Esmolol for Septic Shock?

February 16, 2021

Written by Clay Smith

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When septic patients with persistent tachycardia after initial resuscitation received ultra-short acting β-blockers, 28-day mortality was significantly lower, NNT 5.5.

Why does this matter?
Catecholamine excess can be bad for the heart (i.e. Takotsubo). But is giving a β-blocker to a tachycardic patient with sepsis like putting a piece of black tape over your car’s “Check Engine” light? Or is the hyper-sympathetic state of sepsis something we could moderate to improve patient outcomes?

If it’s fast, slow it?
This was a systematic review of 7 RCTs, 613 patients, with sepsis and persistent tachycardia after initial resuscitation who received either esmolol or landiolol. Initial resuscitation consisted of an undetermined amount of fluid plus vasopressors in most trials. Six trials (572 patients) were meta-analyzed for the outcome of 28-day mortality; mortality risk was reduced by 32% in patients who received a β-blocker vs placebo (risk ratio, 0.68; 95% CI 0.54 to 0.85). Overall mortality rate was 36.7% in the esmolol/landiolol cohort, 54.9% in the placebo group; absolute risk reduction 18.2%, NNT 5.5. Heterogeneity was low (I2 = 31%). Heart rate was significantly lower in all seven trials in patients who received the β-blocker, but MAP was not significantly reduced. Five of the trials were done in China, one in Japan, and one in Italy, which could impact generalizability. Five of six trials used esmolol. Landiolol is not FDA approved in the U.S. and was used in one trial. Landiolol has a similar β1 cardioselective mechanism of action to esmolol and is also ultra-short acting. This looks encouraging. But there was a wide range of mortality across these centers, from 12-62% in the β-blocker group; 20-80% in the placebo group. All of these were small RCTs. It seems like a large RCT is warranted to confirm this.

Source
EFFECT OF ULTRA-SHORT-ACTING β-BLOCKERS ON MORTALITY IN PATIENTS WITH PERSISTENT TACHYCARDIA DESPITE INITIAL RESUSCITATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. Chest. 2021 Jan 9;S0012-3692(21)00035-0. doi: 10.1016/j.chest.2021.01.009. Online ahead of print.