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IV fluids linked to worse outcomes in patients hospitalized for HF
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Among patients hospitalized for HF who were treated with loop diuretics, those who also received IV fluids had higher rates of death and other poor outcomes, according to a retrospective cohort study.
Researchers analyzed a Premier Inc. database representing approximately 20% of annual acute care hospitalizations in the United States. They assessed the use of IV fluids during the first 2 days of hospitalization among 131,430 patients hospitalized for HF (57% aged older than 75 years; 53% women; 63% white) across 346 institutions from 2009 to 2010.
The primary outcome was the proportion of hospitalizations including treatment with IV fluids in the first 2 days. Secondary outcomes included length of stay, in-hospital death and critical care admission, intubation and renal replacement therapy after day 2 of hospitalization.
Behnood Bikdeli, MD, and colleagues found that 11% of patients were treated with IV fluids, most commonly normal saline (80%) and half-normal saline (12%), during the first 2 days of hospitalization. The median volume of administered fluid was 1,000 ml (interquartile range, 1,000-2,000 mL). They did not observe any differences in demographics or comorbidities between those who received IV fluids and those who did not.
Fluids linked with worse outcomes
Compared with those who received only diuretics, those treated with diuretics plus IV fluids had a higher rate of subsequent critical care admission (5.7% of patients vs. 3.8%; P < .0001), intubation (1.4% vs. 1%; P = .0012), renal replacement therapy (0.6% vs. 0.3%; P < .0001) and in-hospital death (3.3% vs. 1.8%; P < .0001), according to the researchers.
Bikdeli, an internal medicine resident at Yale University and Yale-New Haven Hospital, and colleagues found that use of IV fluids varied widely across hospitals (range, 0% to 71% of hospitalizations; median, 12.5%).
“This practice may occur inadvertently for many patients, warrants further investigation and may be an opportunity for improvement,” Bikdeli and colleagues wrote.
Individual patient differences
Larry A. Allen
In a related editorial, Larry A. Allen, MD, MHS, wrote that a limitation of the study is that the database used “lacks important information about dynamic renal function, vital signs and other factors that can and should influence IV fluid use. This not only affects the ability to understand individual patient differences, but thereby also limits the ability to adjust for associations with outcomes and for hospital-level differences reflective of patient mix.”
However, Allen, from the section of advanced heart failure and transplantation of the division of cardiology and the Colorado Health Outcomes Program at the University of Colorado School of Medicine, Aurora, Colo., and the Colorado Cardiovascular Outcomes Research Consortium, Denver, wrote that “pointing out the frequency with which US hospitals give IV fluid and loop diuretics to patients with worsening [HF] suggests a way forward to our goal of improving acute care. Specific to [HF], we need to pay attention to what matters most: a thoughtful approach to the control of fluid status.”
Disclosures: One researcher reports financial ties with Johnson & Johnson, Medtronic and United Healthcare. Allen reports being supported by an award from the NIH.
For more information:
Allen LA. J Am Coll Cardiol HF. 2015;doi:10.1016/j.jchf.2014.11.001.
Bikdeli B, et al. J Am Coll Cardiol HF. 2015;doi:10.1016/j.jchf.2014.09.007.
Perspective
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Jay N. Cohn, MD
Management of acute decompensated HF must be individualized. Large databases may be helpful for identifying strategies that are, on average, effective or dangerous, but management based on an individual patient’s circulatory state is essential for a favorable short-term outcome. The observations by Bikdeli and colleagues give us no new insights into patient management, but raise the possibility that hospitalized patients, in at least some institutions, are receiving unordered saline as part of routine hospital management. To the extent that the patient with HF usually has diminished ability to excrete sodium, the basis for loop diuretic therapy, this sodium load is probably inappropriate in most. If hospitals and caregivers are insensitive to this inappropriate use of saline, it could account, at least in part, for why the saline users had worse outcomes. It would be of interest to know whether patients in academic centers or managed by cardiologists received less saline. But the message should be that all aspects of patient management, including the casual introduction of an IV line, should be carefully monitored for optimal individualized care.
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