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E4: Submerge: Paper Deep Dive (Fluid in septic HF pts)

• Mohamed Hagahmed

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🚨 Submerge into the complexities of fluid resuscitation in septic patients with heart failure! 🩺 

Join me and Dr. Addy Kothare as we dissect an #EmergencyMedicine paper that challenges our current practice when caring for these patients.

📚 https://doi.org/10.1016/j.ajem.2023.08.006

M0:

Welcome back to Emergent EM, where we break down the latest emergency medicine and critical care to empower our global community. Today we're deep diving and dissecting a paper by Zeydeh Etal that discusses a complex topic and personally is the dilemma for me, and I'm sure it's for you as well, fluid resuscitation strategies in septic patients with heart failure. Our guide through this nuanced discussion is a none other than Dr. Addy, who is a friend of mine and a colleague, and I enjoy working with you. Welcome to the podcast, Addy. I'm happy you're

Addy:

Thanks so much. Yeah I'm really pumped to be here too. This is my first time ever doing this sort of thing too, so I'm very excited.

M0:

Can you tell us a little bit about you? Addy

Addy:

so I'm originally from Regina, Saskatchewan in Canada, and I'm currently doing a simulations and medical education fellowship through the University of Pittsburgh. And in my spare time, I love to practice some good old emergency medicine with my colleagues and friends.

M0:

Thank you for joining and I'm happy you're here. So let's break it down for you, Addy. And this is a situation you went through at some point earlier either last week or last month. EMS brings you a 55 year old male who was found basically septic, febrile, tachycardic. And then shows up to your department. Your awesome resident sees them and then they come and tell you, Yeah, they're septic. I'm doing all the work up and I want to give them fluid. And then they pause by saying they have history of heart failure and I will likely not give them that much fluid. How do you approach that?

Addy:

Yeah, I feel like this is, Such a common thing. And the answer 60 years ago would have been no, just flood them with fluid. Let's see what happens. And then the answer may be. Maybe 20 years ago changed to say, whoa, whoa, whoa, we need to be very careful because the issue with patients and heart failure is they don't have much squeeze. They don't have much forward flow. And so therefore they're at higher risk of pulmonary congestion and vascular congestion secondary to the fluid that we provide. I'm of the mind, though, that it's very, very individualized, and I don't think it's a one size fits all. It really depends on what you're seeing. When you talk to the patient, if they're this septic, have they been eating and drinking much in the past couple of days? Maybe they would benefit from a little bit more fluids than what the resident wants to get, which will probably be a tiny little aliquot of 250 to 500 cc's. What's their exam look like? Do they look like they're in flash pulmonary edema? Do they look like they're overloaded? Do they have Massive pedal edema. Do they have a massive jugular venous distension and also what their ultrasound looks like, too? So that's why I'm actually hoping that we can discuss a paper that may help us break down that dogma That's been there this entire time of whoa fluids and heart failure patients. Are you crazy? I think it's not as simple as that

M0:

So let's break this paper down to our audience

Addy:

This is

M0:

systematic review. And meta analysis that looked at fluid resuscitation in sepsis patients with heart failure. Can you summarize the findings? Absolutely, so the patient population we are looking at are patients with sepsis

Addy:

You with evidence of heart failure the paper compared two separate strategies. One was a guideline based approach of at least 30 cc's per kilogram of IV crystalloids within three hours versus a much more restrictive approach of less than 30 cc's per kilogram in that same time frame. And the study actually found that patients who received the restrictive fluid strategy had a significantly higher in hospital mortality, an odds ratio of about 1. 81. 1. 81. So it's clear evidence that despite concerns about volume overload in heart failure patients, perhaps restricting fluids too much might do more harm than good in sepsis.

M0:

That's fascinating, man. I mean, this strikes at the heart of a common clinical dilemma that you and I see in the ED or ICU. So balancing the need to optimize. tissue perfusion in sepsis while avoiding volume overload in patients with heart failure. What are your thoughts on the clinical implications?

Addy:

I think this is the fun of our job. You know, We're not practicing cookie cutter medicine. It truly is a tightrope sepsis management really hinges upon rapid fluid administration and resuscitation to restore that perfusion. And those 30 cc per kilogram guideline from surviving sepsis really created that with this in mind. However, many of us do hesitate to apply it uniformly in heart failure patients because of the risk of causing pulmonary edema or exacerbating cardiogenic shock and what this paper at least is able to start the process of us thinking about is Maybe the benefit of aggressive fluid resuscitation outweighs those risks that are there

M0:

This is a struggle for me because, I'll be honest with you, Addy, I tend to be very cautious with giving these patients large amount of fluids. And just like as you mentioned earlier, I tend to first proceed with some diagnostic modalities, getting a bedside ultrasound, of course, starting with the history and getting a thorough examination. Like you said, JVD, pedal edema, looking for abnormal lung sounds, looking for signs of volume overload on the ultrasounds before I even give that fluid. So are you telling me that by me, maybe. Delaying that 30 cc per kilo of fluid for just additional hours so I can get more data. Is that harmful to my patients?

Addy:

I don't think it's necessarily harmful and I think you're very much right to have that sort of approach of whoa let's slow down. Let's take it one step at a time here. I think though. You Once you obtain that data, then it's important for us to act upon it. I had a resident come up to me with this exact scenario and their first initial instinct was, I'm going to give a, I'm going to give a 500 cc bolus of normal saline. And if I see no improvement, I'm starting pressers. And that for me is quite aggressive and perhaps not entirely the most sound approach for me. It really is taking that time at the bedside. Make sure that I evaluate this patient. Make sure I look at this human being in front of me and really think to myself, like, how is there a fluid status? How do they look from that regards? And then it is a calculated risk, but I have to say, I've changed my practice in recent years. If this was me in residency looking back, I'd be like, Addy, are you kidding me? But nowadays I am a bit more aggressive. Maybe I will start off with a liter. Maybe two liters and just be very mindful and cautious and reevaluate frequently, but not be scared to provide a little bit more.

M0:

That's very interesting you bring that up because a recent study and I'm sure you've heard of is the Clover's study, the Clover's trial, the looked at exactly that patient population with that dilemma, giving restrictive fluid strategy versus liberal fluid strategy. They concluded that. With sepsis induced hypotension, the restrictive fluid strategy did not increase or decrease in mortality or safety concerns before discharge. This is by day 90 compared to the liberal fluid strategy. So there was basically no difference.

Addy:

Yeah,

M0:

I'm not sure maybe that would maybe prompt us to discuss the limitations of this study that we are discussing today.

Addy:

The data of the study and of those studies are very compelling and I think the biggest takeaway for me is that it's not a one size fits all scenario. We're not able to look at more. Like closer subgroups, for example patients of different injection fractions, other hemodynamic considerations. So in this study, one of the biggest limitations that I have is that it is a retrospective study. It's limited by potential confounders and a lot of selection bias. For example, the patients who received less fluid may have had more baseline considerations or delays in sepsis recognition compared to those that received a more liberal fluid strategy. And more than anything, this highlights the need for more prospective trials to look into this issue.

M0:

Yeah, that's great insight. I also noticed that the paper emphasized the need to further research on subgroups of patients. For example, like heart failure with reduced ejection fraction versus heart failure patients with preserved ejection fractions. What are your thoughts

Addy:

Absolutely. I think patients that, for example, have evidence of diastology only. And no element of any sort of systolic dysfunction, those patients may be able to be more responsive to dynamic fluid changes as opposed to those who lack both diastole and systole, are unable to push the fluid forward per se. And of course, as a result, things like invasive hemodynamic monitoring, like arterial lines or dynamic assessments, like a passive leg raise or a little aliquot of fluids. That could help more in those scenarios of personalizing your fluid strategies and reassessing the patient.

M0:

And that's exactly highlights the crucial point of using bedside ultrasound as much as possible in these cohort of patients. That way you can get an idea of their underlying cardiac functioning. So let's bring this back to bedside for an emergency medicine physician like you and I, or even a critical care physician facing a septic patient. What's your practice advice?

Addy:

Absolutely. First, I feel like actually the first advice that I would give is take a second, take a deep breath, go to the bedside and talk to this patient and examine them. Ask those key questions. Have you eaten and drank in the past couple of days? Do you feel thirsty? That sometimes can hint one way or the other. Examine them thoroughly. I know the JVD sounds like some magic Harry Potter thing, but I don't think it is as difficult as what people sound, look at the two heads of the sternocleidomastoid, look for that pulsation, see if it's above the sternocleidomastoid. It gives you a data point one way or the other. Secondly, don't delay the fluids. As you're trying to hem and haw about this, start cautiously, maybe 10 cc's or 20 cc's per kilogram and be sure to reassess frequently. There is always a chance you could make them go into pulmonary edema, but if you're careful and you think critically, it's less likely to happen. Make sure to use your bedside tools. Point of care ultrasound is so incredible nowadays and it really can help give more data points to monitor volume status and look at the cardiac function. very robustly at the bedside. Thirdly, make sure to collaborate early with both your cardiology and ICU teams, especially if they're available to you and especially if that patient decompensates. And lastly, remember that sepsis is such a dynamic condition and it's important for us not to be static in how we approach it. What works in one hour, May not work in that second hour and it's important for us to be so incredibly mindful for these patients.

M0:

The last point that is right on the spot because reassessment is key. feel like sometimes when they get so busy, we're seeing so many patients are critically ill, we tend sometimes to ignore those subset of patients that been waiting, for example, for an ICU bed, or we forget to

Addy:

Oh,

M0:

them. So that's a very

Addy:

I'm so guilty of that. It's that's why I have great nurses that save my butt on a daily basis and kind of remind me to reevaluate those patients.

M0:

Absolutely, man. This is an enlightening discussion. Please allow me to summarize. The takeaway that you brought up from this paper is that restrictive fluid strategies in sepsis patients with heart failure are linked to higher mortality. However, applying the 30 cc per kilo guideline required thoughtful and patient specific adjustments. Thank you.

Addy:

Absolutely.

M0:

This is not a one size fits all strategy, right, Addy, did I miss

Addy:

No, that's exactly right. We know we spend our entire residency learning the science of medicine and now it's time for us to think more about it as an art. It's about balancing the urgency of sepsis care. with the complexities of heart failure management.

M0:

Man, it's been great. I hope all of you listeners enjoy these small tidbits of dissecting and deep diving into a paper. And please share with us if you have any papers that you would like us to discuss or go through in more detail. And if you found this valuable, please share with your colleagues and friends. And until then, please stay curious and also stay compassionate. Please take care.

Addy:

Thanks everyone.