From the Guidelines
Fluid management in patients with heart failure and infection should prioritize careful balance between treating infection and avoiding fluid overload, with a focus on judicious intravenous fluid administration and diuretic use, as recommended by the most recent guidelines 1. The approach to fluid management in these patients involves:
- Judicious intravenous fluid administration, typically starting with a restricted regimen of 1-1.5 liters per 24 hours
- Close monitoring of vital signs, daily weights, fluid balance, and clinical signs of congestion
- Use of diuretics, particularly loop diuretics like furosemide (20-40mg IV or oral, potentially increasing to 80-120mg daily in divided doses), to manage fluid retention
- Infection treatment with appropriate antibiotics based on the suspected source, with initial empiric therapy such as ceftriaxone 1-2g daily plus azithromycin 500mg daily for respiratory infections, or piperacillin-tazobactam 4.5g every 8 hours for abdominal or urinary sources, adjusted once culture results are available
- Continuation of heart failure medications including ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists unless contraindicated by hypotension or worsening renal function Regular monitoring should include:
- Daily electrolytes
- Renal function
- Daily weights
- Intake/output measurements
- Clinical assessment for signs of worsening heart failure or improving infection This balanced approach is necessary because infections often require fluid resuscitation, but patients with heart failure have limited cardiac reserve and are susceptible to pulmonary edema with excessive fluid administration, making it essential to treat the infection while avoiding volume overload that could exacerbate heart failure, as supported by the guidelines 1.
From the Research
Approach to Fluid Management
The approach to fluid management in a patient with heart failure and infection in a ward setting involves careful consideration of several factors, including:
- Balance of fluids, blood pressure, biomarkers, bioimpedance vector analysis, and blood volume, as suggested by the "5B" approach 2
- Assessment of volume overload status, taking into account the complex pathophysiology of congestion in congestive heart failure and the interactions between interstitial and intravascular fluid compartments 3
- Individualized therapy, guided by quantitative measurement of total blood volume, to address the heterogeneity in plasma volume and red blood cell mass that are features of volume overload in patients with chronic heart failure 3
Fluid Resuscitation and Management
In patients with sepsis and preexisting heart failure, fluid resuscitation should be approached with caution, as large fluid boluses and vasoactive agents can be concerning amid cardiac dysfunction 4. However, evidence suggests that traditional fluid resuscitation targets do not increase the risk of adverse events in heart failure patients with sepsis and may improve outcomes 4.
- Norepinephrine is the most well-supported vasopressor for patients with sepsis and preexisting heart failure, while dopamine may induce more cardiac adverse events 4
- Dobutamine should be used cautiously, but may have an application when combined with norepinephrine in patients with low cardiac output 4
Fluid Restriction
Fluid restriction has long been considered one of the cornerstones in self-care management of patients with heart failure, but its effect on clinical stability or body weight has been poorly evaluated 5.
- Temporary fluid restriction can be considered in decompensated heart failure and/or patients with hyponatremia 5
- Tailored fluid restriction based on body weight (30 ml/kg per day) seems to be most reasonable 5
Monitoring and Education
Fluid balance monitoring is crucial in congestive heart failure patients, and maintaining records of patients' fluid intake and output (I&O) is an important aspect of nursing care 6.