Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock

Adam L Wiss; Bruce A Doepker; Brittany Hoyte; Logan M Olson; Kathryn A Disney; Eric M McLaughlin; Vincent Esguerra; Jessica L Elefritz

doi:10.1016/j.jointm.2023.05.001

Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock

J Intensive Med. 2023 Jun 15;3(3):254-260. doi: 10.1016/j.jointm.2023.05.001. eCollection 2023 Jul 31.

Authors

Adam L Wiss¹, Bruce A Doepker², Brittany Hoyte³, Logan M Olson⁴, Kathryn A Disney⁵, Eric M McLaughlin⁶, Vincent Esguerra⁷, Jessica L Elefritz²

Affiliations

¹ Department of Pharmacy, Ascension Saint Thomas Hospital West, Nashville, TN 37205, USA.
² Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
³ Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA.
⁴ Department of Pharmacy, Nebraska Medicine, Omaha, NE 68105, USA.
⁵ Department of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT 84112, USA.
⁶ Center for Biostatistics, The Ohio State University, Columbus, OH 43210, USA.
⁷ Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine. The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.

Abstract

Background: Fluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock.

Methods: This multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids.

Results: One hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2-23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2-53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS.

Conclusions: In patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.

Keywords: Fluid resuscitation; Heart failure; Sepsis; Septic shock.