Beta-blockers' effect on Levels of Lactate in patients with suspected sepsis - The BeLLa study

Impact of premorbid use of beta‑blockers on survival outcomes of patients with sepsis: A systematic review and meta‑analysis

It is unclear if premorbid use of beta-blockers affects sepsis outcomes. The present systematic review aimed to assess the impact of premorbid beta-blocker use on mortality and the need for mechanical ventilation in patients with sepsis. Embase, Scopus, PubMed and Web of Science were searched for studies comparing outcomes of patients with sepsis based on the premorbid use of beta-blockers. The primary outcome was mortality, and the secondary outcome was the need for mechanical ventilation. The results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). A total of 17 studies including 64,586 patients with sepsis were included. Of them, 8,665 patients received premorbid beta-blockers and 55,921 patients were not treated with premorbid beta-blockers and served as a control group. Pooled analysis of mortality rates revealed that premorbid use of beta-blockers did not affect in-hospital mortality (OR: 0.96; 95% CI: 0.78, 1.18; and I2=63%) but significantly reduced one-month mortality rates (OR: 0.83; 95% CI: 0.72, 0.96; and I2=63%). Combined analysis of adjusted data showed that premorbid beta-blockers were associated with a significant survival advantage in patients with sepsis (OR: 0.81; 95% CI: 0.72, 0.92; and I2=70%). However, there was no effect of premorbid use of beta-blockers on the need for mechanical ventilation (OR: 0.93; 95% CI: 0.66, 1.30); and I2=72%). The results of the present study indicated that premorbid use of beta-blockers is associated with improved survival in patients with sepsis. However, it does not impact the need for mechanical ventilation. The results should be interpreted with caution as the data is observational and unadjusted.

Exploring the Impact of Prior Beta-Blocker and Calcium Channel Blocker Usage on Clinical Outcomes in Critically Ill Patients With Sepsis: An Observational Study

Background Sepsis is associated with increased Ca++ levels in many cell types that can cause cytotoxicity and cell death through multiple mechanisms. In patients with sepsis, limiting beta-adrenergic stimulation may also be beneficial. The intense adrenergic stimulation of sepsis results in cardiac and extra-cardiac effects. In the intensive care unit (ICU), the question of whether to continue calcium channel blockers (CCBs) and beta-blockers in patients with sepsis who were using these medications before ICU admission is of significant concern. Methodology In this prospective observational study, we have included 114 patients who met the inclusion criteria of being diagnosed as having sepsis, aged 18 to 65 years, and expected to stay in the ICU for more than 72 hours. These patients were divided into three groups: group 1 consisted of patients taking CCBs before admission, group 2 included those taking beta-blockers before admission, and group 3 served as the control group, comprising patients who had not taken either of these medications before admission. Disease severity in the ICU was assessed and documented by the Sequential Organ Failure Assessment (SOFA) score. Clinical outcomes among three groups were compared regarding the need for vasopressor support, serum procalcitonin (PCT), serum lactate, serum quantitative C-reactive protein (qCRP), SOFA score, and 28 days mortality. Parametric data were expressed as mean ± standard deviation. The Kruskal-Wallis test was used to analyze parametric data between the two groups and among three groups. Results Mortality was found lower in group 1 (21.05%) and group 2 (26.31%) than in group 3 (47.36%), and this association was found to be statistically significant (P = 0.033). We also found a significant difference in mortality between groups 1 and 3 (P = 0.015) and no significant difference between groups 2 and 3 (P = 0.057). Mortality was found to be significantly associated with high SOFA scores on days 1, 3, and 7. Conclusions From the aforementioned results, we concluded that the mortality rate in patients with sepsis was improved when they were pretreated with beta-blockers or CCBs before admission to the ICU and that medication should be continued if not contraindicated in the ICU course.

Premorbid beta blockade in sepsis is associated with a lower risk of a lactate concentration above the lactate threshold, a retrospective cohort study

Sepsis and septic shock represent a significant worldwide mortality burden. A lactate greater than 4 mmol/L is associated with increased mortality in septic patients. This is the concentration at the "lactate threshold" where serum lactate concentrations rise markedly with increased workload in exercise. Hyperlactatemia in both sepsis and exercise is contributed to by adrenergic agonism which stimulates aerobic glycolysis, increasing lactate production and decreasing lactate clearance. Our hypothesis is that in patients with sepsis, treatment with beta blockers in the community will be associated with a lower probability of initial lactate ≥ 4 mmol/L. This was single centre retrospective cohort study. We used an in-house SQL Database for all admissions to ICU/HDU for the 2017-2020 calendar years. The dataset was filtered for an APACHE III Diagnosis of sepsis. T-tests were used for continuous data, Chi squared and Fisher's exact test were used as appropriate to compare proportions. Logistic regression was used to investigate covariate effects. Of the 160 patient records analysed, 49 were prescribed beta blockers. A greater proportion of patients not prescribed beta blockers in the community had a first lactate ≥ 4 mmol/L (p = 0.049). This was robust to regression analysis. There was no difference in the proportion of patients with lactate ≥ 2 mmol/L (p = 0.52). In our cohort patients previously prescribed beta blockers were less likely to have a lactate of ≥ 4 mmol/mL. This supports the proposed mechanism that treatment with beta blockers increases the lactate threshold in sepsis. Further study is warranted.

Beta-blockers in septic shock: What is new?

The use of beta(β)-blockers during septic shock aimed at countering peripheral adrenergic stress may be justified by the early reduction in deleterious effects resulting from sympathetic overactivation, and could improve the prognosis of patients in septic shock. Animal studies have demonstrated either a maintenance or increase in cardiac output (CO) despite the decrease in heart rate (HR) associated with improved myocardial performance. The mechanism by which β-blockers alter hemodynamics in septic shock is debated; however, preclinical and clinical data show that β-blockers are safe when started at a low dose. Recent publications (2019-2021) on adrenergic β1 receptor antagonists used in septic shock indicate that esmolol and landiolol should not be used in the early phase. While there is no optimal timing for their administration, a minimum of 12 h after the initiation of vasopressor therapy in stabilized euvolemic patients is a reasonable option. Patients should have a normal cardiac function, although a slight depression is compatible with landiolol use under hemodynamic monitoring. Slow titration in patients who remain tachycardic is preferable to rapid titration. When used to decrease HR, landiolol is also effective in reducing the incidence of new arrhythmias. Results of a well-performed and well-powered randomized controlled trial (RCT) demonstrating a positive effect on survival - or at least on hard surrogates such as the incidence/duration of organ failure - are pending.

Effect of Premorbid Beta-Blockers on Mortality in Patients With Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to conduct a systematic review and meta-analysis to investigate the impact of premorbid beta-blockers on mortality in patients with sepsis.

DATA SOURCES

We searched EMBASE, the Cochrane Central Register of Controlled Trials, and MEDLINE for eligible studies. The protocol was registered at the PROSPERO (CRD42021256813).

STUDY SELECTION

Two authors independently evaluated the following inclusion criteria: (1) randomized controlled trials, cohort studies, cross-sectional studies; (2) patients with sepsis aged ≥18 years, and (3) premorbid beta-blocker use.

DATA EXTRACTION

Two authors extracted the patients' characteristics and outcomes independently. All analyses were performed using the random-effects models. The primary outcome was short-term mortality, defined as mortality within 30 days, in-hospital or intensive care unit mortality.

DATA SYNTHESIS

Ten studies (n = 24 748 patients) were included. The pooled odds ratio (OR) of short-term mortality associated with the premorbid use of beta-blockers was 0.85 (95% confidence interval [CI], 0.69-1.04; P = .12; I² = 50%). Five studies reported an adjusted OR of short-term mortality. The pooled adjusted OR of short-term mortality associated with the premorbid use of beta-blockers was 0.73 (95% CI, 0.65-0.83; P < .001; I² = 0%).

CONCLUSION

Premorbid beta-blockers were associated with a lower short-term mortality in patients with sepsis.

Association Between Premorbid Beta-Blocker Exposure and Sepsis Outcomes-The Beta-Blockers in European and Australian/American Septic Patients (BEAST) Study

OBJECTIVES

To examine the effect of premorbid β-blocker exposure on mortality and organ dysfunction in sepsis.

DESIGN

Retrospective observational study.

SETTING

ICUs in Australia, the Czech Republic, and the United States.

PATIENTS

Total of 4,086 critical care patients above 18 years old with sepsis between January 2014 and December 2018.

INTERVENTION

Premorbid beta-blocker exposure.

MEASUREMENTS AND MAIN RESULTS

One thousand five hundred fifty-six patients (38%) with premorbid β-blocker exposure were identified. Overall ICU mortality rate was 15.1%. In adjusted models, premorbid β-blocker exposure was associated with decreased ICU (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97; p = 0.025) and hospital (adjusted odds ratio, 0.83; 95% CI, 0.71-0.99; p = 0.033) mortality. The risk reduction in ICU mortality of 16% was significant (hazard ratio, 0.84, 95% CI, 0.71-0.99; p = 0.037). In particular, exposure to noncardioselective β-blocker before septic episode was associated with decreased mortality. Sequential Organ Failure Assessment score analysis showed that premorbid β-blocker exposure had potential benefits in reducing respiratory and neurologic dysfunction.

CONCLUSIONS

This study suggests that β-blocker exposure prior to sepsis, especially to noncardioselective β blockers, may be associated with better outcome. The findings suggest prospective evaluation of β-blocker use in the management of sepsis.