From the Guidelines
Esmolol can be considered as an adjunctive therapy in septic shock patients with persistent tachycardia despite adequate fluid resuscitation, as it may improve cardiac efficiency and reduce mortality in selected patients, as suggested by a small single-centre trial 1. The recommended approach is to start with a low dose of 25-50 mg/hour without a loading dose, then gradually titrate up by 25-50 mg/hour every 20-30 minutes to achieve a heart rate of 80-95 beats per minute, with a maximum dose of 200 mg/hour. Some key points to consider when using esmolol in septic shock include:
- Continuous cardiac monitoring is essential during administration
- Esmolol should only be initiated after adequate fluid resuscitation and vasopressor support are established, typically with norepinephrine as the first-line vasopressor 1, 1
- Before starting esmolol, ensure the patient has a stable blood pressure (typically mean arterial pressure ≥65 mmHg) and no signs of tissue hypoperfusion The rationale for using esmolol in septic shock is that excessive adrenergic stimulation can lead to myocardial dysfunction, increased oxygen consumption, and potentially harmful effects on immune function 1. However, careful patient selection is crucial as beta-blockade can worsen hypotension in unstable patients, and esmolol should be discontinued if hypotension or signs of decreased tissue perfusion develop. It is also important to note that norepinephrine is the recommended first-line vasoactive drug in septic shock, and other agents such as epinephrine, phenylephrine, and vasopressin are usually considered second-line agents 1. In addition, inotropes such as dobutamine and levosimendan have also been suggested as second-line agents for the management of refractory shock, but their use should be carefully considered due to potential risks and benefits 1, 1.
From the Research
Esmolol in Septic Shock
- Esmolol has been studied as a potential treatment for septic shock, with some studies suggesting it may improve outcomes by reducing heart rate and improving cardiac function 2, 3, 4.
- A randomized controlled trial found that esmolol infusion in patients with septic shock and tachycardia was associated with reduced heart rates and improved hemodynamic outcomes, without increasing adverse events 3.
- Another study found that esmolol treatment improved the efficacy of patients with septic shock, enhanced blood perfusion, improved cardiac function, reduced myocardial injury, and suppressed the inflammatory response 2.
- A systematic review and meta-analysis of randomized controlled trials found that esmolol treatment was associated with decreased 28-day mortality, decreased heart rate, and decreased troponin I levels in patients with septic shock 5.
- However, not all studies have found a significant benefit of esmolol in septic shock, with one study finding no difference in vasopressor requirements or time to shock reversal 6.
Key Findings
- Esmolol may improve outcomes in septic shock by reducing heart rate and improving cardiac function.
- Esmolol treatment has been associated with decreased 28-day mortality, decreased heart rate, and decreased troponin I levels in patients with septic shock.
- The appropriate heart rate change interval for esmolol treatment in septic shock is not well established and requires further study.
Study Limitations
- The current evidence is based on a limited number of studies, and further high-quality and large-scale randomized controlled trials are needed to confirm the benefits of esmolol in septic shock 5.
- The optimal dosing and duration of esmolol treatment in septic shock are not well established and require further study 4, 6.