Rebecca Bruning, PharmD,
PGY1 Pharmacy Practice Resident
University of Kentucky HealthCare
Lexington, Kentucky
Disclosure information not submitted.
Aaron Chase
PGY-2 Critical Care Pharmacy Resident
Augusta University Medical Center
Augusta, Georgia
Disclosure information not submitted.
Naphun Nimmanonda, PharmD
Clinical Pharmacist
Augusta University Medical Center, United States
Disclosure information not submitted.
Timothy Jones, PharmD
PGY1 Pharmacy Practice Resident
University of Georgia College of Pharmacy, United States
Disclosure information not submitted.
Susan Smith, BCCCP, BCPS, PharmD
Clinical Associate Professor
University of Georgia
Athens, Georgia
Disclosure information not submitted.
Andrea Newsome, PharmD, BCPS
Pharmacist
University of Georgia College of Pharmacy
Augusta, Georgia, United States
Disclosure information not submitted.
Title: Early diuretics for de-resuscitation in septic patients with left ventricular dysfunction
Introduction: Management of de-resuscitation in septic patients with heart failure (HF) is not well delineated. The purpose of this study was to determine if diuretic initiation within 48 hours reduced incidence of fluid overload and improved patient outcomes.
Methods: This single center, retrospective cohort study included adult patients with an established diagnosis of chronic congestive heart failure and admitted to the medical or cardiac intensive care unit (ICU) between October 1, 2018, and January 1, 2020, with a preliminary diagnosis of sepsis or septic shock. The primary outcome was the incidence of mechanical ventilation (MV) in patients receiving early (< 48 hours) versus late ( >48 hours) initiation of diuresis. Secondary outcomes included hospital mortality, duration of MV, ventilator-free days, incidence of diuretic-associated side effects including Acute Kidney Injury (AKI) and electrolyte abnormalities, and fluid balance at 24, 48, and 72 hours after admission in each group. Continuous variables were assessed using independent t-test or Mann-Whitney U while categorical variables were assessed using the Pearson Chi-squared test.
RESULTS & CONCLUSIONS: A total of 101 patients were included. No significant difference was observed in the primary outcome of incidence of MV between the early and late diuretic group (72% vs. 75%, p=0.856). The duration of MV (4 vs. 5 days, p=0.129), MV-free days (22 vs. 18.5 days, p=0.129), and mortality (28 [38%] vs. 12 [43%], p=0.821) were also similar between groups. In a subgroup analysis (n=76) that excluded patients requiring renal replacement therapy (RRT), early administration of diuretics was associated with a reduced incidence of MV (41 [73.2%] vs 20 [100%], p=0.01) and reduced duration of MV (4 vs. 8 days, p=0.018). Both the entire cohort and subgroup without RRT had a significantly lower incidence of AKI, had no difference in electrolyte derangements, and had a lower mean net fluid balance at 24, 48, and 72 hours with early diuretics. Diuretic use within 48 hours in septic patients with HF resulted in decreased incidence of AKI and lower mean net fluid balance. Further, in non-RRT patients, early diuretic use resulted in decreased incidence and duration of MV.