How to reverse beta (beta blockers) blocker induced hypotension?

From the Guidelines

To reverse beta blocker induced hypotension, administer glucagon as a first-line treatment at a dose of 1-5 mg IV bolus, followed by an infusion of 1-5 mg/hour. This approach is based on the principle of bypassing the blocked beta receptors to restore cardiac function and blood pressure. According to the most recent and highest quality study available, 1, the management of beta blocker induced hypotension involves careful consideration of the patient's clinical status and the potential for hypoperfusion.

Key Considerations

• If hypotension is accompanied by other clinical evidence of hypoperfusion, beta-blocker therapy should be decreased or discontinued pending further patient evaluation 1.
• Administering the beta blocker and ACE inhibitor at different times during the day may minimize the risk of hypotension 1.
• Hypotensive symptoms may also resolve after a decrease in the dose of diuretics in patients who are volume depleted 1.

Treatment Options

• Glucagon: 1-5 mg IV bolus, followed by an infusion of 1-5 mg/hour, as it activates adenylyl cyclase independently of beta receptors.
• High-dose vasopressors: such as epinephrine (starting at 0.05-0.1 mcg/kg/min) or norepinephrine (starting at 0.05-0.1 mcg/kg/min), which stimulate alpha receptors to increase peripheral resistance.
• Calcium: calcium chloride (10-20 mg/kg IV) or calcium gluconate (30-60 mg/kg IV) to improve cardiac contractility directly.
• Intravenous lipid emulsion therapy: 1.5 mL/kg bolus followed by 0.25 mL/kg/min infusion for 30-60 minutes, which may be effective for lipophilic beta blockers.
• Insulin-glucose therapy: 1 unit/kg regular insulin bolus with glucose to maintain euglycemia, followed by 0.5-1 unit/kg/hour infusion, which improves cardiac efficiency and performance through metabolic effects.

Additional Measures

• Atropine may help with bradycardia but is often ineffective for hypotension.
• The symptom of fatigue is multifactorial and should be addressed with consideration of other causes, including sleep apnea, overdiuresis, or depression 1.

From the Research

Reversing Beta Blocker Induced Hypotension

To reverse beta blocker induced hypotension, several treatment options are available. The choice of treatment depends on the severity of the hypotension and the patient's overall condition.

• Glucagon Therapy: Glucagon has been shown to be effective in reversing beta blocker induced hypotension 2. It increases heart rate and myocardial contractility, and improves atrioventricular conduction. The recommended dose is 50 micrograms/kg iv loading dose, followed by a continuous infusion of 1-15 mg/h, titrated to patient response.
• Catecholamines and Vasopressors: Catecholamines, such as norepinephrine, and vasopressors, such as vasopressin, can be used to increase blood pressure and heart rate 3. However, they may also increase systemic vascular resistance, which can decrease cardiac output and perfusion of vascular beds.
• High-Dose Insulin Euglycaemic Therapy: High-dose insulin therapy has emerged as an effective treatment for severe beta blocker and calcium channel blocker poisoning 4. It increases inotropy, intracellular glucose transport, and vascular dilatation. The recommended dose is 1 U/kg insulin bolus followed by a 1-10 U/kg/h continuous infusion.
• Milrinone: Milrinone, a phosphodiesterase inhibitor, has been shown to be effective in treating beta blocker induced hypotension 5. It increases cardiac output and decreases systemic vascular resistance.
• Vasopressin: Vasopressin can be used to increase blood pressure and improve hemodynamics in patients with beta blocker induced hypotension 6. It is particularly useful in patients who are unresponsive to other treatments.

Treatment Considerations

When treating beta blocker induced hypotension, it is essential to consider the following:

• Monitoring: Patients should be closely monitored for signs of hypoglycemia, hypokalemia, and other adverse effects of treatment.
• Dosing: The dose of the chosen treatment should be titrated to patient response to avoid adverse effects.
• Combination Therapy: Combination therapy, such as using glucagon and high-dose insulin, may be effective in severe cases of beta blocker induced hypotension.
• Supportive Care: Supportive care, such as fluid resuscitation and oxygen therapy, should be provided as needed to support the patient's overall condition.