A Protective Fluid Resuscitation Strategy In HF Patients With Sepsis Does Not Significantly Influence Mortality

Abstract

<h3>Objective</h3> : Administration of at least 30mL/kg of IV crystalloids within the first 3 hours of recognition of sepsis is the current fluid resuscitation goal per the 2018 Surviving Sepsis Campaign update. However, sepsis and concomitant heart failure create a challenging clinical scenario due to fear of volume overload. Our meta-analysis sought to determine if this strategy vs. lower infusion rates influences in-hospital mortality for heart failure patients with sepsis. <h3>Methods</h3> : The terms "heart failure" and "sepsis" or "septic shock" and "fluid bolus" or "fluid administration" were used in Embase and Pubmed. Studies were included if they had: sepsis patients with heart failure, or a subgroup of patients with heart failure, and mortality data on these patients that did or did not meet the 30mL/kg-by-3 hour (30 × 3) goal. Five eligible studies were found. The odds ratio and 95% confidence interval for mortality among HF patients with sepsis who received <30 × 3 vs. at least 30 × 3 were calculated for the five studies using their mortality data. The mortality data from the five studies were totaled to calculate a total odds ratio and 95% CI. <h3>Results</h3> : One study demonstrated a statistically significant increase in the odds ratio for in-hospital mortality when comparing the <30 × 3 vs. the 30 × 3 group (OR 2.96; 95% CI 1.18-7.41) (Table 1 and Figure 1). All other studies demonstrated a non-significant increase in odds of in-hospital mortality. Totaling the data from these studies resulted in 616 patients with HF and sepsis. 78 of the 281 in the <30 × 3 group died and 84 of the 335 in the 30 × 3 group died (OR=1.14; 95% CI 0.84-1.64). <b>Conclusions</b>: Our meta-analysis shows a non-significant increase in odds of in-hospital mortality among hospitalized HF patients with sepsis/septic shock who received a restrictive resuscitation strategy compared to those who met the 30 × 3 goal. This study highlights the need for larger prospective trials to study this interaction further. Limitations include the retrospective nature of the studies. Additional work is needed to account for the influence of systolic vs. diastolic heart failure history, sepsis severity, pressor requirement, ICU vs. non-ICU level of care, and use of invasive hemodynamic monitoring to guide resuscitation.