 cal/day will replace the average renal loss so that the total requirement is 116.7 ml/100 cal/day. As water of oxidation will supply approximately 16.7 ml/100 cal/day, the remaining 100 ml/100 cal/day must be supplied to meet the remaining water losses of patients on parenteral fluid therapy. Possible exceptions to this figure are discussed. Maintenance requirements of sodium, chloride and potassium are 3.0, 2.0 and 2.0 mEq/100 cal/day, respectively.