Study: Too many heart failure patients are treated with IV fluids

Many patients hospitalized with severe heart failure are receiving potentially harmful treatment with intravenous fluids, according to a Yale-led study, published in the Journal of the American College of Cardiology: Heart Failure.

This retrospective cohort study is the first to examine use of common IV fluids in hospitalized heart failure patients.

Lead study author Behnood Bikdeli, MD, an internal medicine resident at Yale School of Medicine and a research scholar at Yale Center for Outcomes Research and Evaluation (CORE), and researchers reviewed data with decompensated heart failure who received IV fluids during the first 2 days. The database was created by Premier, Inc., and included roughly 20% of hospitalizations nationwide.

“We looked for hospitalizations with heart failure in which patients were treated with loop diuretics,” said Dr Bikdeli. "Among those, we determined the proportion of patients who were treated with IV fluids in the same time period. To have a fairly clean cohort, we excluded those would could have required IV fluids for other specific reasons [eg, sepsis, shock, major cardiovascular procedures, etc].”

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The researchers found that 11% of the patients were treated with IV fluids in addition to diuretics.

“What we found was that even among a fairly clean cohort of over 130,000 hospitalizations from roughly 350 hospitals across the nation, over 10% were receiving significant volumes of IV fluids, in addition to diuretics, early in their course of hospital stay,” said Dr Bikdeli.

That percentage is significant, he noted, considering that approximately 5 million people in the United States have a diagnosis of heart failure.

“Such practice was associated with higher rates of ICU admission, endotracheal intubation, need for renal replacement therapy, and in-hospital death. There was also much variation across hospitals about that practice, suggesting that the hospital policy/culture plays a role,” he said.

Patients with heart failure most commonly have congestive symptoms-excessive build up of fluids-and especially when they get hospitalized with a decompensation, it most frequently associated with worsening of such congestive symptoms, according to Dr Bikdeli.

“That is why the vast majority of them receive diuretics during the hospital course. Nevertheless, IV fluids are a common practice for most hospitalized patients, and have turned into a ‘routine’ irrespective of the cause of admission. So, we were curious to see if use of IV fluids was happening among patients with heart failure, who are already on diuretics-it would be paradoxical to see both diuretics and fluids in the same time course.”

At the patient level, Dr Bikdeli and the researchers noted that this practice happens to several patients with heart failure, and those patients did have worse outcomes.

“The next step is to see who these patients are, why they received significant volumes of fluids, and whether use of IV fluids was the cause of worse outcomes in some of them,” he explained.

At the policy level, the wide variation that we observed would be beyond what we would expect from case-mix differences and represents structural/cultural differences across institutions.

“Our study was a first step to a very important and previously unrecognized issue,” Dr Bikdeli said. “Until we have further investigations at patient and institution levels, it would be reasonable for hospital managers to implement strategies that would reduce the likelihood of inadvertent IV fluid use in patients with heart failure-adding reminders to the chart, removing the ‘routine’ fluid orders per admission, etc.”