From the Guidelines
For patients with congestive heart failure (CHF) who develop sepsis, the best initial fluid choice is typically a balanced crystalloid solution such as lactated Ringer's or Plasma-Lyte, administered cautiously at 250-500 mL boluses with frequent reassessment. This approach is supported by the Surviving Sepsis Campaign guidelines, which recommend crystalloids as the fluid of choice for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock 1. The guidelines suggest using either balanced crystalloids or saline for fluid resuscitation, but with a weak recommendation and low quality of evidence 1.
Given the patient's CHF, it is crucial to minimize the risk of fluid overload, which could worsen heart failure. Therefore, the total fluid volume should be limited compared to standard sepsis protocols, with a recommended initial target of 20-30 mL/kg rather than the standard 30 mL/kg. Close monitoring is essential during fluid administration, including vital signs, urine output, jugular venous distention, lung sounds, and peripheral edema. If the patient shows signs of fluid overload, fluid administration should be stopped, and inotropic support with agents like dobutamine or vasopressors like norepinephrine should be considered early 1.
Key considerations in fluid management for these patients include:
- Using a fluid challenge technique to guide fluid administration, continuing as long as hemodynamic factors continue to improve 1
- Avoiding the use of hydroxyethyl starches for intravascular volume replacement due to the strong recommendation against it with high-quality evidence 1
- Considering the use of albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement when patients require substantial amounts of crystalloids, although this is a weak recommendation with low-quality evidence 1
Overall, the management of patients with CHF and sepsis requires a balanced approach that addresses both the need for adequate perfusion in sepsis and the risk of fluid overload in CHF, guided by the most recent and highest-quality evidence available 1.
From the Research
Fluid Choice for CHF Patients with Sepsis
- The best initial fluid choice for a patient with Congestive Heart Failure (CHF) who is flagged for sepsis is a topic of ongoing research and debate 2, 3, 4, 5, 6.
- Current guidelines recommend crystalloids as the initial fluid solution of choice in the resuscitation of patients with severe sepsis and septic shock 2.
- Balanced crystalloids, such as lactated Ringer's solution, may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 2, 3, 5.
- Normal saline is associated with increased mortality and kidney injury, and its use should be avoided if possible 4, 5.
- Albumin is similar to crystalloids in terms of outcomes in the septic population, but it is costlier and its role in the resuscitation of patients with severe sepsis and sepsis is uncertain 2, 4.
- Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients 4.
- Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future 6.
Key Findings
- A study published in 2025 found that initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, might be associated with improved survival in patients with sepsis-induced hypotension 3.
- A 2014 study found that resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality among critically ill adults with sepsis 5.
- A 2016 review found that balanced crystalloids may be a safer alternative to normal saline, and that albumin is similar to crystalloids in terms of outcomes in the septic population 4.
- A 2023 review found that personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future, and that well-designed large randomized controlled trials are needed to compare fluid choices specifically in the septic patient 6.