Role of Hemodynamics in

Managing COVID-19 Patients

Yasser Nassef MD PhD

Assistant Prof. CSMU

© Copyrights Nassef/OM/CSMU-2020
(Not for commercial use)
 CoVid-19
• COVID-19 (formerly known as 2019 novel
coronavirus [2019-nCoV]) broke out in
December 2019, and it spread from Wuhan,
Hubei Province, to all over China and many
other countries in the world
• Since December 2019, when coronavirus
disease 2019 (Covid-19) emerged in Wuhan
city and rapidly spread throughout China, we
needed data on the clinical characteristics of
the affected patients.
Wei‐jie Guan, Ph.D., Zheng‐yi Ni, M.D., Yu Hu, M.D., Wen‐hua Liang, Ph.D., Chun‐quan Ou, Ph.D., 
Jian‐xing He, M.D., Lei Liu, M.D., Hong Shan, M.D., Chun‐liang Lei, M.D., David S.C. Hui, M.D., Bin Du, 
M.D., Lan‐juan Li, M.D., et al., for the China Medical Treatment Expert Group for Covid‐19
 CoVid-19
• Characteristics of patients with confirmed COVID-
19 are based on recent epidemiologic data from
China, including characteristics of patients with
COVID-19 admitted to the intensive care unit and
data on pediatric cases
• Data regarding COVID-19 viral shedding among
asymptomatic persons, and data from a recent
report of viable COVID-19 isolation from stool
• Accessibility of investigational drug therapies for
COVID-19 treatment through clinical trial
enrollment in the United States

https://www.cdc.gov/coronavirus/2019‐ncov/hcp/clinical‐guidance‐
management‐patients.html
 CoVid-19
• Some symptoms are more frequently seen
than others.
• Based on confirmed cases, the WHO says:
– 88 percent of infected people experienced
a fever.
– 67.7 percent had a dry cough.
– Less frequent symptoms include
• Mucus (33.4 percent)
• Shortness of breath (18.6 percent)
• Sore throat (13.9 percent)
• Headache (13.6 percent).
 Transmission of CoVid19 from
Asymptomatic Contact in Germany
A 33-year-old healthy German businessman (Patient 1) became ill
with a sore throat, chills, and myalgias on January 24, 2020, on Jan.
25, a fever of 39.1°C developed, along with a productive cough. By
the evening of 26 Jan. he started to feel better and went back to
work on January 27.
Before these symptoms, he had attended meetings with a Chinese
business partner (Shanghai Resident) at his company near Munich
on January 20 and 21 (who was visiting Germany Jan. 19-22).
During her stay, she had been well with no signs or symptoms of
infection but had become ill on her flight back to China, where she
tested positive for COVID-19 on January 26 (index patient in Fig. 1)
On 27 Jan. the first patient was detected and on 28 Jan. 3
additional employees had signs and symptoms
 Transmission of CoVid19 from
Asymptomatic Contact in Germany
Transmission of CoVid19 from
Asymptomatic Contact in Germany
• This case of COVID-19 infection was diagnosed in
Germany and transmitted outside Asia. However, it is
notable that the infection appears to have been
transmitted during the incubation period of the index
patient, in whom the illness was brief and nonspecific.
• The fact that asymptomatic persons are potential
sources of COVID-19 infection may warrant a
reassessment of transmission dynamics of the current
outbreak.

Wolfgang Guggemos, M.D. Michael Seilmaier, M.D. Klinikum Mü nchen‐Schwabing Munich, Germany
Christian Drosten, M.D. Charité Universitätsmedizin Berlin Berlin, Germany
Patrick Vollmar, M.D. Katrin Zwirglmaier, Ph.D.Sabine Zange, M.D. Roman Wölfel, M.D. Bundeswehr Institute of Microbiology 
Munich, Germany ‐ Michael Hoelscher, M.D., Ph.D. University Hospital LMU Munich Munich, Germany
 A Locally Transmitted Case of
CoVid-19 Infection in Taiwan
• On January 25, 2020, a 52-year-old woman with a
history of type 2 diabetes presented with a fever to an
emergency department in Taiwan. She was admitted
to the hospital because of suspicion of pneumonia
associated with COVID-19 infection
• She had lived in Wuhan since October 21, 2019 and
she returned to Taiwan from Wuhan on January 20 on
an airplane.
• On the same day, a throat swab was obtained from
another passenger on that flight; that passenger was
confirmed to have the first known imported case of
COVID-19 infection in Taiwan when the swab was
found to be positive for the virus on January 21
 A Locally Transmitted Case of
CoVid-19 Infection in Taiwan
Fever and myalgia developed
in the woman on January 25,
a total of 5 days after she
returned to Taiwan from
Wuhan.
She reported that she did not
have cough, dyspnea, chest
pain, or diarrhea.
Chest radiography showed
diffuse infiltrates in the
bilateral lower lungs.
March 12, 2020
N Engl J Med 2020; 382:1070‐1072
DOI: 10.1056/NEJMc2001573
 A Locally Transmitted Case of
CoVid-19 Infection in Taiwan
On day 1 of hospitalization, the
patient received supportive
therapies, and oseltamivir and
levofloxacin were added as
empirical therapy on day 3 of
hospitalization after COVID-19
was detected on RT-PCR. Cough,
rhinorrhea, and sore throat
developed on day 5, and chest
radiography revealed progressive
diffuse interstitial opacities and
consolidation in the bilateral March 12, 2020
N Engl J Med 2020; 382:1070‐1072
parahilar areas and lower lung DOI: 10.1056/NEJMc2001573
fields
Ying‐Chu Liu, M.D. Ching‐Hui Liao, M.D. Chin‐Fu Chang, M.D. Chu‐Chung Chou, M.D., Ph.D. Yan‐Ren Lin, 
M.D., Ph.D. Changhua Christian Hospital Changhua City, Taiwan h6213.lac@gmail.com
Severe CoVid‐19 Pneumonia Diagnosed 
with Volume‐Rendered Chest CT
A 54-year-old woman with a travel history to
Wuhan was admitted to the hospital with a 7-
day history of fever (38.5°C), cough, fatigue,
and chest congestion. Laboratory examinations
showed normal white blood cell count and
lymphocytopenia, increased C-reactive protein
level and erythrocyte sedimentation rate.
Unenhanced chest CT revealed patchy
peripheral ground-glass opacities with upper
lobe predominance (Fig 1).
Lei Tang, Xiaoyong Zhang, Yvquan Wang, Xianchun Zeng 
Published Online:Mar 6 2020https://doi.org/10.1148/ryct.2020200044
Severe CoVid‐19 Pneumonia Diagnosed 
with Volume‐Rendered Chest CT
A three-dimensional volume-rendering technique
(PULMO 3D software, Siemens, Germany) highlighted
the distribution of pulmonary opacities, which was useful
to determine the extension of the disease. Her
nasopharyngeal swab was positive for COVID-19 with a
real-time fluorescent PCR test. The patient was
diagnosed with severe COVID-19 pneumonia.
When treated with oxygen inhalation, moxifloxacin,
lopinavir/ritonavir, umifenovir, interferon, and thymosin,
her body temperature returned to normal and the
symptoms slightly improved.
CT reexamination on the 5th day of hospitalization
indicated increased lesions but mild absorption on the
9th day.
 Figure 1: CT images in a
54-year-old woman with
severe COVID-19
pneumonia. Transverse
and coronal images reveal
patchy peripheral ground-
glass opacities with upper
lobe predominance

Figure 2: CT images in a 54-year-old woman with severe COVID-19 pneumonia. A,

The color coronal image highlights the distribution of lung lesions (red areas)
because software is used to automatically segment and render. B, On a three-
dimensional volume-rendering image, trachea, bronchus, lung tissues, and lesions
are differentiated by CT values and automatically segmented.
1099 patients with laboratory-confirmed COVID-19
from 552 hospitals in 30 provinces, autonomous
regions, and municipalities in mainland China
through January 29, 2020. The primary composite
end point was admission to an intensive care unit
(ICU), the use of mechanical ventilation, or death.
Clinical Characteristics of CoVid‐19 
Disease in China
The primary composite end point occurred in 
67 patients (6.1%)

5.0% who were admitted  1.4% who 
to the ICU died

2.3% who underwent 
invasive mechanical 
ventilation
Clinical Characteristics of CoVid‐19 
Symptoms:
• Lymphocytopenia in 83.2% of the patients,
fever (43.8% on admission and 88.7%
hospitalization).
• Cough (67.8%) on admission, Ground-glass
opacity was the most common radiologic
finding on chest computed tomography (CT)
(56.4%).
No radiographic or CT abnormality was found
in 157 of 877 patients (17.9%) with non-
severe disease.
Patients with COVID-19 pneumonia (confirmed by
next-generation sequencing or RT-PCR) who were
admitted to one of two hospitals in Wuhan and who
underwent serial chest CT scans were retrospectively
enrolled.
Patients were grouped on the basis of the interval
between symptom onset and the first CT scan:
– group 1 (subclinical patients; scans done before
symptom onset).
– group 2 (scans done ≤1 week after symptom onset).
– group 3 (>1 week to 2 weeks).
– group 4 (>2 weeks to 3 weeks).
Imaging features and their distribution were analyzed
and compared across the four groups.
• 81 patients admitted to hospital between Dec 20,
2019, and Jan 23, 2020, were retrospectively
enrolled.
• The cohort included 42 (52%) men and 39 (48%)
women.
• Mean age was 49ꞏ5 years.
• Mean number of involved lung segments was 10ꞏ5
(SD 6ꞏ4) overall:
– 2ꞏ8 (3ꞏ3) in group 1.
– 11ꞏ1 (5ꞏ4) in group 2.
– 13ꞏ0 (5ꞏ7) in group 3.
– 12ꞏ1 (5ꞏ9) in group 4.
Department of Radiology, Union Hospital, Tongji Medical, College, Huazhong 
University of Science and Technology, Wuhan, Hubei, China
Hemodynamics
• Achieving circulatory stability is a real
challenge sometimes in critical patients due
to the complex hemodynamics (flow,
resistance and fluid status) of these patients,
and the difficulty to use invasive lines
sometimes
• The clinical assessment of systemic blood
flow (SBF) by indirect parameters, such as
“blood pressure, capillary refill time, heart
rate, urine output, and CVP”.. is inaccurate

Hemodynamics: From Developmental Physiology to Comprehensive Monitoring, Front Ped. 2018; 6: 87, Sabine L. 
Vrancken, Arno F. van Heijst, and Willem P. de Boode
Hemodynamics.. Why?
• Information on cardiac output, systemic vascular
resistance and end organ perfusion should be
obtained to detect inadequate tissue perfusion
and oxygenation at early stage.. Why?
• To decide to initiate treatment (should every
patient with hypotension be treated the same
way?) and if so, which therapy is the best for
each patient (inotropes, vasopressors or fluid)?
• To detect the hemodynamic response to the
initiated treatment regularly and modify dose
accordingly, as changes in cardiovascular
function can happen quickly.

Hemodynamics: From Developmental Physiology to Comprehensive Monitoring, Front Ped. 2018; 6: 87, Sabine L. 
Vrancken, Arno F. van Heijst, and Willem P. de Boode
Getting The Full Hemodynamic Picture

Systemic 
Blood 
Vascular 
Pressure 
Resistance (SVR)
(MAP)

Stroke 
Cardiac 
Volume 
Output (CO)
(SV)
( )

Tissue  Contractilit
Heart  Preload  Afterload
Fluids  y 
Rate (HR) (SVV, FTC) (SVR)
((TFC)) ((ICON, STR)
, )

+ or – + or – + or –

+ or –
Diuretics Chrono‐ Vascular  Vascular 
Inotrope
tropy Volume Tone
Our Needs for These Critical Patients

• Today needs for a hemodynamic device:

– Non-Invasive
– Accurate
– Reliable
– Validated for all ages (including Neonates
and Obese)
– Lower Patient Risk
– Cost Effective
– Quick and easy to use
– Continuous (beat by beat)
– User independent
– Can be used on CoVid-19 patients safely
Electrical Cardiometry (Berlin, Germany)
4 sensors placed on head, neck and chest
and upper leg
Current transmitted by outer electrodes
and seeks path of least resistance: blood
filled aorta
With each heartbeat, RBCs alignment
change, & blood volume and flow and
velocity in the aorta change
Corresponding change in conductivity is
measured
Baseline and changes in RBCs and
resistance are used to measure and
calculate hemodynamic parameters
RBCs alignment is a main reason for
conductivity change  higher accuracy in
different ages
 Electrical CardiometryTM Parameters
• HR (Heart Rate) and (Blood Pressure)
• SV/ SI (Stroke Volume / Index)
• CO/CI (Cardiac Output / Index)
• SVR / SVRI (Systemic Vascular Resistance / Index)
• SVV (Stroke Volume Variation)
• FTC (Flow Time Corrected)
• TFC (Thoracic Fluid Content)
• PEP (Pre-Ejection Period)
• LVET (LV Ejection Time)
• ICON ( Cardiac Contractility)
• STR (Systolic Time Ratio)  (Ejection Fraction indicator)
• DO2 (Delivered Oxygen) (Calculated)
Thoracic Fluid Content
Thoracic Fluid Content (TFC)
represents the total fluids in the
chest of the patient:
• Intravascular fluids,
• Intracellular fluids,
• Intra-alveolar fluids,
• Pleural fluids and
• Interstitial fluids.
X-Ray - Chest Congestion

Healthy Chest X-Ray Chest Congestion Pleural Effusion Chest X-Ray

 Non-invasive adjustment of fluid status in
critically ill patients. Role of TFC Cardiometry
30 critically ill patients were enrolled. Clinical
assessment of volume overload and hemodynamics
(BP, MAP, CVP, TFC, SV, SVV), monitored by
Electrical Cardiometry ICON®.
Results: There was positive correlation between
volume and TFC (Thoracic Fluid) (r = 0.410,
P = 0.025). Out of the 30 pts. studied 18 pts (60%)
were hemodynamically stable vs 12 pts. (40%) that
had hypotension represented by non responders'
group and had lower TFC compared to the
hemodynamically stable group (26.45 kohm−1 vs
37.8 kohm−1) with P value of 0.004 indicating that
they were hypovolemic.
Khaled Hamed Mahmoud Mohamed Sherif Mokhtar Randa,  Aly Soliman Mohamed, 
Mohamed Khaled, https://doi.org/10.1016/j.ejccm.2016.06.001
 Non-invasive adjustment of fluid status in
critically ill patients. Role of TFC Cardiometry
Out of the 30 pts studied 18 pts (60%) weren’t
congested vs 12 pts (40%) remained persistently
congested after accomplishing HD session with
significantly higher TFC when compared to those
who got rid of chest congestion (43.14 ± 9.9 kohm−1
vs 25.44 ± 5.5 kohm−1) with P value of 0.0001
indicating that they were still hypervolemic.
Using analysis of ROC curve TFC at 25.34 kohm−1
was a significant predictor of hypotension (P value of
0.002, AUC 83.4%, sensitivity 67% and specificity
100%).
Also TFC cutoff value predicting persistent
congestion was 37.02 kohm−1 with P value of
0.0001, AUC 95.8%, sensitivity 83% and specificity
100%
 Non-invasive adjustment of fluid status in
critically ill patients. Role of TFC Cardiometry
• TFC of Electrical Cardiometry is an
evolving noninvasive tool for adjusting fluid
status and chest congestion of critically ill
patients
• Using Thoracic Fluid Content (TFC) as an
indicator of fluid status that could be used
to avoid hemodynamic instability and
manage persistent volume overload and
chest congestion.
Khaled Hamed Mahmoud Mohamed Sherif Mokhtar Randa,  Aly Soliman Mohamed  
Mohamed Khaled https://doi.org/10.1016/j.ejccm.2016.06.001
Thoracic fluid content, a novel parameter for
predicting weaning from mechanical ventilation
Weaning of patients from the mechanical ventilation
remains one of the critical decisions in intensive care
unit. This study aimed to evaluate the accuracy of
thoracic fluid content (TFC) as a predictor of weaning
outcome.
64 critically ill surgical patients who were eligible for
extubation. Before initiating the spontaneous breathing
trial, the TFC was measured using the electrical
cardiometry technology. Patients were followed up after
extubation and divided into successful weaning group
and failed weaning group.
Shymaa Fathy, Ahmed M. Hasanin, Mohamed Raafat, Maha M. A. Mostafa, Ahmed M. Fetouh, Mohamed Elsayed, 
Esraa M. Badr, Hanan M. Kamal & Ahmed Z. Fouad Journal of Intensive Care volume  8, Article number: 20 (2020) 
Thoracic fluid content, a novel parameter for
predicting weaning from mechanical ventilation
TFC was significantly higher in the failed weaning
group compared to the successful weaning group.
The area under the curves (AUCs) showed
moderate predictive ability for the TFC in
predicting weaning failure (AUC [95% confidence
interval] 0.69 [0.57–0.8], cutoff value > 50 kΩ−1),
while the predictive ability of TFC was excellent in
the subgroup of patients with ejection fraction <
40% (AUC [95% confidence interval 0.93 [0.72–1],
cutoff value > 50 kΩ−1).

Shymaa Fathy, Ahmed M. Hasanin, Mohamed Raafat, Maha M. A. Mostafa, Ahmed M. Fetouh, Mohamed Elsayed, 
Esraa M. Badr, Hanan M. Kamal & Ahmed Z. Fouad Journal of Intensive Care volume  8, Article number: 20 (2020) 
Thoracic fluid content, a novel parameter for
predicting weaning from mechanical ventilation

Conclusions
Thoracic fluid content showed moderate
ability for predicting weaning outcome in
surgical critically ill patients.
However, in the subgroup of patients with
ejection fraction less than 40%, TFC above
50 kΩ−1 has an excellent ability to predict
weaning failure.
Shymaa Fathy, Ahmed M. Hasanin, Mohamed Raafat, Maha M. A. Mostafa, Ahmed M. Fetouh, Mohamed Elsayed, 
Esraa M. Badr, Hanan M. Kamal & Ahmed Z. Fouad Journal of Intensive Care volume  8, Article number: 20 (2020) 
Background: Thoracic impedance monitoring able to
detect pneumonia in the very early phase of emerging
infiltration prior the patient developed remarkable clinical
symptoms. However, no studies have yet been conducted
on the usefulness of predicting pneumonia patient
outcomes with parameters from electrical cardiometry.
Objective: In the present study, we evaluated whether
parameters measured by electrical cardiometry can predict
clinical outcomes including mortality and length of hospital
stay in patients with community-acquired pneumonia in the
emergency department.
Kyungil Gho1, Seon Hee Woo1, Sang Moog Lee2, Ki Cheol Park3, Gyeong Nam
Park1, Jinwoo Kim4 Sungyoup Hong1- Mary’s Hospital, College of Medicine, The
Catholic University of Korea
Results: Thoracic fluid content has shown to be significantly higher
in the intensive care unit admission group and in the death group.
Expired patients had higher value of thoracic fluid content at
emergency department admission. Thoracic fluid content
presented fair AUC values of 0.72 (95% confidence interval, 0.71–
0.74) and 0.73 (0.62–0.82) for prediction of 28-day mortality and
intensive care unit admission.
Conclusion: Electrical cardiometry indicated new possibility to
anticipate prognosis of community-acquired pneumonia patient.
Increased thoracic fluid content value would relate worse outcome
of the patient like mortality and intensive care unit admission.
EC monitoring allows real-time measurements of thoracic fluid
content without restraining the patient or invasive catheters.
Kyungil Gho1, Seon Hee Woo1, Sang Moog Lee2, Ki Cheol Park3, Gyeong Nam
Park1, Jinwoo Kim4 Sungyoup Hong1- Mary’s Hospital, College of Medicine, The
Catholic University of Korea
Fluid Management

Many critical conditions need proper fluid management:

• Neonates, Pediatrics, Sepsis, Burn, Shock
• Dehydration, Pneumonia, Pancreatitis,
Bleeding,…etc

How do we know that someone needs fluid?

NIBP, Lab tests, CVP line…etc

How much shall I give? And when shall I stop?

 Cardiac preload 
estimation via CVP 
is not an accurate 
method for 
predicting fluid 
responsiveness in 
patients with 
acute circulatory 
failure.

This systematic review demonstrated a very poor relationship between 
CVP and blood volume as well as the inability of CVP/ΔCVP to predict the 
hemodynamic response to a fluid challenge. CVP should not be used to 
make clinical decisions regarding fluid management.
BJA Review on Fluid Responsiveness

P. E. Marik, J. Lemson, BJA: British Journal of Anaesthesia, Volume 112, Issue 4, April 
2014, Pages 617–620, https://doi.org/10.1093/bja/aet590, Published: 16 Feb. 2014
BJA review on Fluid Responsiveness
SVV Stroke Volume Variation

Stroke volume variation is a naturally occurring

phenomenon due to changes in intra-thoracic pressure
The normal range of variation in spontaneously
breathing patients has been reported between 5-10%
SVV has been shown to have a very high sensitivity
when compared to traditional indicators of volume
status and Pre-load (HR, MAP, CVP, PAOP), and their
ability to determine fluid responsiveness
High SVV means low intravascular fluids, and low pre-
load
Arrhythmia and vasodilators may affect the accuracy of
SVV
Flow Time Corrected (FTc)
Flow Time Corrected is a
parameter represent the time
where the Aortic Valve is open
(LVET) but corrected to the heart
rate
Highly dependant on SVR.
Its trend value is more important.
Could be used together with
SVV
to confirm Fluid responsiveness
in case of Arrhythmia
Corrected Flow Time
SVV is a reliable indicator of preload responsiveness on
control-ventilated and regularly breathing patients

SVV > 13% →→→ Fluid Challenge
Fluid responsiveness in patient with spontaneous breathing
Frank Starling diagram
Baseline: semi-recumbent position

Passive lag raising: legs elevated to 45°

Recovery: semi-recumbent position

Need real time CO
SVV in Spontaneously Breathing Patients
Role or ICON in CoVid-19 Patient Management
• SVV (Stroke Volume Variation) and FTc (Flow Time), are
good predictors of Intravascular Volume and Fluid
Responsive Patients
• TFC (Thoracic Fluid Content) is a very good parameter to
estimate and detect lung and chest congestion, on a beat
by beat basis without the need for regular chest X-Ray
• TFC can detect the response for diuretics on chest
congestion (CoVid-19 patients has congested chest)
• Monitoring Pre-load and chest congestion at the same
time in a non-invasive way helps us decide the type of
fluid to give to our patients (Crystalloids or Colloids)
• In addition to other Hemodynamic parameters (SV, CO,
SVR, Contractility, Ejection Fraction, LVET,…etc)
ICON helps CoVid-19 Patients in China
ICON helps CoVid-19 Patients in China
 ICON® CardiometerTM

Start screen

Bar-diagram – HemoviewTM

Trend of Parameters
Hemodynamic Status Report
Thank You

Ya s s e r N a s s e f M D P h D
CS Medical University
Not for commercial use
© Copyrights Nassef/OM/CSMU-2020