Managing Septic Shock in Patients with Dialysis and/or Congestive Heart Failure

Initial Resuscitation Strategy

The American College of Critical Care Medicine recommends proceeding with standard aggressive fluid resuscitation (30 mL/kg crystalloids within 3 hours) and early vasopressors in septic patients with ESRD on dialysis or CHF, with the use of continuous renal replacement therapy (CRRT) rather than intermittent hemodialysis for hemodynamically unstable patients to facilitate fluid balance management during resuscitation 1, 2.
The Society of Critical Care Medicine suggests that the presence of CHF or ESRD should not prevent the administration of the standard 30 mL/kg crystalloid bolus within the first 3 hours of septic shock recognition, as this aggressive approach improves outcomes even in patients with pre-existing heart failure 3.

The European Society of Intensive Care Medicine recommends norepinephrine as the first-line vasopressor for maintaining MAP ≥65 mmHg in both CHF and dialysis patients 1, 3, 4.
The American Heart Association suggests initiating vasopressors in conjunction with fluids rather than waiting for complete fluid resuscitation if MAP remains <65 mmHg 4, 5.

The International Society of Nephrology recommends using CRRT rather than intermittent hemodialysis for hemodynamically unstable septic patients with ESRD or acute kidney injury 1, 6, 7, 2, 4, 8.
The National Kidney Foundation suggests that CRRT facilitates fluid balance management during aggressive septic shock resuscitation, and intermittent hemodialysis can cause hemodynamic instability in vasopressor-dependent patients 1, 2, 4, 6, 7.

The American Diabetes Association recommends targeting blood glucose ≤180 mg/dL using protocolized insulin therapy, and avoiding tight glycemic control (≤110 mg/dL) as it increases risk without benefit 1, 6, 7, 2, 4.
The Society of Critical Care Medicine suggests not using sodium bicarbonate to improve hemodynamics or reduce vasopressor requirements if pH ≥7.15, even in dialysis patients with metabolic acidosis 1, 6, 7, 2, 4.

The American College of Chest Physicians recommends using low-molecular-weight heparin (LMWH) rather than unfractionated heparin for VTE prophylaxis, and combining pharmacologic prophylaxis with mechanical prophylaxis (intermittent pneumatic compression) whenever possible 1, 2, 4, 6, 7.

The Society of Critical Care Medicine suggests providing stress ulcer prophylaxis with proton pump inhibitor (preferred) or H2-receptor antagonist for patients with GI bleeding risk factors, as both sepsis and renal dysfunction are risk factors warranting prophylaxis 1, 6, 7, 2, 8, 5.
The American Society for Parenteral and Enteral Nutrition recommends initiating early enteral nutrition within 48 hours if tolerated, preferentially over parenteral nutrition, and targeting 1.0-1.5 g/kg/day protein if on RRT; up to 1.7 g/kg/day if on CRRT or hypercatabolic 1, 8.