What is the management for Congestive Heart Failure (CHF) with sepsis?

Management of CHF with Sepsis

Patients with CHF and sepsis should receive aggressive initial fluid resuscitation (minimum 30 mL/kg crystalloids) followed by early vasopressor support with norepinephrine, targeting a mean arterial pressure ≥65 mmHg, with dobutamine added only when low cardiac output persists despite adequate filling pressures and ScvO2 <70%. 1

Initial Resuscitation

Fluid Management

• Administer an initial fluid bolus of at least 30 mL/kg of crystalloids within the first 6 hours of recognition, delivered rapidly over 5-10 minutes 1
• Continue fluid challenges as long as hemodynamic improvement occurs based on dynamic or static variables 1
• Despite concerns about fluid overload in CHF patients, evidence shows traditional fluid resuscitation targets do not increase adverse events and likely improve outcomes 2
• Monitor fluid accumulation index (FAI = fluid balance/fluid intake ratio); values >0.42 are associated with significantly higher mortality (OR 1.461) 3
• Use crystalloids as first-line; consider albumin only if substantial crystalloid volumes are required to maintain adequate MAP 1
• Avoid hetastarch formulations entirely 1

Vasopressor Therapy

• Initiate norepinephrine as the first-choice vasopressor when MAP <65 mmHg despite adequate fluid resuscitation 1
• Norepinephrine remains the most well-supported vasopressor specifically in CHF patients with sepsis 2
• Target MAP ≥65 mmHg (though MAP 60-65 mmHg appears safe in older patients) 1, 4
• Avoid dopamine except in highly selected circumstances, as it may induce more cardiac adverse events in CHF patients 1, 2
• Vasopressin (0.03 U/min) can be added to norepinephrine to raise MAP or decrease norepinephrine dose, but should not be used as initial vasopressor 1

Inotropic Support

• Do NOT routinely use inotropes 1
• Administer dobutamine only when BOTH conditions are met: 1, 5
  • Low cardiac output with elevated cardiac filling pressures, AND
  • ScvO2 <70% despite adequate fluid resuscitation and MAP optimization
• The combination of dobutamine plus norepinephrine is recommended as first-line inotropic therapy when indicated 1
• Titrate inotropes to targeted responses: improvements in ScvO2, myocardial function indices, and lactate reduction 1
• Use dobutamine cautiously in CHF patients given generally detrimental effects, but it may benefit those with ventriculo-atrial uncoupling from depressed contractility 5, 2
• Achieving supranormal cardiac output (CI >4.5 L/min/m²) and oxygen delivery (DO2 >12 ml/min/kg) reduces mortality in appropriately selected patients 5

Antimicrobial and Source Control

• Obtain blood cultures before antibiotic administration 1
• Administer broad-spectrum antimicrobials within 1 hour of recognizing septic shock 1
• Perform imaging studies promptly to confirm potential infection source 1

Monitoring Targets

• Hourly urine output 1
• Lactate levels and biochemical markers of renal function 1
• ScvO2 with target ≥70% 1, 5
• MAP ≥65 mmHg 1
• Hemoglobin target 7-9 g/dL (transfuse if below this range in absence of active bleeding or acute coronary syndrome) 1

Adjunctive Management

Glucose Control

• Commence insulin when two consecutive blood glucose levels are >180 mg/dL 1
• Target upper blood glucose ≤180 mg/dL (NOT ≤110 mg/dL) 1
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1

Chronic Heart Failure Medications

• Carefully consider continuation versus discontinuation of chronic CHF medications upon sepsis development 2
• β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation 2
• After acute hemodynamic stabilization, β-blockers may be beneficial for atrial fibrillation management and have shown independent benefits in sepsis 2

Renal Replacement Therapy

• Continuous and intermittent renal replacement therapy are equivalent 1
• Use continuous therapies to facilitate fluid balance management in hemodynamically unstable patients 1
• Monitor carefully for effects on cardiac function when CHF is present 2

Mechanical Ventilation

• If mechanical ventilation required, use low tidal volume strategy 1
• Elevate head of bed unless contraindicated 1
• Monitor positive pressure ventilatory support carefully for effects on cardiac function 2

Prophylaxis

• Provide daily pharmacologic VTE prophylaxis with subcutaneous LMWH (or UFH if creatinine clearance <30 mL/min) 1
• Administer stress ulcer prophylaxis with H2 blocker or proton pump inhibitor if bleeding risk factors present 1

Critical Pitfalls

• Avoid withholding adequate initial fluid resuscitation due to CHF diagnosis—patients with CHF and sepsis who receive less fluid have worse outcomes 2, 3
• Do not use inotropes based solely on low cardiac output measurement; require concurrent ScvO2 <70% 1
• Recognize that CHF patients with sepsis have significantly higher mortality (35% vs 32%) and require aggressive early intervention 6
• Monitor fluid accumulation index closely; excessive fluid retention (FAI >0.42) dramatically increases mortality 3