Improvement in Mortality With Early Fluid Bolus in Sepsis Patients With a History of Congestive Heart Failure

Taenzer, Andreas H.; Patel, Shilpa J.; Allen, Todd L.; Doerfler, Martin E.; Park, Tae Ryong; Savitz, Lucy A.; Park, John G.

doi:10.1016/j.mayocpiqo.2020.05.008

Cited by 17 publications

(7 citation statements)

References 13 publications

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“…Our study found that the need for mechanical ventilation increased the chances of in-hospital mortality. There are a few retrospective studies where the authors concluded that the use of ≥30 mL/Kg fluid bolus in CHF patients was not associated with increased mortality or respiratory failure [ 14 , 15 ]. Additionally, some studies supported similar findings not only for CHF patients but also for other conditions that are generally considered high risk for fluid overload such as ESRD on hemodialysis (HD) and cirrhosis [ 16 , 17 ].…”

Section: Discussionmentioning

confidence: 99%

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study

et al. 2021

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Background The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data. Methods The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation. Results The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82–0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93–1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90–0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus. Conclusion The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.

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Section: Discussionmentioning

confidence: 99%

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study

et al. 2021

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“… 28 Similar findings have been reported in sepsis patients with a history of congestive heart failure. 29 Conversely, a multicentre retrospective analysis did not find an association between mortality and time to completion of a fluid bolus up to 12 hours, although a small effect was found when patients who completed the fluid bolus between 12 and 24h are included. 30 An Australian study among patients with infection presenting to the ED found an association between a larger volume of IV fluid in the first 24 hours and reduced in-hospital mortality, 31 while a Chinese observational study found the lowest mortality among septic shock patients who received an initial IV fluid volume of 20–30mL/kg compared to both the group who received <20mL/kg and those who received >30mL/kg.…”

Section: Evidence For Benefit Of IV Fluid Resuscitationmentioning

confidence: 94%

Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights

Macdonald¹

2022

OAEM

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Intravenous (IV) fluid resuscitation is a key component of the initial resuscitation of septic shock, with international consensus guidelines suggesting the administration of at least 30mL/kg of isotonic crystalloid fluid. The rationale is to restore circulating fluid volume and optimise stroke volume. It is acknowledged that there is a paucity of high-level evidence to support this strategy, with most studies being observational or retrospective in design. In the past decade, evidence has emerged that a large positive fluid balance is associated with worse outcomes among patients with septic shock in intensive care who have already received initial resuscitation. Randomised trials undertaken in low-income countries have found increased mortality among patients with sepsis and hypoperfusion administered a larger fluid volume as part of initial resuscitation, however, translating these findings to other settings is not possible. This uncertainty has led to variation in practice with some advocating a more conservative fluid strategy coupled with the earlier introduction of vasopressors for haemodynamic support. This question is the subject of several ongoing clinical trials. This article summarises the current state of the evidence for IV fluid resuscitation in septic shock and provides guidance for practitioners in the face of our evolving understanding of this important area.

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“…Several studies support guideline directed fluid resuscitation (30 mL/kg of crystalloid by 3 hours) in HF showing either neutral or improved outcomes with traditional fluid boluses in sepsis and septic shock with comorbid HF. 6 - 13 However, the timing and degree of de-resuscitation after initial fluids is essential as fluid overload and positive fluid balances have been associated with poor outcomes in septic and intensive care patients. 14 - 17 …”

Section: Introductionmentioning

confidence: 99%

“…5 Several studies support guideline directed fluid resuscitation (30 mL/kg of crystalloid by 3 hours) in HF showing either neutral or improved outcomes with traditional fluid boluses in sepsis and septic shock with comorbid HF. [6][7][8][9][10][11][12][13] However, the timing and degree of de-resuscitation after initial fluids is essential as fluid overload and positive fluid balances have been associated with poor outcomes in septic and intensive care patients. [14][15][16][17] The ROSE curve provides a useful model of fluid stewardship in the septic patient with four specific phases: initial fluid Resuscitation, Optimization of hemodynamics, Stabilization, and Evacuation of fluid after stability is achieved.…”

Section: Introductionmentioning

confidence: 99%

Early Diuretics for De-resuscitation in Septic Patients With Left Ventricular Dysfunction

Jones

Chase

Bruning

et al. 2022

Clin Med Insights Cardiol

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Introduction: De-resuscitation practices in septic patients with heart failure (HF) are not well characterized. This study aimed to determine if diuretic initiation within 48 hours of intensive care unit (ICU) admission was associated with a positive fluid balance and patient outcomes. Methods: This single-center, retrospective cohort study included adult patients with an established diagnosis of HF admitted to the ICU with sepsis or septic shock. The primary outcome was the incidence of positive fluid balance in patients receiving early (<48 hours) versus late (>48 hours) initiation of diuresis. Secondary outcomes included hospital mortality, ventilator-free days, and hospital and ICU length of stay. Continuous variables were assessed using independent t-test or Mann-Whitney U, while categorical variables were evaluated using the Pearson Chi-squared test. Results: A total of 101 patients were included. Positive fluid balance was significantly reduced at 72 hours (−139 mL vs 4370 mL, P < .001). The duration of mechanical ventilation (4 vs 5 days, P = .129), ventilator-free days (22 vs 18.5 days, P = .129), and in-hospital mortality (28 (38%) vs 12 (43%), P = .821) were similar between groups. In a subgroup analysis excluding patients not receiving renal replacement therap (RRT) (n = 76), early diuretics was associated with lower incidence of mechanical ventilation (41 [73.2%] vs 20 (100%), P = .01) and reduced duration of mechanical ventilation (4 vs 8 days, P = .018). Conclusions: Diuretic use within 48 hours of ICU admission in septic patients with HF resulted in less incidence of positive fluid balance. Early diuresis in this unique patient population warrants further investigation.

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Improvement in Mortality With Early Fluid Bolus in Sepsis Patients With a History of Congestive Heart Failure

Cited by 17 publications

References 13 publications

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study

Fluid Resuscitation in Patients Presenting with Sepsis: Current Insights

Early Diuretics for De-resuscitation in Septic Patients With Left Ventricular Dysfunction

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