How is tachycardia managed in sepsis?

From the Guidelines

Tachycardia in sepsis is primarily managed by treating the underlying infection while supporting hemodynamics, with a focus on aggressive fluid resuscitation and vasopressor therapy as needed to maintain mean arterial pressure ≥65 mmHg, as recommended by the Surviving Sepsis Campaign guidelines 1.

Initial Management

Initial management focuses on aggressive fluid resuscitation with crystalloids (typically 30 ml/kg within the first 3 hours) to improve preload and cardiac output, as suggested by the guidelines 1. Early administration of appropriate antibiotics is crucial, with broad-spectrum coverage tailored to the suspected source of infection.

Vasopressor Therapy

If tachycardia persists despite adequate fluid resuscitation, vasopressors are indicated, with norepinephrine (starting at 0.05-0.1 mcg/kg/min, titrated to effect) as the first-line agent to maintain mean arterial pressure ≥65 mmHg, as recommended by the guidelines 1.

• Norepinephrine is the first-choice vasopressor, with epinephrine and vasopressin considered as additional or alternative agents in specific circumstances 1.
• Dopamine may be considered as an alternative vasopressor agent in highly selected patients, such as those with low risk of tachyarrhythmias and absolute or relative bradycardia 1.

Additional Considerations

• Beta-blockers such as esmolol may be cautiously considered in select patients with persistent tachycardia despite resolved hypovolemia, but should be used only when hemodynamically stable as they can worsen hypotension.
• Addressing fever with antipyretics like acetaminophen (650-1000 mg every 4-6 hours) can help reduce tachycardia.
• Continuous cardiac monitoring is essential throughout treatment, as recommended by the guidelines 1. The tachycardia in sepsis represents a compensatory mechanism to maintain cardiac output during decreased systemic vascular resistance and relative hypovolemia, so treating the underlying cause rather than directly targeting the heart rate is the most effective approach.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

1. 1 Dosing for the Treatment of Supraventricular Tachycardia or Noncompensatory Sinus Tachycardia Esmolol hydrochloride is administered by continuous intravenous infusion with or without a loading dose. Additional loading doses and/or titration of the maintenance infusion (step-wise dosing) may be necessary based on desired ventricular response Table 1: Step-Wise Dosing In the absence of loading doses, continuous infusion of a single concentration of esmolol reaches pharmacokinetic and pharmacodynamic steady-state in about 30 minutes. The effective maintenance dose for continuous and step-wise dosing is 50 to 200 mcg per kg per minute, although doses as low as 25 mcg per kg per minute have been adequate Dosages greater than 200 mcg per kg per minute provide little added heart-rate lowering effect, and the rate of adverse reactions increases.

The management of tachycardia in sepsis with esmolol involves administering the drug by continuous intravenous infusion, with or without a loading dose.

• The effective maintenance dose is 50 to 200 mcg per kg per minute.
• Doses as low as 25 mcg per kg per minute have been adequate.
• Dosages greater than 200 mcg per kg per minute provide little added heart-rate lowering effect and increase the rate of adverse reactions. 2

From the Research

Management of Tachycardia in Sepsis

• Tachycardia in sepsis is a common complication that requires prompt management to prevent further deterioration of the patient's condition 3.
• The management of tachycardia in sepsis involves a multifaceted approach, including fluid resuscitation, vasopressor therapy, and inotropic support 4, 5, 6.
• Fluid resuscitation is the initial step in managing sepsis, with the goal of achieving a mean arterial pressure of at least 65 mmHg 4, 5.
• Vasopressor therapy, such as dopamine or norepinephrine, may be necessary to maintain blood pressure and perfusion of vital organs 4, 5.
• Inotropic agents, such as dobutamine, may be used to support cardiac function in patients with sepsis and tachycardia 4.
• Beta-blockers (BBs) have been shown to be effective in reducing mortality in patients with sepsis and tachycardia, particularly in those with absolute or relative tachycardia 3.

Role of Beta-Blockers in Managing Tachycardia in Sepsis

• Beta-blockers have been found to reduce the risk of mortality in patients with sepsis and tachycardia by blunting the effects of excessive catecholamine release on the heart 3.
• Selective beta-blockers have been shown to have a stronger protective effect than non-selective beta-blockers in reducing mortality in patients with sepsis and tachycardia 3.
• The use of beta-blockers in patients with sepsis and tachycardia should be considered on a case-by-case basis, taking into account the patient's underlying medical conditions and the severity of their sepsis 3.

Challenges in Managing Tachycardia in Sepsis

• Managing tachycardia in sepsis can be challenging, particularly in patients with underlying cardiac conditions or those who have experienced a recent ischemic event 7.
• The presence of tachycardia in sepsis can be a sign of underlying organ dysfunction, and prompt recognition and management are critical to preventing further deterioration of the patient's condition 4, 5, 6.