Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon

Associations Between Volume of Early Intravenous Fluid and Hospital Outcomes in Septic Patients With and Without Heart Failure: A Retrospective Cohort Study

OBJECTIVES

To evaluate the relationship between early IV fluid volume and hospital outcomes, including death in-hospital or discharge to hospice, in septic patients with and without heart failure (HF).

DESIGN

A retrospective cohort study using logistic regression with restricted cubic splines to assess for nonlinear relationships between fluid volume and outcomes, stratified by HF status and adjusted for propensity to receive a given fluid volume in the first 6 hours. An ICU subgroup analysis was performed. Secondary outcomes of vasopressor use, mechanical ventilation, and length of stay in survivors were assessed.

SETTING

An urban university-based hospital.

PATIENTS

A total of 9613 adult patients were admitted from the emergency department from 2012 to 2021 that met electronic health record-based Sepsis-3 criteria. Preexisting HF diagnosis was identified by the International Classification of Diseases codes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 1449 admissions from patients with HF. The relationship between fluid volume and death or discharge to hospice was nonlinear in patients without HF, and approximately linear in patients with HF. Receiving 0-15 mL/kg in the first 6 hours was associated with lower likelihood of death or discharge to hospice compared with 30-45 mL/kg (odds ratio = 0.61; 95% CI, 0.41-0.90; p = 0.01) in HF patients, but no significant difference for non-HF patients. A similar pattern was identified in ICU admissions and some secondary outcomes. Volumes larger than 15-30 mL/kg for non-HF patients and 30-45 mL/kg for ICU-admitted non-HF patients were not associated with improved outcomes.

CONCLUSIONS

Early fluid resuscitation showed distinct patterns of potential harm and benefit between patients with and without HF who met Sepsis-3 criteria. Restricted cubic splines analysis highlighted the importance of considering nonlinear fluid outcomes relationships and identified potential points of diminishing returns (15-30 mL/kg across all patients without HF and 30-45 mL/kg when admitted to the ICU). Receiving less than 15 mL/kg was associated with better outcomes in HF patients, suggesting small volumes may be appropriate in select patients. Future studies may benefit from investigating nonlinear fluid-outcome associations and a focus on other conditions like HF.

Care pathways of sepsis survivors: sequelae, mortality and use of healthcare services in France, 2015-2018

BACKGROUND

Individuals who survive sepsis are at high risk of chronic sequelae, resulting in significant health-economic costs. Several studies have focused on aspects of healthcare pathways of sepsis survivors but comprehensive, longitudinal overview of their pathways of care are scarce. The aim of this retrospective, longitudinal cohort study is to identify sepsis survivor profiles based on their healthcare pathways and describe their healthcare consumption and costs over the 3 years following their index hospitalization.

METHODS

The data were extracted from the French National Hospital Discharge Database. The study population included all patients above 15 years old, with bacterial sepsis, who survived an incident hospitalization in an acute care facility in 2015. To identify survivor profiles, state sequence and clustering analyses were conducted over the year following the index hospitalization. For each profile, patient characteristics and their index hospital stay and sequelae were described, as well as use of care and its associated monetary costs, both pre- and post-sepsis.

RESULTS

New medical (79.2%), psychological (26.9%) and cognitive (18.5%) impairments were identified post-sepsis, and 65.3% of survivors were rehospitalized in acute care. Cumulative mortality reached 36.6% by 3 years post-sepsis. The total medical cost increased by 856 million € in the year post-sepsis. Five patient clusters were identified: home (65.6% of patients), early death (12.9%), late death (6.8%), short-term rehabilitation (11.3%) and long-term rehabilitation (3.3%). Survivors with early and late death clusters had high rates of cancer and primary bacteremia and experienced more hospital-at-home care post-sepsis. Survivors in short- or long-term rehabilitation clusters were older, with higher percentage of septic shock than those coming back home, and had high rates of multiple site infections and higher rates of new psychological and cognitive impairment.

CONCLUSIONS

Over three years post-sepsis, different profiles of sepsis survivors were identified with different mortality rates, sequels and healthcare services usage and cost. This study confirmed the importance of sepsis burden and suggests that strategies of post-discharge care, in accordance with patient profile, should be further tested in order to reduce sepsis burden.

Association between chronic obstructive pulmonary disease and 28-day mortality in patients with sepsis: a retrospective study based on the MIMIC-III database

BACKGROUND

Sepsis is a common cause of mortality in critically ill patients, and chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in septic patients. However, the impact of COPD on patients with sepsis remained unclear. Therefore, the purpose of this study aimed to assess the effect of COPD on the prognosis of septic patients based on Medical Information Mart for Intensive Care (MIMIC-III) database.

METHODS

In this retrospective study based on the (MIMIC)-III database version 1.4 (v1.4), we collected clinical data and 28-day all-cause mortality from patients with sepsis in intensive care unit (ICU) and these patients met the diagnostic criteria of Sepsis 3 on ICU admission between 2008 and 2012. International Classification of Diseases (ICD-9) (4660, 490, 4910, 4911, 49120, 49121, 4918, 4919, 4920, 4928, 494, 4940, 4941, 496) was used to identified COPD. We applied Kaplan-Meier analysis to compare difference of 28-day all-cause mortality between septic patients with and without COPD. Cox proportional-hazards model was applied to explore the risk factor associated with 28-day all-cause mortality in patients with sepsis.

RESULTS

Six thousand two hundred fifty seven patients with sepsis were included in this study, including 955 (15.3%) patients with COPD and 5302 patients without COPD (84.7%). Compared with patients without COPD, patients with COPD were older (median: 73.5 [64.4, 82.0] vs 65.8 [52.9, 79.1], P < 0.001), had higher simplified acute physiology score II (SAPSII) (median: 40.0 [33.0, 49.0] vs 38.0 [29.0,47.0], P < 0.001) and greater proportion of mechanical ventilatory support (MV) (55.0% vs 48.9%, P = 0.001). In our study, septic patients with COPD had higher 28-day all-cause mortality (23.6% vs 16.4%, P < 0.001) than patients without COPD. After adjusting for covariates, the results showed that COPD was an independent risk factor for the 28-day all-cause mortality of patients with sepsis (HR 1.30, 95%CI: 1.12-1.50, P = 0.001).

CONCLUSIONS

COPD was an independent risk factor of 28-day all-cause mortality in septic patients. Clinically, septic patients with COPD should be given additional care.

Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock

Background

Fluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock.

Methods

This multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids.

Results

One hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2-23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2-53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS.

Conclusions

In patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.

Vasopressor Discontinuation Order in Septic Shock With Reduced Left Ventricular Function

BACKGROUND

The optimal vasopressor management for septic patients with left ventricular (LV) dysfunction has not been well established, and current evidence is conflicting regarding the optimal vasopressor discontinuation order.

OBJECTIVE

The objective was to evaluate the impact of LV dysfunction on the hemodynamic management of septic shock by assessing the incidence of clinically significant hypotension after vasopressor discontinuation.

METHODS

In this single-center, retrospective cohort study, adult patients were included if they met the Sepsis-3 definition of septic shock, had LV dysfunction (defined as an ejection fraction ≤40%), and received norepinephrine and vasopressin as the last vasopressors discontinued. The primary outcome was the incidence of clinically significant hypotension following discontinuation of vasopressin or norepinephrine. Clinically significant hypotension was defined as a MAP less than 60 mmHg and the need for either: 1) the reinstitution of the previously discontinued agent at any dosage, 2) the receipt of at least 500 mL of a crystalloid at a rate of at least 500 mL/hour, 3) or the receipt of at least 25 grams of albumin 5% at a rate of at least 25 gram/hour. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and ICU and hospital mortality.

RESULTS

A total of 78 patients met inclusion criteria, with 37 patients having vasopressin discontinued first and 41 having norepinephrine discontinued first. Clinically significant hypotension occurred in 28 patients (76%) following the discontinuation of vasopressin, compared to 28 patients (81%) following the discontinuation of norepinephrine (p = 0.61). ICU length of stay was 9 days in the vasopressin discontinued first cohort, compared to 15 days in the norepinephrine discontinued first cohort (p = 0.01). There was no statistically significant difference in mortality observed.

CONCLUSION

The discontinuation order of norepinephrine and vasopressin did not impact the incidence of clinically significant hypotension in patients with septic shock and LV dysfunction, but may influence ICU length of stay, although other factors may have impacted this finding.

Association Between Preexisting Heart Failure With Reduced Ejection Fraction and Fluid Administration Among Patients With Sepsis

Importance

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).

Objective

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.

Exposures

Preexisting heart failure with reduced ejection fraction (≤40%) measured by transthoracic echocardiogram within 1 year prior to hospitalization for sepsis.

Main Outcomes and Measures

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.

Results

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).

Conclusions and Relevance

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.

Do septic patients with reduced left ventricular ejection fraction require a low-volume resuscitative strategy?

BACKGROUND

Many clinicians are wary of administering 30 cc/kg of intravenous fluid (IVF) to septic patients with reduced left-ventricular ejection fraction (rLVEF), fearing volume overload. Prior studies have used history of heart failure, rather than LVEF measured at presentation, thereby potentially distorting the relationship between rLVEF, IVF, and adverse outcomes. Our goal was to assess the relationship between IVF volume and outcomes in patients with, versus without, rLVEF.

METHODS

This was a prospective observational study performed at an urban Emergency Department (ED). Included patients were adults with suspected sepsis, defined as being treated for infection plus either systolic blood pressure <90 mm/Hg or lactate >2 mmol/L. All patients had LVEF assessed by ED echocardiogram, prior to receipt of >1 l IVF.

MEASUREMENTS AND MAIN RESULTS

We enrolled 73 patients, of whom 33 had rLVEF, defined as <40%. Patients with rLVEF were older, had greater initial lactate, more ICU admission, and more vasopressor use. IVF volume was similar between LVEF groups at 3-h (2.2 (IQR 0.8) vs 2.0 (IQR 2.4) liters) while patients with rLVEF were more likely to achieve 30 cc/kg (61% (CI 44-75) vs 45% (CI 31-60). In the reduced versus not-reduced LVEF groups, hospital days, ICU days, and ventilator days were similar: 8 (IQR 7) vs 6.5 (8.5) days, 7 (IQR 7) vs 5 (4) days, and 4 (IQR 8) vs. 5 (10) days, respectively.

CONCLUSIONS

Septic patients with rLVEF at presentation received similar volume of IVF as those without rLVEF, without an increase in adverse outcomes attributable to volume overload. While validation is needed, our results suggest that limiting IVF administration in the setting of rLVEF is not necessary.

Impact of Underlying Congestive Heart Failure on In-Hospital Outcomes in Patients with Septic Shock

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P < .001), incidence of ischemic stroke (2.71% vs 2.53%, P = .0032), and acute kidney injury (69.9% vs 63.9%, P = .001) were significantly higher in patients with SS and CHF when compared to those with SS and no CHF. Conclusions: This study identified CHF as a strong adverse prognosticator for inpatient mortality and several major adverse clinical outcomes. Study findings suggest the need for further investigation into these findings' mechanisms to improve outcomes in patients with SS and underlying CHF.

Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study

BACKGROUND

The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data.

METHODS

The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation.

RESULTS

The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82-0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93-1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90-0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus.

CONCLUSION

The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.

Astragaloside IV-targeting miRNA-1 attenuates lipopolysaccharide-induced cardiac dysfunction in rats through inhibition of apoptosis and autophagy

Astragaloside IV (AS-IV), the major active constituent purified from Astragalus membranaceus, was previously reported to have protective effects against cardiac dysfunction. However, the underlying mechanism remains unknown. In the present study, we investigated the protective effect of AS-IV on lipopolysaccharide (LPS)-induced cardiac dysfunction and explored the potential mechanism by focusing on miRNA-1 (miR-1) at the animal and cellular levels. A series of methods were used, including echocardiography, flow cytometry, ELISA, immunofluorescence, transmission electron microscopy, RT-PCR, and western blotting. The results showed that both AS-IV and the miR-1 inhibitor improved cardiac dysfunction, reduced heart injury, inhibited apoptosis and autophagy, and regulated the expression of calcium- and mitochondrial energy metabolism-related proteins in the heart tissue of rats treated with LPS. Importantly, AS-IV downregulated the expression of miR-1 mRNA in heart tissue. All effects of AS-IV were at least partly abolished by miR-1 mimics. In the in vitro study, both AS-IV and the miR-1 inhibitor inhibited apoptosis and autophagy and regulated the expression of calcium- and mitochondrial energy metabolism-related proteins in heart cells treated with LPS. Similarly, AS-IV downregulated the expression of miR-1 mRNA in heart cells. All effects of AS-IV on cells were at least partly abolished by miR-1 mimics. Furthermore, miR-1 mimics exhibited effects similar to LPS both in animal and cellular studies. Taken together, these results suggest that AS-IV protects against LPS-induced cardiac dysfunction by inhibiting calcium-mediated apoptosis and autophagy by targeting miR-1, highlighting a new mechanism for the therapeutic effect of AS-IV on cardiac dysfunction.

An Evaluation of the Use of Aggressive Fluid Resuscitation in the Early Treatment of Sepsis Patients

Introduction

Fluid resuscitation is a critical aspect of the sepsis protocol with the usual initial dose being 30 mL per kilogram. Although this dose is well accepted in patients with normal cardiac function, there is some significant variation in clinical practice concerning the optimal fluid resuscitation in septic patients with underlying congestive heart failure (CHF). Many different approaches have been tried to best treat these patients by using lesser volumes of fluid. The purpose of this retrospective study is to attempt to better define optimal fluid resuscitation in congestive heart failure patients and whether standard fluid resuscitation exacerbates CHF in these cases.

Methods

This was a retrospective study involving patients admitted to the Emergency Department (ED) during the time period of September of 2016 through March of 2019 with a primary diagnosis of sepsis and pre-existing CHF. Data collected from the data warehouse and patient charts included demographics, total amount of fluid received in the ED and outcome data. Evidence of fluid overload (chest X-ray [CXR] evidence, rising B-type natriuretic peptide [BNP], or use of diuretics), was evaluated with respect to in-hospital mortality, white blood cell (WBC) count and comorbidities (chronic obstructive pulmonary disease [COPD], hypertension and coronary artery disease).

Results

There were 422 patients included in the cohort. Of the 422, 113 (26.8%) patients showed evidence of fluid overload on CXR during hospital stay and received diuretics and therefore considered in the CHF exacerbation group. The patients that experienced CHF exacerbation were significantly older (mean ± SD, 70.9 ± 11.8 years versus 67.4 ± 15.1 years, p=0.014). Patients with exacerbation also received more fluid (median and interquartile range, 3.0, 2:5.5 L versus 2.0, 1:4.3 L, p=0.017). The receiver operating characteristic curve analysis for fluid to predict exacerbation resulted in an area under the curve of 0.59 with a 95% confidence interval (CI) of 0.52 to 0.65, p=0.012. The Youden Index was used to determine an optimal cutoff value of 2.6 L. The percentage of patients in the exacerbation group above the threshold was significantly higher (57.3%) than those without exacerbation (43.3%), p=0.019. Following multivariate analysis, age greater than 60 (odds ratio [OR]: 2.5; CI: 1.4-4.6, p=0.003) and fluid cutoff of 2.6 L (OR: 1.9; CI: 1.2-3.1, p=0.007) were both found to be independent predictors of CHF exacerbation. There was no significant difference in mortality based on the total fluid received in the ED.

Conclusion

The findings of this study showed that septic patients with pre-existing CHF who received more than 2.6 L of fluid in the ED were 90% more likely to develop symptoms of CHF exacerbation with no evidence of lowering mortality compared to the group that received less than 2.6 L. Our data supports the practice of limiting total fluid resuscitation in CHF to 2.6 L and reconfirms the idea that fluid resuscitation for patients with CHF needs to be individualized.

Association between left ventricular diastolic dysfunction and septic acute kidney injury in severe sepsis and septic shock: A multicenter retrospective study

INTRODUCTION

Left ventricular diastolic dysfunction (LVDD) adversely impacts renal function, and E/e' is a significant predictor of adverse kidney events under different clinical conditions. However, no studies have evaluated the association between LVDD and septic acute kidney injury (AKI) among patients with severe sepsis and septic shock.

METHODS

This multicenter retrospective study evaluated adult patients with severe sepsis or septic shock between January 1, 2013, and December 31, 2019, who underwent echocardiography within 24 hours after admission to an intensive care unit.

RESULTS

A total of 495 adult patients were enrolled in the study. LVDD grades II and III were associated with severe (stage 3) AKI (p < 0.001, p for trend < 0.001). E/e' and e' were risk factors for septic AKI (OR, 1.155; 95% CI, 1.088-1.226, p < 0.001; and OR, 7.218; 95% CI, 2.942-17.712, p < 0.001, respectively) in the multivariate logistic regression analysis. The area under the receiver operating characteristic curve of E/e' and e' was 0.728 (95% CI, 0.680-0.777, p < 0.001) and 0.715 (95% CI, 0.665-0.764, p < 0.001), respectively.

CONCLUSIONS

LVDD was associated with septic AKI, and E/e' and e' are useful predictors of septic AKI among patients with severe sepsis or septic shock.

TRIAL REGISTRATION

The study was registered at the Chinese Clinical Trial Registry (Protocol No. ChiCTR2000033083).

Clinical Outcome of Septic Patients With Heart Failure With Preserved Ejection Fraction Presenting to the Emergency Department of a Tertiary Hospital: A Retrospective Cohort Study

Background: Patients with heart failure with preserved ejection fraction (HFpEF) may be at a higher risk of mortality from sepsis than patients without heart failure. Objective: The aim of this study is to compare sepsis-related morbidity and mortality between patients with HFpEF and patients without heart failure presenting to the emergency department (ED) of a tertiary medical center. Design: Single-center retrospective cohort study conducted at an academic ED between January 1, 2015 and December 31, 2018. Patients: Patients with a diagnosis of sepsis were included. Main Measures: Bivariate and multivariate analyses were performed to look at differences in demographics, infection, and treatment parameters as well as outcomes of patients with sepsis. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED mortality, lengths of stay, and treatment differences between both groups. Key Results: A total of 1,092 patients presented with sepsis to the ED, of which 305 (27.93%) had HFpEF. There was no significant difference in in-hospital mortality between the two groups (40.7% vs. 37.4%; p = 0.314). However, there was a significant increase in ED mortality for septic HFpEF patients compared to non-heart failure patients (2.4 vs. 0.4%; p = 0.003). Septic HFpEF patients presenting to the ED were older than non-heart failure patients (76.84 vs. 68.44 years old; p < 0.0001). On the other hand, there was no significant increase in the use of vasopressors in the first 24 h between both groups. There was a significantly higher rate of intubation in the first 48 h for septic HFpEF patients (17.5 vs. 8.9%; p < 0.0001). Finally, there was significantly less intravenous fluid requirement at 6 h (1.94 L vs. 2.41L; p < 0.0001) and 24 h (3.11 L vs. 3.54L; p = 0.004) for septic patients with HFpEF compared to non-heart failure patients. Conclusion: Septic HFpEF patients experienced an increase in ED mortality, intubation, and steroid use compared to septic non-heart failure patients.

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features

Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

Impact of left ventricular dysfunction and fluid balance on the outcomes of patients with sepsis

OBJECTIVE

Left ventricular (LV) dysfunction is a predictor of mortality in patients with sepsis. However, whether the adverse impact of LV dysfunction depends on fluid balance remains unclear. We retrospectively investigated the impact of LV dysfunction and fluid balance on various outcomes of patients with sepsis.

METHODS

Critically ill patients with sepsis were classified according to their LV function: normal LV function, diastolic dysfunction (septal e' of <10 and E/e' of ≥15 with ejection fraction of ≥50%), and systolic dysfunction (ejection fraction of <50%).

RESULTS

There were 83 (51.2%) patients with normal LV function, 39 (24.1%) with diastolic dysfunction, and 40 (24.7%) with systolic dysfunction. The cumulative and daily fluid balances after intensive care unit admission did not differ. However, acute kidney injury was more prevalent in the patients with diastolic and systolic dysfunction than in those with normal LV function (82.1%, 87.5%, and 69.9%, respectively; P = 0.065). LV dysfunction lengthened the duration of renal replacement therapy, independent of baseline renal dysfunction and the daily fluid balance (P = 0.008). Moreover, both diastolic and systolic dysfunction were associated with mortality (hazard ratio: 2.7 and 3.0; P = 0.047 and P = 0.028, respectively), regardless of the daily fluid balance, which was also a significant predictor of mortality (P < 0.001).

CONCLUSIONS

LV dysfunction has an adverse impact on renal outcomes and mortality in patients with sepsis and seems to be independent of fluid balance. Additional therapeutic options to restore organ perfusion are needed for patients with sepsis who have LV dysfunction, in addition to intravenous fluid restriction.

Anaerobic Bacteremias in Left Ventricular Assist Devices and Advanced Heart Failure

Left ventricular assisted devices (LVADs) have revolutionized the treatment of advanced heart failure, providing meaningful increases in survival, functional capacity, and quality of life. There are two categories of LVADs patients: (1) bridge-to-transplant and (2) destination therapy. Advanced heart failure and destination LVADs often carry a poor prognosis. The overall 1-year mortality rate remains as high as 30%. LVAD-specific infections, LVAD-related infections, and non-LVAD-related infections represent important emerging clinical problems in this setting. With an incidence ranging from 30 to 50%, these lead to high rates of hospitalization, morbidity, and mortality. Bacteremias caused by anaerobic pathogens in patients with LVAD are underreported. Herein, we describe the microbiological findings, treatment, and clinical outcome of four patients with LVADs and advanced heart failure with anaerobic bacteremias. Fusobacterium species was the most frequent etiological agent. Most patients had a relatively favorable short-term outcome with survival rates of 100% at 30 days and of 50% at 90 days. However, due to other multiple long-term complications, overall mortality remains at 50% during the first year and increases to 75% beyond the first year. Anaerobic bacteremia sources included the oral cavity from odontogenic infections and aspiration pneumonia. Anaerobic bacteremia constitutes an unfavorable mortality prognostic factor in patients with destination LVADs. We recommend implementing preventive strategies with a comprehensive dental care evaluation in patients with LVADs and advanced heart failure.

The practical management of fluid retention in adults with right heart failure due to pulmonary arterial hypertension

Our aim with this review is to provide practical advice and management support for nurses and other healthcare practitioners in managing fluid retention in adults with right heart failure (RHF) due to pulmonary arterial hypertension (PAH). Vigilant management of RHF is important for maintaining patient quality of life, as fluid overload can lead to abdominal bloating (ascites) and peripheral oedema, which also has a major impact on patients' morbidity and mortality. Patients with RHF should be assessed regularly for signs of fluid retention. If fluid overload develops, it is important to determine whether it is caused by the progression of PAH, a side effect of PAH-specific treatment, or another drug or comorbid condition, as this affects both the prognosis and the management strategy. Right heart failure can be treated with both pharmacological and non-pharmacological interventions to reduce fluid retention; including altering fluid and salt intake, weight monitoring, and use of diuretics. All patients on diuretics should be regularly monitored for renal dysfunction and electrolyte imbalance and given advice on how to manage the side effects associated with diuretic use. Fluid retention is often assessed and treated in clinical practice by specialist nurses, who act as a key patient contact providing advice and information on symptom management. This review provides an overview of the challenges related to fluid retention, including strategies to help patients manage symptoms and side effects of treatment.

Neutrophil to lymphocyte ratio (NLR) as a prognostic marker for in-hospital mortality of patients with sepsis: A secondary analysis based on a single-center, retrospective, cohort study

Neutrophil-to-lymphocyte ratio (NLR) has been reported to serve as a prognostic marker in inflammatory diseases. The purpose of this study was to evaluate the association of NLR at admission with in-hospital mortality in patients with sepsis presenting to emergency department.This was a secondary analysis based on a single-center, retrospective, cohort study. Patients with sepsis admitted to an academic emergency department between January 2010 and January 2015 were enrolled. NLR of patients was analyzed from the hospital's electronic health record (EHR) system. A total of 174 adult patients, of which 80 (46.0%) died in hospital. The primary outcome was in-hospital mortality. Secondary outcome was 28-day mortality.Contrary to previous studies, a larger NLR was found to have less odds of in-hospital mortality, as well as the presence of bacteremia. Patients who has severe/shock or had a history of chronic heart failure (CHF) had larger odds of death during hospital. Multivariate logistic regression analysis indicated that low NLR was an independent predictor of in-hospital mortality (OR = -0.98; 95% CI -0.96 to -0.99; P = .022). However, no correlation was found between the NLR and 28-day hospital mortality in patients with sepsis (P = .988). As a predictor of in-hospital survival, the area under curve (AUC) of the NLR was 0.622 (95%CI 0.54-0.71; P = .006) and the cut-off value was 9.11 with 0.551 sensitivity and 0.707 specificity.NLR at admission was an independent predictor of in-hospital mortality of sepsis patients.