How do you manage septic shock in a patient with congestive heart failure (CHF) and/or end-stage renal disease (ESRD) on dialysis?

Managing Septic Shock in Patients with Dialysis and/or Congestive Heart Failure

In septic patients with ESRD on dialysis or CHF, proceed with standard aggressive fluid resuscitation (30 mL/kg crystalloids within 3 hours) and early vasopressors, but use continuous renal replacement therapy (CRRT) rather than intermittent hemodialysis for hemodynamically unstable patients to facilitate fluid balance management during resuscitation. 1

Initial Resuscitation Strategy

The presence of CHF or ESRD should not prevent you from administering the standard 30 mL/kg crystalloid bolus within the first 3 hours of septic shock recognition. 1, 2 This aggressive approach improves outcomes even in patients with pre-existing heart failure, as inadequate resuscitation worsens both sepsis-associated acute kidney injury and mortality. 2, 3

Key principle: Under-resuscitation due to fear of volume overload causes more harm than appropriate fluid administration in septic shock. 2, 3

Specific Fluid Thresholds for CHF Patients

• For CHF patients specifically, consider limiting total ED fluid to approximately 2.6 L if clinical improvement is achieved, as volumes exceeding this threshold increase CHF exacerbation risk by 90% without mortality benefit. 4
• However, this threshold applies only after initial resuscitation goals are met—do not withhold initial fluids if the patient remains hypoperfused. 5, 4

Vasopressor Management

Norepinephrine remains the first-line vasopressor for maintaining MAP ≥65 mmHg in both CHF and dialysis patients. 1, 2

• Initiate vasopressors in conjunction with fluids rather than waiting for complete fluid resuscitation if MAP remains <65 mmHg. 2, 3
• Avoid dopamine in CHF patients, as it induces more cardiac adverse events compared to norepinephrine. 5
• 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

Inotrope Considerations in CHF

Use dobutamine cautiously and only when there is clear evidence of low cardiac output with adequate preload. 5, 6

• Dobutamine may be beneficial when combined with norepinephrine in patients with myocardial dysfunction, elevated cardiac filling pressures, and low cardiac output. 1
• Start at 3-5 μg/kg/min and titrate up to 20 μg/kg/min if needed for septic cardiomyopathy. 7
• Critical pitfall: If blood pressure drops despite fluid resuscitation, consider septic cardiomyopathy—increase inotropic support and reduce cardiac preload by slowing fluid administration. 7

Renal Replacement Therapy Strategy

For hemodynamically unstable septic patients with ESRD or acute kidney injury, use CRRT rather than intermittent hemodialysis. 1, 2, 8

This recommendation is particularly important because:

• CRRT facilitates fluid balance management during aggressive septic shock resuscitation. 1, 2
• Intermittent hemodialysis can cause hemodynamic instability in vasopressor-dependent patients. 1

Indications for RRT Initiation

Initiate RRT only for definitive indications: 1, 2, 8

• Severe acidosis (pH <7.15)
• Hyperkalemia
• Uremic complications
• Refractory volume overload

Do not initiate RRT solely for creatinine elevation or oliguria without other definitive indications. 1, 2, 8

Metabolic and Acid-Base Management

Glucose Control

• Target blood glucose ≤180 mg/dL using protocolized insulin therapy. 1, 2
• Avoid tight glycemic control (≤110 mg/dL), as this increases risk without benefit. 1
• Monitor glucose every 1-2 hours until stable, then every 4 hours. 1

Bicarbonate Therapy

Do not use sodium bicarbonate to improve hemodynamics or reduce vasopressor requirements if pH ≥7.15. 1, 2

This applies even in dialysis patients with metabolic acidosis, as bicarbonate does not improve outcomes and may worsen volume overload. 2, 3

VTE Prophylaxis in Renal Dysfunction

Use low-molecular-weight heparin (LMWH) rather than unfractionated heparin for VTE prophylaxis. 1, 2

Dosing Adjustments for Renal Impairment

• If creatinine clearance <30 mL/min, use dalteparin or another LMWH with low renal metabolism, or switch to unfractionated heparin. 1, 2
• Combine pharmacologic prophylaxis with mechanical prophylaxis (intermittent pneumatic compression) whenever possible. 1

Supportive Care Measures

Stress Ulcer Prophylaxis

• Provide stress ulcer prophylaxis with proton pump inhibitor (preferred) or H2-receptor antagonist for patients with GI bleeding risk factors. 1, 8, 3
• Both sepsis and renal dysfunction are risk factors warranting prophylaxis. 3

Nutrition

• Initiate early enteral nutrition within 48 hours if tolerated, preferentially over parenteral nutrition. 1, 8
• Target 1.0-1.5 g/kg/day protein if on RRT; up to 1.7 g/kg/day if on CRRT or hypercatabolic. 8

Critical Pitfalls to Avoid

Do not withhold antibiotics due to nephrotoxicity concerns—treatment of sepsis takes absolute priority, as mortality risk from untreated sepsis far exceeds risk of worsening kidney function. 2, 3

Do not avoid colloids (albumin, hydroxyethyl starch) in favor of crystalloids—colloids increase risk of acute kidney injury without improving outcomes. 2

Do not continue chronic CHF medications blindly—β-blockers may be appropriate to continue in absence of acute hemodynamic decompensation, but carefully consider continuation versus discontinuation of other agents. 5

Monitor for septic cardiomyopathy: If circulation deteriorates despite adequate fluid resuscitation, consider cardiac dysfunction rather than reflexively administering more fluid. 7, 6