Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study

Abstract

Sepsis management includes intravenous fluid (IVF) resuscitation, but patients with pre-existing congestive heart failure (CHF) have a higher risk of fluid overload. Further, patients with sepsis with concomitant CHF present worse clinical outcomes. Nevertheless, there is limited evidence of the association between fluid management and the outcomes of patients with concomitant sepsis and CHF. This retrospective cohort study aimed to evaluate the association between fluid management and in-hospital mortality in patients with sepsis and concomitant heart failure (HF). The patients' data were extracted from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was in-hospital mortality. A restricted cubic spline model was used to explore the relationship between variables and in-hospital mortality. Logistic models were built using the linear spline function and design variables to investigate the association of fluid balance (FB), fluid intake (FI), and fluid accumulation index (FAI, calculated as the FB/FI ratio) with mortality. Overall, 1,801 patients were included. The overall mortality rate was 27.7%. After adjusting for confounding variables, FAI was found to be associated with in-hospital mortality, whereas FB and FI were not. With FAI values of 0–0.42 set as references, FAI values <0 were not associated with in-hospital mortality [odds ratio (OR): 1.078; 95% confidence interval (CI): 0.774–1.503], whereas FAI values > 0.42 were significantly associated with higher in-hospital mortality (OR: 1.461; 95% CI: 1.099–1.954). High FAI values (>0.42) were associated with high in-hospital mortality in patients with sepsis with HF, while FB and FI were not. Proper fluid management may improve the outcomes of patients with sepsis and concomitant HF.

Fluid overload and mortality in critically ill patients with severe heart failure and cardiogenic shock–An observational cohort study

“…In our study, we were not able to show an independent association between FO at ICU discharge and mortality in critically ill patients with cardiogenic shock/severe heart failure. This contrasts with previous studies in subgroups of cardiac patients admitted to the ICU, e.g., with HF and sepsis, after cardiac surgery (18,20,27). There are several reasons why our results differ from previous investigations.…”

“…Second, in our study, we examined the association of FO at ICU discharge, while previous studies mostly focused on perioperative FO (12 h) (27), as well as early FB (within 2 days) (18)(19)(20). The optimal time point of FO assessment (or FB as a surrogate marker) is not yet clarified.…”

“…The FAI consists of the ratio of FB to fluid intake as a measure of the patients’ ability to regulate his body water ( 33 ). A retrospective cohort study in HF patients with septic shock demonstrated an association of the FAI with mortality, while there was no association with FB ( 20 ). Moreover, after adjusting for confounders, some could show that early positive weight-adjusted FB or FAI remains an independent factor for mortality in patients with overt fluid accumulation ( 14 , 19 , 20 ), while others could not demonstrate an association of early positive or negative FB with the incidence of AKI and mortality ( 18 , 27 ).…”

“…Some studies indicate that FO may be associated with increased mortality in critically ill adults admitted for cardiogenic reasons to the ICU ( 1 , 15 , 16 ) as well as critically ill children and children after heart surgery ( 11 , 17 ). Only few studies ( 18 – 20 ) assessed FO as an independent risk factor for poor outcomes in patients with heart disease treated in the ICU. Moreover, these investigations are mainly restricted to either very specific subgroups of patients such as HF patients with sepsis ( 20 ) or patients on extracorporeal membrane oxygenation (ECMO) ( 14 , 19 ), or to only peri-operative outcomes ( 20 ) and early FO ( 14 , 19 ).…”

“…Only few studies ( 18 – 20 ) assessed FO as an independent risk factor for poor outcomes in patients with heart disease treated in the ICU. Moreover, these investigations are mainly restricted to either very specific subgroups of patients such as HF patients with sepsis ( 20 ) or patients on extracorporeal membrane oxygenation (ECMO) ( 14 , 19 ), or to only peri-operative outcomes ( 20 ) and early FO ( 14 , 19 ). Therefore, the aim of this cohort trial was to evaluate the association of FO with 30-day mortality in patients admitted to the ICU with severe HF and/or cardiogenic shock.…”