Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2022 Oct 3;5(10):e2235331. doi: 10.1001/jamanetworkopen.2022.35331.
Intravenous 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).
To 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 PARTICIPANTS: A 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.
Preexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis.
Multivariable 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.
Of 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).
The 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.
静脉输液被推荐用于改善脓毒性休克患者的预后。然而，关于伴有射血分数降低的心力衰竭（HFrEF）的患者的输液管理的数据很少。
评估伴有射血分数降低的心力衰竭（HFrEF）的患者，指南推荐的静脉液体复苏与社区获得性脓毒症和脓毒性休克患者死亡率之间的关系。
设计、地点和参与者：对 2013 年 1 月 1 日至 2015 年 12 月 31 日期间在一个综合医疗保健系统住院的患有社区获得性败血症且预先评估了心脏功能的成年患者进行了队列研究。随访至 2016 年 7 月 1 日。数据分析于 2020 年 11 月 1 日至 2022 年 8 月 8 日进行。
在脓毒症住院前 1 年内通过经胸超声心动图测量的射血分数降低的心力衰竭（<40%）。
多变量模型根据患者因素和脓毒症严重程度进行调整，并在医院层面进行聚类，以生成调整后的优势比（aOR）和 95%置信区间。主要结局是在脓毒症发病后 6 小时内给予 30 mL/kg 的静脉输液。次要结局包括院内死亡率、重症监护病房入院、有创机械通气率和血管活性药物的使用。
在 5278 名患有败血症的患者（2673 名男性[51%]；中位年龄为 70 岁[IQR，60-81 岁]；4349 名白人患者[82%]；中位序贯器官衰竭评估评分，4[IQR，3-5]）中，884 名（17%）患有射血分数降低的心力衰竭，2291 名（43%）符合脓毒性休克的标准。伴有脓毒性休克和射血分数降低的心力衰竭的患者比伴有脓毒性休克而无射血分数降低的心力衰竭的患者更不可能接受指南推荐的静脉输液（380 名患者中的 96 名[25%]比 1911 名患者中的 699 名[37%]；P<0.001），但院内死亡率相似（380 名患者中的 47 名[12%]比 1911 名患者中的 244 名[13%]；P=0.83）。在多变量模型中，射血分数降低与发病后 6 小时内接受 30 mL/kg 静脉输液的风险调整后几率降低相关（aOR，0.63；95%CI，0.47-0.85；P=0.002）。伴有射血分数降低的心力衰竭的患者的风险调整死亡率与无射血分数降低的心力衰竭的患者没有显著差异（aOR，0.92；95%CI，0.69-1.24；P=0.59），且与静脉输液量之间没有交互作用（aOR，1.00；95%CI，0.98-1.03；P=0.72）。
这项对伴有社区获得性脓毒性休克的患者进行的队列研究的结果表明，射血分数降低的心力衰竭很常见，并且与接受指南推荐的静脉输液的几率降低相关。
