Background: The Surviving Sepsis Campaign recommends patients with sepsis-induced hypoperfusion receive 30 mL/kg of crystalloid fluid within the first three hours of resuscitation (30by3). However, our previous study demonstrated that patients with comorbid congestive heart failure (HF) were ~60% less likely to receive 30by3. The purpose of this study is to evaluate whether ejection fraction (EF) <50%, history of pulmonary hypertension (PH), or documentation of fluid overload affects fluid administration and subsequent mortality, delayed hypotension, and ICU admission/length of stay (LOS).
Methods: : This was a single-center retrospective cohort study. Using ICD 9 and 10 codes in combination with Sepsis-2 criteria, 1,032 patients were included between January 1, 2014-May 30, 2017. Of this, 229 had comorbid HF. Logistic regression was used, and all models adjusted for Mortality in Emergency Department Sepsis score, severe vs. septic shock, and obesity
Results: Fifty-eight patients with HF reached the 30by3 fluid goal (25.3%). Patients with HF received less fluid volume by three hours when compared to patients without HF (median 14.3 mL/kg vs. 30.0 mL/kg) and often reached the 30mL/kg fluid amount significantly later (10.7 hours vs. 2.7 hours; OR 0.42, 95% CI 0.29-0.60). In a subset of patients with HF, documentation of fluid overload was associated with decreased odds of meeting 30by3 (OR 0.17, 95% CI 0.07-0.43), while EF <50% and history of PH were not associated with meeting fluid goals (OR 1.36, 95% CI 0.62-2.98 and OR 0.42, 95% CI 0.16-1.12, respectively). For HF patients not receiving 30by3, mortality, delayed hypotension, and ICU admission were no different amongst patients with reduced EF, PH, or with documentation of fluid overload. Patients with preserved EFs not receiving 30by3 had longer ICU LOS when compared to those with reduced EF (OR 1.14 vs. 0.32, interaction p=0.03).
Conclusion: Patients with HF were more likely to be under-resuscitated and have significant delays in reaching 30by3. History of reduced EF or PH had no influence on meeting 30by3, however documentation of volume overload was associated with failing to meet 30by3. For HF patients not receiving 30by3, there were no observed differences in mortality, delayed hypotension, or ICU admission amongst groups, however, patients with preserved EF had longer ICU LOS when compared to those with reduced EF.