Discussion
Several studies have shown that the prognosis of COVID-19-related ARDS
is unfavorable.1-5 Furthermore, as Rh-negative is
quite a rare blood type, ECMO could not be applied to this COVID-19
patient with Rh-negative blood type because it is unreasonable to ensure
enough blood products with the same blood type. Thus, we severely
restricted the volume of infusion and administered favipiravir and
ciclesonide. Despite the presence of acute kidney injury and
hypotension, we managed these complications using hydrocortisone and two
types of renal replacement therapy. Finally, the patient survived and
was discharged from the hospital.
Some clinical guidelines on ARDS recommend conservative fluid
management, aiming to achieve a negative balance in body fluid
management.14,15 In fact, the benefit of conservative
fluid strategy has been supported in the recent randomized controlled
trials (RCT).16,17 In the conservative group of these
RCTs, the total amount of fluid used in the fluid therapy was
3,000–5,000 mL/day. Meanwhile, in our case, the average total fluids
from day 2–7 were 2,942 mL/day. These differences indicate that in
order to prioritize minimum lung damage, severe restriction of total
fluids was required. We believe that this severe conservative management
would enable the successful treatment of respiratory failure without
ECMO, although it might partially induce acute kidney injury and
refractory hypotension.
As for corticosteroids, there are pros and cons of hydrocortisone
administration for critically ill COVID-19 patients.18In fact, the U.S. National Institute of Health guidelines mention that
the efficacy of hydrocortisone has not been robustly supported as that
of dexamethasone. The reason for this ambiguous statement could be that
the two recent RCTs did not demonstrate the efficacy of hydrocortisone,
although a significant reduction in the mortality rate was observed with
the use of dexamethasone.19-21 However, we believe
that hydrocortisone should be positively considered for severe COVID-19
patients who are suffering from refractory hypotension due to secondary
adrenal insufficiency like our case. In such cases, the hydrocortisone
could provide the following two beneficial effects: suppressing the
extreme inflammatory response and raising the blood pressure. Actually,
in the latter RCT, the hydrocortisone group which was given dependent on
the vasopressor requirements, showed the lowest mortality rate, although
with no statistical significance.19 In fact, in our
case, although the purpose of hydrocortisone was to improve the
hemodynamics without excessive fluid overload, the oxygenation was also
restored rapidly in a short while after administration.
Thus, this case highlights the importance of severely conservative fluid
management and hydrocortisone therapy for COVID-19 patients,
particularly for those with Rh-negative blood type and secondary adrenal
insufficiency. These medical interventions need to be positively
considered for COVID-19 patients with rare blood types.