Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure: Results of a Multicenter Clinician Survey

Gabriel Wardi, Ian Joel, Julian Villar, Michael Lava, Eric Gross, Vaishal Tolia, Raghu R. Seethala, Robert L. Owens, Rebecca E. Sell, Sydney B. Montesi, Farbod N. Rahaghi, Somnath Bose, Ashish Rai, Elizabeth K. Stevenson, Jakob McSparron, Vaishal Tolia, Jeremy R. Beitler

Research output: Contribution to journalArticle

Abstract

Purpose: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. Methods: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. Results: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P <.01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. Conclusions: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.

Original languageEnglish (US)
JournalJournal of Intensive Care Medicine
DOIs
StateAccepted/In press - Jan 1 2019

Fingerprint

Septic Shock
Resuscitation
Heart Failure
Sepsis
Controlled Hypotension
Emergency Medicine
Practice Guidelines
Shock
Logistic Models
Surveys and Questionnaires
boldenone undecylenate
Patient Preference
Internal Medicine
Nonparametric Statistics
Body Weight
Guidelines
Physicians

Keywords

  • crystalloid
  • fluid challenge
  • resuscitation
  • septic shock
  • systolic heart failure

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure : Results of a Multicenter Clinician Survey. / Wardi, Gabriel; Joel, Ian; Villar, Julian; Lava, Michael; Gross, Eric; Tolia, Vaishal; Seethala, Raghu R.; Owens, Robert L.; Sell, Rebecca E.; Montesi, Sydney B.; Rahaghi, Farbod N.; Bose, Somnath; Rai, Ashish; Stevenson, Elizabeth K.; McSparron, Jakob; Tolia, Vaishal; Beitler, Jeremy R.

In: Journal of Intensive Care Medicine, 01.01.2019.

Research output: Contribution to journalArticle

Wardi, G, Joel, I, Villar, J, Lava, M, Gross, E, Tolia, V, Seethala, RR, Owens, RL, Sell, RE, Montesi, SB, Rahaghi, FN, Bose, S, Rai, A, Stevenson, EK, McSparron, J, Tolia, V & Beitler, JR 2019, 'Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure: Results of a Multicenter Clinician Survey', Journal of Intensive Care Medicine. https://doi.org/10.1177/0885066619871247
Wardi, Gabriel ; Joel, Ian ; Villar, Julian ; Lava, Michael ; Gross, Eric ; Tolia, Vaishal ; Seethala, Raghu R. ; Owens, Robert L. ; Sell, Rebecca E. ; Montesi, Sydney B. ; Rahaghi, Farbod N. ; Bose, Somnath ; Rai, Ashish ; Stevenson, Elizabeth K. ; McSparron, Jakob ; Tolia, Vaishal ; Beitler, Jeremy R. / Equipoise in Appropriate Initial Volume Resuscitation for Patients in Septic Shock With Heart Failure : Results of a Multicenter Clinician Survey. In: Journal of Intensive Care Medicine. 2019.
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abstract = "Purpose: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. Methods: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40{\%}. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. Results: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3{\%}). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4{\%} of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4{\%} of respondents for patients with concomitant HFrEF, compared to 89.1{\%} of respondents for patients without HFrEF (P <.01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. Conclusions: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.",
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T2 - Results of a Multicenter Clinician Survey

AU - Wardi, Gabriel

AU - Joel, Ian

AU - Villar, Julian

AU - Lava, Michael

AU - Gross, Eric

AU - Tolia, Vaishal

AU - Seethala, Raghu R.

AU - Owens, Robert L.

AU - Sell, Rebecca E.

AU - Montesi, Sydney B.

AU - Rahaghi, Farbod N.

AU - Bose, Somnath

AU - Rai, Ashish

AU - Stevenson, Elizabeth K.

AU - McSparron, Jakob

AU - Tolia, Vaishal

AU - Beitler, Jeremy R.

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N2 - Purpose: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. Methods: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. Results: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P <.01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. Conclusions: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.

AB - Purpose: International clinical practice guidelines call for initial volume resuscitation of at least 30 mL/kg body weight for patients with sepsis-induced hypotension or shock. Although not considered in the guidelines, preexisting cardiac dysfunction may be an important factor clinicians weigh in deciding the quantity of volume resuscitation for patients with septic shock. Methods: We conducted a multicenter survey of clinicians who routinely treat patients with sepsis to evaluate their beliefs, behaviors, knowledge, and perceived structural barriers regarding initial volume resuscitation for patients with sepsis and concomitant heart failure with reduced ejection fraction (HFrEF) <40%. Initial volume resuscitation preferences were captured as ordinal values, and additional testing for volume resuscitation preferences was performed using McNemar and Wilcoxon signed rank tests as indicated. Univariable logistic regression models were used to identify significant predictors of ≥30 mL/kg fluid administration. Results: A total of 317 clinicians at 9 US hospitals completed the survey (response rate 47.3%). Most respondents were specialists in either internal medicine or emergency medicine. Substantial heterogeneity was found regarding sepsis resuscitation preferences for patients with concomitant HFrEF. The belief that patients with septic shock and HFrEF should be exempt from current sepsis bundle initiatives was shared by 39.4% of respondents. A minimum fluid challenge of ∼30 mL/kg or more was deemed appropriate in septic shock by only 56.4% of respondents for patients with concomitant HFrEF, compared to 89.1% of respondents for patients without HFrEF (P <.01). Emergency medicine physicians were most likely to feel that <30 mL/kg was most appropriate in patients with septic shock and HFrEF. Conclusions: Clinical equipoise exists regarding initial volume resuscitation for patients with sepsis-induced hypotension or shock and concomitant HFrEF. Future studies and clinical practice guidelines should explicitly address resuscitation in this subpopulation.

KW - crystalloid

KW - fluid challenge

KW - resuscitation

KW - septic shock

KW - systolic heart failure

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