Liberal vs Restrictive Fluid Resuscitation in Sepsis With Underlying Heart Failure: A Meta-Analysis

Introduction: In patients with sepsis, fluid resuscitation plays a pivotal role in restoring tissue perfusion. However, when sepsis occurs in the setting of pre-existing heart failure (HF), maintaining tissue perfusion becomes particularly challenging. Liberal fluid strategies may enhance perfusion but increase the risk of volume overload, whereas restrictive approaches aim to prevent fluid-related complications but may compromise organ perfusion. Current guidelines do not provide clear recommendations for fluid resuscitation in this complex population. This meta-analysis aimed to evaluate the impact of liberal versus restrictive fluid resuscitation strategies in this high-risk population.


Methods: A systematic review and meta-analysis were conducted to evaluate research studies that compared liberal and restrictive fluid resuscitation strategies for septic patients with HF. The primary outcome was all-cause mortality and mechanical ventilation needs, and ICU length of stay (LOS) were evaluated as secondary outcomes. The random-effects model served as the method to pool data from the studies. Odds ratios (ORs) and mean differences (MDs) along with their corresponding 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using the I² statistic.


Results: The primary analysis incorporated seven studies (n = 1,070; 514 liberal, 556 restrictive) to determine the outcomes. Liberal fluid resuscitation was associated with a non-significant reduction in all-cause mortality compared to restrictive strategies (OR 0.76; 95% CI 0.54-1.06; I² = 15%). The four studies (n = 528) which investigated mechanical ventilation requirements showed no significant difference (OR 0.79; 95% CI 0.27-2.33; I² = 83%). ICU length of stay, assessed in four studies (n = 582), was also comparable between groups (MD –0.13 days; 95% CI –1.04-0.77; I² = 31%).


Conclusions: Liberal fluid resuscitation demonstrated a non-significant trend toward lower all-cause mortality in septic patients with pre-existing HF. Rates of mechanical ventilation and ICU LOS were comparable between liberal and restrictive strategies. These results highlight the need for high-quality prospective trials to better define optimal fluid resuscitation strategies in septic patients with coexisting HF.