Impact of left ventricular dysfunction and fluid balance on the outcomes of patients with sepsis

Published:December 13, 2019DOI:


      • We assessed whether the impact of LV dysfunction depends on fluid balance in sepsis.
      • AKI was prevalent in the patients with diastolic and systolic dysfunction.
      • Diastolic and systolic dysfunction were associated with longer duration of RRT.
      • Diastolic and systolic dysfunction were associated with mortality.
      • Their associations were independent of daily fluid balance.



      Left ventricular (LV) dysfunction is a predictor of mortality in patients with sepsis. However, whether the adverse impact of LV dysfunction depends on fluid balance remains unclear. We retrospectively investigated the impact of LV dysfunction and fluid balance on various outcomes of patients with sepsis.


      Critically ill patients with sepsis were classified according to their LV function: normal LV function, diastolic dysfunction (septal e′ of <10 and E/e′ of ≥15 with ejection fraction of ≥50%), and systolic dysfunction (ejection fraction of <50%).


      There were 83 (51.2%) patients with normal LV function, 39 (24.1%) with diastolic dysfunction, and 40 (24.7%) with systolic dysfunction. The cumulative and daily fluid balances after intensive care unit admission did not differ. However, acute kidney injury was more prevalent in the patients with diastolic and systolic dysfunction than in those with normal LV function (82.1%, 87.5%, and 69.9%, respectively; P = 0.065). LV dysfunction lengthened the duration of renal replacement therapy, independent of baseline renal dysfunction and the daily fluid balance (P = 0.008). Moreover, both diastolic and systolic dysfunction were associated with mortality (hazard ratio: 2.7 and 3.0; P = 0.047 and P = 0.028, respectively), regardless of the daily fluid balance, which was also a significant predictor of mortality (P < 0.001).


      LV dysfunction has an adverse impact on renal outcomes and mortality in patients with sepsis and seems to be independent of fluid balance. Additional therapeutic options to restore organ perfusion are needed for patients with sepsis who have LV dysfunction, in addition to intravenous fluid restriction.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Singer M
        • Deutschman CS
        • Seymour CW
        • Shankar-Hari M
        • Annane D
        • Bauer M
        • et al.
        The third international consensus definitions for sepsis and septic shock (Sepsis-3).
        JAMA. 2016; 315: 801-810
        • Rivers E.
        • Nguyen B.
        • Havstad S.
        • Ressler J.
        • Muzzin A.
        • Knoblich B.
        • et al.
        Early goal-directed therapy in the treatment of severe sepsis and septic shock.
        N Engl J Med. 2001; 345: 1368-1377
        • Rhodes A
        • Evans LE
        • Alhazzani W
        • Levy MM
        • Antonelli M
        • Ferrer R
        • et al.
        Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016.
        Crit Care Med. 2017; 45: 486-552
        • Byrne L
        • Van Haren F
        Fluid resuscitation in human sepsis: time to rewrite history?.
        Ann Intensive Care. 2017; 7: 4
        • Boyd J.H.
        • Forbes J.
        • Nakada T.A.
        • Walley K.R.
        • Russell J.A
        Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality.
        Crit Care Med. 2011; 39: 259-265
        • Kelm D.J.
        • Perrin J.T.
        • Cartin-Ceba R.
        • Gajic O.
        • Schenck L.
        • Kennedy C.C
        Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death.
        Shock. 2015; 43: 68-73
        • Marik P.E.
        • Linde-Zwirble W.T.
        • Bittner E.A.
        • Sahatjian J.
        • Hansell D
        Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database.
        Intensive Care Med. 2017; 43: 625-632
        • Sakr Y
        • Rubatto Birri PN
        • Kotfis K
        • Nanchal R
        • Shah B
        • Kluge S
        • et al.
        Higher fluid balance increases the risk of death from sepsis: results from a large international audit.
        Crit Care Med. 2017; 45: 386-394
        • Andrews B
        • Semler MW
        • Muchemwa L
        • Kelly P
        • Lakhi S
        • Heimburger DC
        • et al.
        Effect of an early resuscitation protocol on in-hospital mortality among adults with sepsis and hypotension: a randomized clinical trial.
        JAMA. 2017; 318: 1233-1240
        • Corl KA
        • Prodromou M
        • Merchant RC
        • Gareen I
        • Marks S
        • Banerjee D
        • et al.
        The restrictive iv fluid trial in severe sepsis and septic shock (RIFTS): a randomized pilot study.
        Crit Care Med. 2019; 47: 951-959
        • Vieillard-Baron A.
        • Caille V.
        • Charron C.
        • Belliard G.
        • Page B.
        • Jardin F
        Actual incidence of global left ventricular hypokinesia in adult septic shock.
        Crit Care Med. 2008; 36: 1701-1706
        • Sanfilippo F.
        • Corredor C.
        • Fletcher N.
        • Landesberg G.
        • Benedetto U.
        • Foex P.
        • et al.
        Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis.
        Intensive Care Med. 2015; 41: 1004-1013
        • Sanfilippo F.
        • Corredor C.
        • Arcadipane A.
        • Landesberg G.
        • Vieillard-Baron A.
        • Cecconi M.
        • et al.
        Tissue Doppler assessment of diastolic function and relationship with mortality in critically ill septic patients: a systematic review and meta-analysis.
        Br J Anaesth. 2017; 119: 583-594
        • Gonzalez C.
        • Begot E.
        • Dalmay F.
        • Pichon N.
        • Francois B.
        • Fedou A.L.
        • et al.
        Prognostic impact of left ventricular diastolic function in patients with septic shock.
        Ann Intensive Care. 2016; 6: 36
        • Sanfilippo F.
        • Corredor C.
        • Fletcher N.
        • Tritapepe L.
        • Lorini F.L.
        • Arcadipane A.
        • et al.
        Left ventricular systolic function evaluated by strain echocardiography and relationship with mortality in patients with severe sepsis or septic shock: a systematic review and meta-analysis.
        Crit Care. 2018; 22: 183
        • Abou Dagher G
        • Hajjar K
        • Khoury C
        • El Hajj N
        • Kanso M
        • Makki M
        • et al.
        Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon.
        BMJ Open. 2018; 8e022185
        • Micek S.T.
        • McEvoy C.
        • McKenzie M.
        • Hampton N.
        • Doherty J.A.
        • Kollef M.H
        Fluid balance and cardiac function in septic shock as predictors of hospital mortality.
        Crit Care. 2013; 17: R246
        • Lanspa M.J.
        • Gutsche A.R.
        • Wilson E.L.
        • Olsen T.D.
        • Hirshberg E.L.
        • Knox D.B.
        • et al.
        Application of a simplified definition of diastolic function in severe sepsis and septic shock.
        Crit Care. 2016; 20: 243
        • Beddhu S.
        • Bruns F.J.
        • Saul M.
        • Seddon P.
        • Zeidel M.L
        A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients.
        Am J Med. 2000; 108: 609-613
        • Vincent J.L.
        • de Mendonca A.
        • Cantraine F.
        • Moreno R.
        • Takala J.
        • Suter P.M.
        • et al.
        Use of the Sofa score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine.
        Crit Care Med. 1998; 26: 1793-1800
        • Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
        KDIGO clinical practice guideline for acute kidney injury.
        Kidney Int. 2012; 2: 138
        • Thomas M.E.
        • Blaine C.
        • Dawnay A.
        • Devonald M.A.
        • Ftouh S.
        • Laing C.
        • et al.
        The definition of acute kidney injury and its use in practice.
        Kidney Int. 2015; 87: 62-73
        • Alphonsus CS
        • Rodseth RN
        The endothelial glycocalyx: a review of the vascular barrier.
        Anaesthesia. 2014; 69: 777-784
        • Brooks H.F.
        • Moss R.F.
        • Davies N.A.
        • Jalan R.
        • Davies D.C
        Caecal ligation and puncture induced sepsis in the rat results in increased brain water content and perimicrovessel oedema.
        Metab Brain Dis. 2014; 29: 837-843
        • Glassford N.J.
        • Eastwood G.M.
        • Bellomo R
        Physiological changes after fluid bolus therapy in sepsis: a systematic review of contemporary data.
        Crit Care. 2014; 18: 696
        • Kellum J.A.
        • Cerda J.
        • Kaplan L.J.
        • Nadim M.K.
        • Palevsky P.M
        Fluids for prevention and management of acute kidney injury.
        Int J Artif Organs. 2008; 31: 96-110
        • Uchino S
        • Kellum JA
        • Bellomo R
        • Doig GS
        • Morimatsu H
        • Morgera S
        • et al.
        Acute renal failure in critically ill patients: a multinational, multicenter study.
        JAMA. 2005; 294: 813-818
        • Payen D.
        • de Pont A.C.
        • Sakr Y.
        • Spies C.
        • Reinhart K.
        • Vincent J.L.
        • et al.
        A positive fluid balance is associated with a worse outcome in patients with acute renal failure.
        Crit Care. 2008; 12: R74
        • Bouchard J.
        • Soroko S.B.
        • Chertow G.M.
        • Himmelfarb J.
        • Ikizler T.A.
        • Paganini E.P.
        • et al.
        Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury.
        Kidney Int. 2009; 76: 422-427
        • de Oliveira F.S.
        • Freitas F.G.
        • Ferreira E.M.
        • de Castro I.
        • Bafi A.T.
        • de Azevedo L.C.
        • et al.
        Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock.
        J Crit Care. 2015; 30: 97-101
        • Hoste E.A.
        • Maitland K.
        • Brudney C.S.
        • Mehta R.
        • Vincent J.L.
        • Yates D.
        • et al.
        Four phases of intravenous fluid therapy: a conceptual model.
        Br J Anaesth. 2014; 113: 740-747
        • Ronco C.
        • McCullough P.
        • Anker S.D.
        • Anand I.
        • Aspromonte N.
        • Bagshaw S.M.
        • et al.
        Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative.
        Eur Heart J. 2010; 31: 703-711
        • Damman K.
        • Testani J.M.
        The kidney in heart failure: an update.
        Eur Heart J. 2015; 36: 1437-1444
        • Yamagishi T.
        • Matsushita K.
        • Minamishima T.
        • Goda A.
        • Sakata K.
        • Satoh T.
        • et al.
        Comparison of risk factors for acute worsening renal function in heart failure patients with and without preserved ejection fraction.
        Eur J Intern Med. 2015; 26: 599-602
        • Travessa A.M.
        • Menezes Falcao L
        Vasodilators in acute heart failure - evidence based on new studies.
        Eur J Intern Med. 2018; 51: 1-10
        • Vieillard Baron A
        • Schmitt JM
        • Beauchet A
        • Augarde R
        • Prin S
        • Page B
        • et al.
        Early preload adaptation in septic shock? A transesophageal echocardiographic study.
        Anesthesiology. 2001; 94: 400-406