Here's my respectful $0.02 attempt at an answer - there is no generalizable answer for fluid bolus requirements in CHF, or anyone else for that matter. The resuscitation must be monitored.
To elaborate: 1) *Fluid bolus for severe sepsis, septic shock in general.* There was no specific bolus prescribed in the original EGDT study. The only bolus referenced in that study was the 20-30 ml/kg/30 min bolus used to exclude from the study hypotensive patients who responded. That, of course, does not mean that patients in the study received no bolus, but whatever bolus they received and total 6 hour fluid requirements were determined by judgments about individual patient characteristics such as severity and phase of illness, severity of hypotension, and most importantly the amount of fluid required to achieve resuscitation goals. EGDT group required a mean of 5 L at 6 hours but standard deviations were huge with estimated range of 1 - 11 L. 2008 SSC Guidelines for lactate *>*4 mmol/L or systolic BP *<*90 mm Hg shown below also avoided specifics: - Target a CVP *>*8 mm Hg *(>*12 mm Hg if mechanically ventilated - Use a fluid challenge technique while associated with a hemodynamic improvement - Give a fluid challenge of 1000 ml of crystalloid or 300-500 ml colloid over 30 minutes. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion. - Rate of fluid administration should be reduced if cardiac filling pressures increase without concurrent hemodynamic improvement. 2) *Fluid bolus for severe sepsis, septic shock in "CHF*" The Guidelines above would apply with the special cautionary note in the last bullet point. Early monitoring in this group would be particularly important, where some would definitely prefer a PA line to a CVP line in the more difficult cases. One would think these patients would require or tolerate less fluid than all-comers but there isn't much data. CHF comes in many flavors. A history of CHF (Systolic? Diastolic? Compensated? Acute? Chronic? Resolved?) isn't of much value in managing the individual patient . Reduced EF (systolic heart failure) is a poor guide to resuscitation because many patients with low EF have fully compensated "CHF" with normal CO and normal filling pressures. Diastolic heart failure with elevated filling pressures due to reduced ventricular compliance is of perhaps greater concern, can vary from time to time, and requires close monitoring as fluid is administered. Sepsis-related cardiac depression is also an additional factor that will vary with time from case to case. 3) *Monitoring in CHF* Patients may in stable health have CVPs exceeding the target goal range of 8 - 12 mm Hg, including those with pulmonary hypertension, chronic compensated CHF, and end-stage renal disease. One may have to adjust resuscitation goals for severe sepsis accordingly. 4) *Monitoring Before Line Placement* Delayed line placement after diagnosis is frequent and is associated with lower likelihood of meeting resuscitation goals at 6 hours. The long-forgotten bedside skill of estimating CVP can be a real help in guiding fluid resuscitation until the line is placed. 5) *Relative Mortality Risks of Fluid Overload and Under-Resuscitated Severe Sepsis* A frequently overlooked consideration in addressing fluid in septic CHF patients is the fact that under-resuscitation is far more lethal than fluid overload. If one is going to make mistakes with septic patients (as all of us do... or maybe its just me), one would rather err on the wet side. Moreover, one can count on the fingers of two hands the number of times we've seen consequential fluid overload in our thousands of patients, including those with "CHF". Often, overload is seen when the diagnosis of sepsis is in error and/or the patients aren't adequately monitored. 6) *Institutional Fluid Bolus Requirements* Despite the above, many if not most of us have internal standards for what we regard as "an adequate fluid bolus". Such standards can be somewhat confusing because they often include both goals (achievement of specific resuscitation of MAP, CVP, ScvO2) and processes required to get there (fluid, etc.), while ignoring individual patient characteristics. (One of our clinicians was chastised for omitting a fluid bolus in a patient with initial CVP of 25. Does that make much sense?) Nonetheless, a prescribed bolus can be defended as a means of erring on the wet side until that delayed line is placed, benefiting many while risking overload in few. In fact, some institutions recommend a bolus for all patients with severe sepsis, including those with normal BP, lactate <4, or isolated sepsis-related organ dysfunction. I'll be interested in other comments. Thanks Ron Elkin, MD California Pacific Medical Center San Francisco ** On Fri, Aug 17, 2012 at 9:13 AM, Mulligan, Ann W. <[email protected]>wrote: > ** ** ** ** ** ** ** ** > > Our hospital continues to struggle with meeting the fluid bolus > requirements when a CHF patient with a low EF presents with sepsis. > Cardiology is suggesting that ED perform a bedside ECHO if the patient has > CHF and/or know reduced ejection fraction, and to be prudent when giving > several liters of fluid.**** > > ** ** > > How are other hospitals approaching these patients, and what is the latest > guidelines for sepsis treatment within this diagnosis?**** > > Ann Mulligan, RN, BSN, ****CPHQ** > **Manager Quality & Outcomes** > **Alta** **Bates** ******Summit****** **Medical** **Center**** > ****2450 Ashby Ave.**** > ****Berkeley**, **CA** **94705**** > Ph: (510) 204-2986 > Fax: (510) 204-1221 > Cell: (510) 325-4044 > [email protected] **** > > *Confidential Notice:** This email is for the sole use of the intended > recipient and may contain material that is confidential and protected by > state and federal regulations. If you are not the intended recipient > please immediately delete it and contact the sender. Thank you.***** > > **** > > _______________________________________________ > Sepsisgroups mailing list > [email protected] > http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org > >
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