How Much Fluid Can Be Given for CHF Patients with Sepsis?

CASE

A 55 y.o. male with PMH of IVDU, MRSA endocarditis, COPD, chronic discitis and osteomyelitis, HFrEF (EF 40-45%) L common femoral DVT presented to the ED with shortness of breath and left leg wound. On arrival, he was febrile to 101.8 and tachypneic with a respiratory rate of 28. His labs came back significant for WBC count of 30, elevated inflammatory markers, Lactate 2.3, and proBNP of 1473.

Given his vitals and labs there was a concern for sepsis with the suspected source of infection being respiratory of skin and soft tissue infection.

His chest x-ray was negative for pneumonia or pleural effusion, however, x-rays of his left tibia/fibula showed “soft tissue ulceration with surrounding soft tissue swelling and edema/induration at the medial lower leg with underlying focal area of periosteal reaction,” unable to rule out underlying osteomyelitis.

Clinical Question: Current guidelines recommend large volume fluid resuscitation for initial sepsis management irregardless of comorbidities but given that CHF is a state characterized by less tolerance of shifts in volume, how much fluid can be given for CHF patients with sepsis?

SUMMARY OF EVIDENCE

The Surviving Sepsis Campaign guidelines for initiating sepsis treatment within the 1st hour recommends rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 ​mmol/L given over 3 hours.[1]

This quantity of fluid resuscitation was derived from observational studies including the landmark Rivers trial[2] which introduced early-goal directed therapy for sepsis treatment and the PROCESS, ARISE, and PROMISE trials. However, the current guidelines do not have recommendations for fluid resuscitation for states concerning for volume overload such as CHF and ESRD.

Studies have shown that patients with a concern for volume overload do not receive the recommended 30mL/kg fluid bolus or have delayed time to receiving the fluids.[3,4] Excessive fluid administration has been linked to multi-organ insufficiency such as pulmonary edema, cardiogenic shock, hepatic congestion, delayed wound healing and tissue breakdown.[5]

Several studies have found that aggressive fluid resuscitation actually decreased the chances of in-hospital mortality.[3,6,7] Oulette and Shah found that there is no increase in mortality, intubation rates, and hypoxic respiratory failure among CHF patients with sepsis who receive the 30mL/kg fluid bolus.[6] This was one of the first case control studies on CHF patients with sepsis, however, this was a single center study with a small sample size, limiting the strength of the findings of the study.

Another study by Acharya et al. found that compliance with 30mL/kg fluid bolus decreased the chances of in-hospital mortality and did not increase the chances of mechanical ventilation in septic patients with CHF.[3] This study was also a single center retrospective case control study but with a larger sample size. One strength of the study was that it had subdivided the control group of patients without CHF and the experimental group with CHF into a fluid bolus group and a no fluid bolus group. This helped strengthen the conclusions of the study by highlighting the difference in both CHF groups. Another strength of the study was that the ejection fraction of the patients was measured during the sepsis event which helped support the conclusions about fluid bolus compliance and in-hospital mortality since fluid status is an important part of management of CHF and sepsis.

Conversely, other studies have shown noncompliance with sepsis guidelines for fluid resuscitation do not have any deleterious effects. Truong et al. found that failure to initiate the 30mL/kg fluid bolus did not affect mortality.[8] This was a retrospective observational study which limits the strength of the findings due to confounding variables that were not controlled for. A strength of the study was that the study analyzed fluid bolus compliance and mortality outcome in patients with CHF, CKD, and chronic liver disease as a separate subgroup. In addition, it analyzed the fluid volumes of patients from 12 hours prior to sepsis identification and 12 hours after sepsis identification which helped determine potential indicators of concerns for volume overload.

Similarly, Akhter et al. found no difference in intubation rates in septic patients with CHF patients who receive 30mL/kg compared to those with more restrictive fluid management.[9] This was also a retrospective single center study with a small sample size that studied only intubation rates in patients with CHF and ESRD weakening the external validity of the study.

RECOMMENDATIONS

1. The body of evidence has shown both decreased risk of mortality and no effect on mortality with compliance with the 30mL.kg fluid bolus. The conclusions have differed depending on the type of study, sample size, and methodology. Many of these studies categorized CHF as one category without taking into account the patient’s ejection fraction, fluid status, and presence or absence of acute CHF exacerbation. Based on current data, CHF patients with sepsis should receive 30mL/kg within 3 hours of identification of sepsis.

2. However, this is an expanding area of research and absence of evidence of harm does not equate to no harm. Therefore, clinicians must exercise their clinical judgment and utilize various tools such as point-of-care ultrasound to assess volume status.

REFERENCES

1. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine: November 2021 - Volume 49 - Issue 11 doi: 10.1097/CCM.0000000000005337

2. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77. doi: 10.1056/NEJMoa010307. PMID: 11794169.

3. Acharya R, Patel A, Schultz E, Bourgeois M, Kandinata N, Paswan R, Kafle S, Sedhai YR, Younus U. Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study. PLoS One. 2021 Aug 19;16(8):e0256368. doi: 10.1371/journal.pone.0256368. PMID: 34411178; PMCID: PMC8376054.

4. Rourke EM, Kuttab HI, Lykins JD, Hughes MD, Keast EP, Kopec JA, Wroblewski K, Purakal J, Ward MA. Fluid Resuscitation in Septic Patients With Comorbid Heart Failure. Crit Care Med. 2021 Feb 1;49(2):e201-e204. doi: 10.1097/CCM.0000000000004730. PMID: 33438983; PMCID: PMC7810156.

5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.

6. Ouellette DR, Shah SZ. Comparison of outcomes from sepsis between patients with and without pre-existing left ventricular dysfunction: a case-control analysis. Crit Care. 2014 Apr 23;18(2):R79. doi: 10.1186/cc13840. PMID: 24758343; PMCID: PMC4057360.

7. Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med. 2021 Sep;36(9):989-1012. doi: 10.1177/0885066620928299. Epub 2020 Jun 4. PMID: 32495686; PMCID: PMC7970342

8. T.N. Truong, A.S. Dunn, K. McCardle, A. Glasser, S. Huprikar, H. Poor, et al. Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: reassessing the “one-size-fits-all” approach. J Crit Care, 51 (2019), pp. 94-98, 10.1016/j.jcrc.2019.02.006

9. Akhter M, Hallare M, Roontiva A, Stowell J. 154 fluid resuscitation of septic patients at risk for fluid overload. Ann Emerg Med. 2017;70(4): S61–S62.