Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Abstract

ImportanceIntravenous fluid administration is recommended to improve outcomes for patients with septic shock. However, there are few data on fluid administration for patients with preexisting heart failure with reduced ejection fraction (HFrEF).ObjectiveTo evaluate the association between preexisting HFrEF, guideline-recommended intravenous fluid resuscitation, and mortality among patients with community-acquired sepsis and septic shock.Design, Setting, and ParticipantsA cohort study was conducted of adult patients hospitalized in an integrated health care system from January 1, 2013, to December 31, 2015, with community-acquired sepsis and preexisting assessment of cardiac function. Follow-up occurred through July 1, 2016. Data analyses were performed from November 1, 2020, to August 8, 2022.ExposuresPreexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis.Main Outcomes and MeasuresMultivariable models were adjusted for patient factors and sepsis severity and clustered at the hospital level to generate adjusted odds ratios (aORs) and 95% CIs. The primary outcome was the administration of 30 mL/kg of intravenous fluid within 6 hours of sepsis onset. Secondary outcomes included in-hospital mortality, intensive care unit admission, rate of invasive mechanical ventilation, and administration of vasoactive medications.ResultsOf 5278 patients with sepsis (2673 men [51%]; median age, 70 years [IQR, 60-81 years]; 4349 White patients [82%]; median Sequential Organ Failure Assessment score, 4 [IQR, 3-5]), 884 (17%) had preexisting HFrEF, and 2291 (43%) met criteria for septic shock. Patients with septic shock and HFrEF were less likely to receive guideline-recommended intravenous fluid than those with septic shock without HFrEF (96 of 380 [25%] vs 699 of 1911 [37%]; P < .001), but in-hospital mortality was similar (47 of 380 [12%] vs 244 of 1911 [13%]; P = .83). In multivariable models, HFrEF was associated with a decreased risk-adjusted odds of receiving 30 mL/kg of intravenous fluid within the first 6 hours of sepsis onset (aOR, 0.63; 95% CI, 0.47-0.85; P = .002). The risk-adjusted mortality was not significantly different among patients with HFrEF (aOR, 0.92; 95% CI, 0.69-1.24; P = .59) compared with those without, and there was no interaction with intravenous fluid volume (aOR, 1.00; 95% CI, 0.98-1.03; P = .72).Conclusions and RelevanceThe results of this cohort study of patients with community-acquired septic shock suggest that preexisting HFrEF was common and was associated with reduced odds of receiving guideline-recommended intravenous fluids.

Construction and validation of a nomogram prediction model for the progression to septic shock in elderly patients with urosepsis

“…Reduced cardiac function, which may be caused by a dysregulated response of the host to infection [ 25 ], can exacerbate sepsis, making the clinical management of these patients more complex. Our research indicates that CHF is linked to a higher likelihood of sepsis progression to septic shock, which is consistent with the findings of previous studies [ 26 , 27 ]. Additionally, our study also demonstrated that invasive ventilation increased the risk of deterioration in elderly patients with urosepsis, as previously reported [ 28 ].…”

Time to treatment and mortality for clinical sepsis subtypes

“…These data confirmed our hypothesis that more rapid intravenous fluid treatment, as an undifferentiated approach, or even by subtype, is not associated with improved risk-adjusted outcomes in septic shock [ 24 ]. In our model of time to completion of the weight-based intravenous fluid bolus, we did not include patients who received less than a 30 mL per kg bolus and did not assess association between total weight-based fluid volume delivered and mortality.…”

Associations Between Volume of Early Intravenous Fluid and Hospital Outcomes in Septic Patients With and Without Heart Failure: A Retrospective Cohort Study

“…Our study supports the notion that HF patients may respond differently to fluid resuscitation compared with patients without HF, an inadequately understood but clinically impactful topic ( 27 , 28 ). Patients with HF may receive smaller fluid volumes that are administered more cautiously ( 27 , 29 , 30 ), even in septic shock ( 30 ), due to concerns about iatrogenic volume overload. It is plausible that HF patients have higher mortality and require interventions like mechanical ventilation more often when receiving excessive fluids.…”