Management of heart failure patients presenting with severe sepsis/septic shock

[mgp6]

Hi, I work in a Coronary Care ICU. Today, I attended my hospital's sepsis day conference and a lot of nurses wanted to clarify/know more about management of septic shock on patients who have high risk for adverse effects of aggressive fluid resuscitation (specifically heart failure, renal failure, and liver failure patients). I searched online for research studies on this topic but cannot find a lot of resources. I would like to know your thoughts on this based on your experiences.

Side note: In regards to sepsis core measures, we were told that if a patient who meets severe sepsis/septic shock criteria but did not receive at least 30ml/kg fluid bolus, it means that we did not fully implement the sepsis bundle, thus reducing our hospital's sepsis bundle compliance.

[MunoRN, RN]

The goal of the initial fluid resuscitation in sepsis is to provide enough volume to facilitate perfusion and provide the pressors with something to squeeze. What volume of fluid a patient needs to achieve that varies, sometime significantly. The 30ml/kg rule is really just a rule of thumb for the typical patient when you're lacking more accurate ways of assessing volume status, so if you're achieving the end goal of perfusion, the amount of fluid that was needed to do that is sort of moot. CMS is planning to start making sepsis bundle compliance count starting in 2016, but it's not clear how it will measure fluid resuscitation.

Generally heart failure, renal failure, and liver failure patients will still require some amount of fluid resuscitation since septic patients have a profound capillary leak, which can make them extravascularly overloaded while being intravascularly dry at the same time. There's not much evidence on albumin vs crystaloids for resuscitation, but it would seem logical that these patient in particular might benefit from adding some albumin to the volume replacement. The main tricky thing is that you don't have nearly as much room to overshoot their volume particularly in heart failure where the heart is further weakened by the negative inotropic effects of the cytokines that are also causing vasodilation. In renal failure the patient may need continuous dialysis or at least more frequent HD runs to clear the byproducts of sepsis. Liver failure patients often don't need as much fluid because much of their extravascular volume may already be full, but are also more at risk in general to a poor outcome with sepsis.

[SubSippi]

Like MunroRN said, the main issue is the lack of room to overshoot volume replacement...for this reason, I think that these patients would benefit from having a PA line. Unfortunately, at my facility, the MDs always refuse (personally, I think it's because they don't know how to put one in). We only have them on patients after open heart surgery.

The patients are still going to need volume, and the best way to gauge the rate and volume these patients can tolerate is with hemos. That way, if you're not able to comply with the facility's sepsis bundles, you have the cold hard numbers to explain why.

[MaxAttack, BSN, RN]

The best way I've heard it put is that sepsis will kill them quicker. Fix the sepsis then fix the heart failure.

Bottom line, they need the volume. Recommend 500 cc fluid challenges if there's uncertainty.