Microvascular Effects of Heart Rate Control With Esmolol in Patients With Septic Shock: A Pilot Study*

Dexmedetomidine Improves Microcirculatory Alterations in Patients With Initial Resuscitated Septic Shock

Trial registration: Clinicaltrials.gov NCT02270281. Registered October 16, 2014.

Mortality in septic patients treated with short-acting betablockers: a comprehensive meta-analysis of randomized controlled trials

BACKGROUND

Treatment with short-acting betablockers in septic patients remains controversial. Two recent large multicenter trials have provided additional evidence on this therapeutic approach. We thus performed a meta-analysis, including the most recent data, to evaluate the potential impacts of treatment with short-acting betablockers on mortality in adult septic patients.

METHODS

The data search included PubMed, Web of Science, ClinicalTrials.gov and the Cochrane Library. A meta-analysis of all eligible peer-reviewed studies was performed in accordance with the PRISMA statement. Only randomized, controlled studies with valid classifications of sepsis and intravenous treatment with short-acting betablockers (landiolol or esmolol) were included. Short-term mortality served as the primary endpoint. Secondary endpoints included effects on short-term mortality regarding patient age and cardiac rhythm.

RESULTS

A total of seven studies summarizing 854 patients fulfilled the predefined criteria and were included. Short-term mortality as well as pooled mortality (longest period of data on mortality) was not significantly impacted by treatment with short-acting betablockers when compared to the reference treatment (Risk difference, - 0.10 [95% CI, - 0.22 to 0.02]; p = 0.11; p for Cochran's Q test = 0.001; I2 = 73%). No difference was seen when comparing patients aged < 65 versus ≥ 65 years (p = 0.11) or sinus tachycardia with atrial fibrillation (p = 0.27). Despite statistical heterogeneity, no significant publication bias was observed.

CONCLUSION

Administration of short-acting betablockers did not reduce short-term mortality in septic patients with persistent tachycardia. Future studies should also provide extensive hemodynamic data to enable characterization of cardiac function before and during treatment.

Metoprolol use is associated with improved outcomes in patients with sepsis-induced cardiomyopathy: an analysis of the MIMIC-IV database

BACKGROUND

Metoprolol is commonly administered to critically ill patients; however, its effect on mortality in patients with sepsis-induced cardiomyopathy (SICM) remains uncertain. This study aimed to investigate the relationship between metoprolol use and mortality in patients with SICM.

METHODS

Adults with SICM were identified from the MIMIC-IV database. The exposure of interest was metoprolol treatment. The outcomes assessed were 30-day mortality, 1-year mortality, and in-hospital mortality. Kaplan-Meier survival analysis evaluated the effect of metoprolol on these outcomes. Multivariable Cox proportional hazards and logistic regression analyses were performed to determine the correlation between metoprolol treatment and mortality in patients with SICM.

RESULTS

1163 patients with SICM were identified, with 882 receiving metoprolol treatment (MET group) and 281 not receiving metoprolol treatment (NOMET group). Overall, the 30-day, 1-year, and in-hospital mortality rates were 10.2%, 18.2%, and 8.9%, respectively. Significant differences in mortality existed between the groups. Multivariable Cox analysis revealed that patients in the NOMET group had a higher risk of 1-year mortality (adjusted hazard ratio [HR] 2.493; 95% confidence interval [CI] 1.800-3.451; P < 0.001) and 30-day mortality (adjusted HR 4.280; 95%CI 2.760-6.637; P < 0.001). Metoprolol treatment was associated with lower in-hospital mortality (odds ratio [OR] 5.076; 95% CI 2.848-9.047; P < 0.001). Subgroup analysis supported these findings.

CONCLUSION

Metoprolol treatment is associated with reduced all-cause mortality in patients with SICM. Prospective studies are required to validate these findings.

Landiolol for heart rate control in patients with septic shock and persistent tachycardia. A multicenter randomized clinical trial (Landi-SEP)

PURPOSE

Excessive tachycardia in resuscitated septic shock patients can impair hemodynamics and worsen patient outcome. We investigated whether heart rate (HR) control can be achieved without increased vasopressor requirements using the titratable highly selective, ultra-short-acting β1-blocker landiolol.

METHODS

This randomized, open-label, controlled trial was conducted at 20 sites in 7 European countries from 2018 to 2022 and investigated the efficacy and safety of landiolol in adult patients with septic shock and persistent tachycardia. Patients were randomly assigned to receive either landiolol along with standard treatment (n = 99) or standard treatment alone (n = 101). The combined primary endpoint was HR response (i.e., HR within the range of 80-94 beats per minute) and its maintenance without increasing vasopressor requirements during the first 24 h after treatment start. Key secondary endpoints were 28-day mortality and adverse events.

RESULTS

Out of 196 included septic shock patients, 98 received standard treatment combined with landiolol and 98 standard treatment alone. A significantly larger proportion of patients met the combined primary endpoint in the landiolol group than in the control group (39.8% [39/98] vs. 23.5% [23/98]), with a between-group difference of 16.5% (95% confidence interval [CI]: 3.4-28.8%; p = 0.013). There were no statistically significant differences between study groups in tested secondary outcomes and adverse events.

CONCLUSION

The ultra-short-acting beta-blocker landiolol was effective in reducing and maintaining HR without increasing vasopressor requirements after 24 h in patients with septic shock and persistent tachycardia. There were no differences in adverse events and clinical outcomes such as 28-day mortality vs. standard of care. The results of this study, in the context of previous trials, do not support a treatment strategy of stringent HR reduction (< 95 bpm) in an unselected septic shock population with persistent tachycardia. Further investigations are needed to identify septic shock patient phenotypes that benefit clinically from HR control.

Ivabradine in Septic Shock: A Narrative Review

In patients with septic shock, compensatory tachycardia initially serves to maintain adequate cardiac output and tissue oxygenation but may persist despite appropriate fluid and vasopressor resuscitation. This sustained elevation in heart rate and altered heart rate variability, indicative of autonomic dysfunction, is a well-established independent predictor of adverse outcomes in critical illness. Elevated heart rate exacerbates myocardial oxygen demand, reduces ventricular filling time, compromises coronary perfusion during diastole, and impairs the isovolumetric relaxation phase of the cardiac cycle, contributing to ventricular-arterial decoupling. This also leads to increased ventricular and atrial filling pressures, with a heightened risk of arrhythmias. Ivabradine, a highly selective inhibitor of the sinoatrial node's pacemaker current (If or "funny" current), mitigates heart rate by modulating diastolic depolarization slope without affecting contractility. By exerting a selective chronotropic effect devoid of negative inotropic properties, ivabradine shows potential for improving hemodynamics in septic shock patients with cardiac dysfunction. This review evaluates the plausible mechanisms and existing evidence regarding the utility of ivabradine in managing patients with septic shock.

The Association Between Tachycardia and Mortality in Septic Shock Patients According to Serum Lactate Level: A Nationwide Multicenter Cohort Study

BACKGROUND

This study aimed to evaluate whether the effect of tachycardia varies according to the degree of tissue perfusion in septic shock.

METHODS

Patients with septic shock admitted to the intensive care units were categorized into the tachycardia (heart rate > 100 beats/min) and non-tachycardia (≤ 100 beats/min) groups. The association of tachycardia with hospital mortality was evaluated in each subgroup with low and high lactate levels, which were identified through a subpopulation treatment effect pattern plot analysis.

RESULTS

In overall patients, hospital mortality did not differ between the two groups (44.6% vs. 41.8%, P = 0.441), however, tachycardia was associated with reduced hospital mortality rates in patients with a lactate level ≥ 5.3 mmol/L (48.7% vs. 60.3%, P = 0.030; adjusted odds ratio [OR], 0.59, 95% confidence interval [CI], 0.35-0.99, P = 0.045), not in patients with a lactate level < 5.3 mmol/L (36.5% vs. 29.7%, P = 0.156; adjusted OR, 1.39, 95% CI, 0.82-2.35, P = 0.227).

CONCLUSION

In septic shock patients, the effect of tachycardia on hospital mortality differed by serum lactate level. Tachycardia was associated with better survival in patients with significantly elevated lactate levels.

Role of aspirin, beta-blocker, statins, and heparin therapy in septic patients under mechanical ventilation: a narrative review

Sepsis is the main cause of death among patients admitted to intensive care units. Management of sepsis includes fluid resuscitation, vasopressors, intravenous antimicrobials, source control, mechanical ventilation, and others. New insights into the potential benefits of non-antimicrobial drugs in sepsis have evolved based on the pathophysiology of the disease and the mechanism of action of some drugs, but the findings are still controversial. In this study, we aimed to evaluate the effect of beta-blockers, aspirin, statins, and heparin as adjunctive treatments in septic patients under mechanical ventilation with non-cardiovascular diseases and their effect on mortality. We searched PubMed with relevant keywords (beta-blockers, aspirin, statins, or heparin, and critically ill or sepsis) for the last 10 years and some personal collection of relevant articles, and then we assessed studies according to prespecified inclusion and exclusion criteria. Our results show that beta-blockers, aspirin, and heparin may have promising feedback on reducing mortality. However, new well-controlled, randomized, multicenter studies are needed to confirm that, and multiple issues regarding their usage need to be addressed. On the other hand, the feedback regarding the effectiveness of statins was not as strong as that of the other drugs studied, and we suggest that further research is needed to confirm these results.

Association between Pre-Existing Long-Term β-Blocker Therapy and the Outcomes of Sepsis-Associated Coagulopathy: A Retrospective Study

Background and Objectives: Previous studies have suggested that long-term β-blocker therapy before sepsis is associated with reduced mortality. Sepsis-associated coagulopathy (SAC) remains a common complication in patients with sepsis and is associated with increased mortality. Adrenergic pathways are involved in the regulation of the coagulation system. Pre-existing long-term β-blocker therapy may have potentially beneficial effects on SAC and has yet to be well characterized. We aimed to assess the potential association between pre-existing long-term β-blocker therapy and the outcomes of patients with SAC. Materials and Methods: This study retrospectively screened the clinical data of adult patients with SAC admitted to the Intensive Care Unit (ICU) and respiratory ICU between May 2020 and October 2022. Patients with SAC who took any β-blocker for at least one year were considered pre-existing long-term β-blocker therapy. All enrolled patients were followed up for 28 days or until death. Results: Among the 228 SAC patients, 48 received long-term β-blocker therapy before septic episodes. Pre-existing long-term β-blocker therapy was associated with reduced vasopressor requirements and a decreased 28-day mortality (log-rank test: p = 0.041). In particular, long-term β-blocker therapy was related to substantially lower D-dimer levels and a trend of improved activated partial thromboplastin time in patients with SAC during initial ICU admission. Multivariable regression analysis showed that long-term β-blocker therapy was significantly and independently associated with a 28-day mortality among patients with SAC (adjusted odds ratio, 0.55; 95% confidence interval, (0.32-0.94); p = 0.030). Conclusions: Pre-existing long-term β-blocker therapy might be associated with reduced vasopressor requirements and a decreased 28-day mortality among patients with SAC, providing evidence for the protective effect of β-blockers against SAC in managing sepsis.

Beta-blocker treatment in the critically ill: a systematic review and meta-analysis

BACKGROUND

Critical illness may lead to activation of the sympathetic system. The sympathetic stimulation may be further increased by exogenous catecholamines, such as vasopressors and inotropes. Excessive adrenergic stress has been associated with organ dysfunction and higher mortality. β-Blockers may reduce the adrenergic burden, but they may also compromise perfusion to vital organs thus worsening organ dysfunction. To assess the effect of treatment with β-blockers in critically ill adults, we conducted a systematic review and meta-analysis of randomized controlled trials.

MATERIALS AND METHODS

We conducted a search from three major databases: Ovid Medline, the Cochrane Central Register for Controlled Trials and Scopus database. Two independent reviewers screened, selected, and assessed the included articles according to prespecified eligibility criteria. We assessed risk of bias of eligible articles according to the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Sixteen randomized controlled trials comprising 2410 critically ill patients were included in the final review. A meta-analysis of 11 trials including 2103 patients showed a significant reduction in mortality in patients treated with β-blockers compared to control (risk ratio 0.65, 95%CI 0.53-0.79; p < .0001). There was no significant difference in mean arterial pressure or vasopressor load. Quality of life, biventricular ejection fraction, blood lactate levels, cardiac biomarkers and mitochondrial function could not be included in meta-analysis due to heterogenous reporting of outcomes.

CONCLUSIONS

In this systematic review we found that β-blocker treatment reduced mortality in critical illness. Use of β-blockers in critical illness thus appears safe after initial hemodynamic stabilization. High-quality RCT's are needed to answer the questions concerning optimal target group of patients, timing of β-blocker treatment, choice of β-blocker, and choice of physiological and hemodynamic parameters to target during β-blocker treatment in critical illness.KEY MESSAGESA potential outcome benefit of β-blocker treatment in critical illness exists according to the current review and meta-analysis. Administration of β-blockers to resuscitated patients in the ICU seems safe in terms of hemodynamic stability and outcome, even during concomitant vasopressor administration. However, further studies, preferably large RCTs on β-blocker treatment in the critically ill are needed to answer the questions concerning timing and choice of β-blocker, patient selection, and optimal hemodynamic targets.

Malign asitli over kanserinde sitoredüktif cerrahide perioperatif hemodinamik optimizasyon

Purpose: In this study, we aimed to evaluate the effects of norepinephrine and albumin use in patients with epithelial ovarian cancer with malignant ascite in order to maintain plasma oncotic pressure and intravascular volume, to provide perioperative hemodynamic stabilization and tissue perfusion. In addition, it was aimed to compare in terms of postoperative intensive care admission, hospital stay and complications. Materials and Methods: A total of 66 patients, 38 with ascites and 28 without ascites, who underwent cytoreductive surgery for ovarian cancer were included in this study. PVI and invasive arterial monitoring of the patients were performed after hemodynamic stabilization (after the start of surgery) (T0). T0, 1st hour (T1) and 2nd hour (T2) and postoperative (Tpostop.) Ascites patients were composed of 3 subgroups which the ones received norepinephrine (NE) infusion, norepinephrine + albumin (NEA) infusion or only fluid therapy (FT). From the perioperative hemodynamic and laboratory data of the patients, tissue perfusion was evaluated with lactate, and hemodynamic status was evaluated with pleth variability index (PVI), perfusion index (PI) and mean arterial pressure (MAP). Results: Demographic and clinical findings did not differ significantly between patients with and without ascites. Lactate level in NEA / NE group in Tpostop, PVI level in T1h, T2h and Tpostop time frames were determined higher than the FT group. PI was found to be significantly lower in the T2 time frame. The postoperative ICU admission rate was higher in the NEA and NE groups. The duration of ICU stay in group NEA was shorter than in group NE. Conclusion: We recommend the use of low-dose NE with albumin to provide perioperative hemodynamic optimization, tissue perfusion and plasma oncotic pressure in surgery of ovarian cancer with malignant ascites. Despite high fluid replacement in these patients, the use of norepinephrine and albumin together may have an important role in preventing / reducing major complications in the perioperative period.

Endothelial Activation and Microcirculatory Disorders in Sepsis

The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.

A Standardized Step-by-Step Approach for the Diagnosis and Treatment of Sepsis

Sepsis is the major culprit of death among critically ill patients who are hospitalized in intensive care units (ICUs). Although sepsis-related mortality is steadily declining year-by-year due to the continuous understanding of the pathophysiological mechanism on sepsis and improvement of the bundle treatment, sepsis-associated hospitalization is rising worldwide. Surviving Sepsis Campaign (SSC) guidelines are continuously updating, while their content is extremely complex and comprehensive for a precisely implementation in clinical practice. As a consequence, a standardized step-by-step approach for the diagnosis and treatment of sepsis is particularly important. In the present study, we proposed a standardized step-by-step approach for the diagnosis and treatment of sepsis using our daily clinical experience and the latest researches, which is close to clinical practice and is easy to implement. The proposed approach may assist clinicians to more effectively diagnose and treat septic patients and avoid the emergence of adverse clinical outcomes.

Esmolol response in septic shock patients in relation to vascular waterfall phenomenon measured by critical closure pressure and mean systemic filling pressure: a prospective observational study

Background

Bedside measurements of critical closure pressure (Pcc) and mean systemic circulation filling pressure (Pmsf) were utilized to evaluate the response to esmolol in septic shock patients, in relation to the vascular waterfall phenomenon and body oxygen supply and demand.

Methods

This prospective observational self-controlled study included patients with septic shock, newly admitted to the intensive care unit, between August 2019 and January 2021. Pcc and Pmsf, along with the heart rate and other hemodynamic indicators were observed and compared before and 1 h after esmolol IV infusion.

Results

After 24 h of initial hemodynamic optimization, 56 patients were finally enrolled. After start of esmolol infusion, patients had a significant decrease in cardiac index (CI) (4.0 vs. 3.3 L/min/m², P < 0.001), a significant increase in stroke index (SI) (34.1 vs. 36.6 mL/m², P < 0.01), and a significant decrease in heart rate (HR) (116.8 vs. 90.6 beats/min, P < 0.001). After 1 h of treatment with esmolol, patients had a significant increase in Pcc (31.4 vs. 36.7 mmHg, P < 0.01). The difference between Pcc and Pmsf before and after treatment was statistically different (4.0 vs. 10.0 mmHg, P < 0.01). After heart rate control with esmolol, the patients had a significant increase in the body circulation vascular resistance indices (RIs) (15.14 vs. 18.25 mmHg/min/m²/L, P < 0.001). There was an increase in ScvO2 in patients after treatment with esmolol, but the difference was not statistically significant (68.4% vs. 69.8%, P > 0.05), while Pcv-aCO2 was significantly lower (6.3 vs. 4.9 mmHg, P < 0.001) and patients had a significant decrease in blood lactate levels (4.0 vs. 3.6 mmol/L, P < 0.05).

Conclusion

Patients with septic shock whose heart rate is greater than 95 beats/min after hemodynamic optimization were treated with esmolol, which could effectively control heart rate and reduce CI, as well as improve Pcc and increase the difference between Pcc and Pmsf (known as “vascular waterfall” phenomenon), without affecting MAP, CVP, Pmsf and arteriovenous vascular resistance, and improve the balance of oxygen supply and demand in the body.

Successful use of intravenous B-blocker therapy in cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation: A case series

Tachycardia in cardiogenic shock (CS) might reduce the cardiac output (CO) by decreasing the ventricular filling time. Nevertheless, heart rate (HR) control with agents that possess negative inotropy might decrease the CO. Therefore, controlling the tachycardia in the setting of CS remains controversial. We herein describe four cases of patients presenting with myocardial infarction complicated with CS that required rescue venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation. Tachycardia was present with HR ∼130-140 beats per minute after VA-ECMO initiation, and hence esmolol was infused continuously at a starting dose of 10-20 mcg/kg/min and titrated according to HR. With the use of esmolol to control the HR in the setting of CS supported with VA-ECMO, lactate cleared, and echocardiographic parameters improved, allowing the four cases to be successfully decannulated from ECMO. Our report indicates that short-acting beta-blocker could be safely used in the complex scenario of severe tachycardia while supported with VA-ECMO.

Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition

Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.

Metoprolol in Critically Ill Patients With COVID-19

BACKGROUND

Severe coronavirus disease-2019 (COVID-19) can progress to an acute respiratory distress syndrome (ARDS), which involves alveolar infiltration by activated neutrophils. The beta-blocker metoprolol has been shown to ameliorate exacerbated inflammation in the myocardial infarction setting.

OBJECTIVES

The purpose of this study was to evaluate the effects of metoprolol on alveolar inflammation and on respiratory function in patients with COVID-19-associated ARDS.

METHODS

A total of 20 COVID-19 patients with ARDS on invasive mechanical ventilation were randomized to metoprolol (15 mg daily for 3 days) or control (no treatment). All patients underwent bronchoalveolar lavage (BAL) before and after metoprolol/control. The safety of metoprolol administration was evaluated by invasive hemodynamic and electrocardiogram monitoring and echocardiography.

RESULTS

Metoprolol administration was without side effects. At baseline, neutrophil content in BAL did not differ between groups. Conversely, patients randomized to metoprolol had significantly fewer neutrophils in BAL on day 4 (median: 14.3 neutrophils/µl [Q1, Q3: 4.63, 265 neutrophils/µl] vs median: 397 neutrophils/µl [Q1, Q3: 222, 1,346 neutrophils/µl] in the metoprolol and control groups, respectively; P = 0.016). Metoprolol also reduced neutrophil extracellular traps content and other markers of lung inflammation. Oxygenation (PaO2:FiO2) significantly improved after 3 days of metoprolol treatment (median: 130 [Q1, Q3: 110, 162] vs median: 267 [Q1, Q3: 199, 298] at baseline and day 4, respectively; P = 0.003), whereas it remained unchanged in control subjects. Metoprolol-treated patients spent fewer days on invasive mechanical ventilation than those in the control group (15.5 ± 7.6 vs 21.9 ± 12.6 days; P = 0.17).

CONCLUSIONS

In this pilot trial, intravenous metoprolol administration to patients with COVID-19-associated ARDS was safe, reduced exacerbated lung inflammation, and improved oxygenation. Repurposing metoprolol for COVID-19-associated ARDS appears to be a safe and inexpensive strategy that can alleviate the burden of the COVID-19 pandemic.

Effectiveness of enteral ivabradine for heart rate control in septic shock: A randomised controlled trial

Persistent tachycardia in patients with septic shock predicts poor outcome. This study sought to investigate the effect of the cardiac pacemaker current inhibitor ivabradine on heart rate and cardio-circulatory function in patients with septic shock. After informed consent, 60 patients with septic shock and persistent tachycardia (heart rate >95 /minute) were prospectively randomly assigned to receive either standard therapy for septic shock (group S) or standard therapy along with enteral ivabradine (group I) for the initial 96 hours after enrolment. Primary outcome was the difference in heart rate between the two groups during the first 96 hours. Secondary outcomes included the effect of ivabradine on haemodynamic, oxygenation, myocardial function and organ function parameters, incidence of adverse events and 30-day overall survival. Heart rate was lower in group I compared to group S (median difference in area under the curve -25.6 (95% confidence intervals -31.4 to -15.9) /minute; P <0.001). Vasopressor requirements, blood lactate levels, Sequential Organ Failure Assessment scores and E/e' ratio were lower in group I compared to group S. Stroke volume index and ejection fraction were higher in group I while cardiac index and oxygen delivery parameters were maintained similar to group S. There was no difference in 30-day mortality or in the incidence of serious adverse events. Enteral ivabradine is effective in reducing heart rate, and improving haemodynamic parameters and cardiac function in patients with septic shock and persistent tachycardia, without increasing the incidence of adverse events.

Premorbid β1-selective (but not non-selective) β-blocker exposure reduces intensive care unit mortality among septic patients

BACKGROUND

β-blockers may protect against catecholaminergic myocardial injury in critically ill patients. Long-term β-blocker users are known to have lower lactate concentrations and favorable sepsis outcomes. However, the effects of β1-selective and nonselective β-blockers on sepsis outcomes have not been compared. This study was conducted to investigate the impacts of different β-blocker classes on the mortality rate in septic patients.

METHODS

We retrospectively screened 2678 patients admitted to the medical or surgical intensive care unit (ICU) between December 2015 and July 2017. Data from patients who met the Sepsis-3 criteria at ICU admission were included in the analysis. Premorbid β-blocker exposure was defined as the prescription of any β-blocker for at least 1 month. Bisoprolol, metoprolol, and atenolol were classified as β1-selective β-blockers, and others were classified as nonselective β-blockers. All patients were followed for 28 days or until death.

RESULTS

Among 1262 septic patients, 209 (16.6%) patients were long-term β-blocker users. Patients with premorbid β-blocker exposure had lower heart rates, initial lactate concentrations, and ICU mortality. After adjustment for disease severity, comorbidities, blood pressure, heart rate, and laboratory data, reduced ICU mortality was associated with premorbid β1-selective [adjusted hazard ratio, 0.40; 95% confidence interval (CI), 0.18-0.92; P = 0.030], but not non-selective β-blocker use.

CONCLUSION

Premorbid β1-selective, but not non-selective, β-blocker use was associated with improved mortality in septic patients. This finding supports the protective effect of β1-selective β-blockers in septic patients. Prospective studies are needed to confirm it.

Effect of heart rate on hospital mortality in critically ill patients may be modified by age: a retrospective observational study from large database

BACKGROUND

Heart rate has been found associated with mortality in critically ill patients. However, whether the association differs between the elderly and non-elderly patients was unknown.

METHODS

We conducted a retrospective observational study of adult patients admitted to the intensive care unit (ICU) in the United States. Demographic, vital signs, laboratory tests, and interventions were extracted and compared between the elderly and non-elderly patients. The main exposure was heart rate, the proportion of time spent in heart rate (PTS-HR) was calculated. The primary outcome was hospital mortality. The multivariable logistic regression model was performed to assess the relationship between PTS-HR and hospital mortality, and interaction between PTS-HR and age categories was explored.

RESULTS

104,276 patients were included, of which 52,378 (50.2%) were elderly patients and 51,898 (49.8%) were non-elderly patients. The median age was 66 (IQR 54-76) years. After adjusting for confounders, PTS-HR < 60 beats per minute (bpm) (OR 0.972, 95% CI [0.945, 0.998], p = 0.031, P_interaction = 0.001) and 60-80 bpm (OR 0.925, 95% CI [0.912, 0.938], p < 0.001, P_interaction = 0.553) were associated with decreased risk of mortality; PTS-HR 80-100 bpm was associated with decreased mortality in the non-elderly patients (OR 0.955, 95% CI [0.941,0.975], p < 0.001) but was associated with increased mortality in the very elderly patients (OR 1.018, 95% CI [1.003,1.029], p = 0.017, P_interaction < 0.001). PTS-HR > 100 bpm (OR 1.093, 95% CI [1.081,1.105], p < 0.001, P_interaction = 0.004) was associated with increased mortality.

CONCLUSIONS

The effect of heart rate on hospital mortality differs between the elderly and non-elderly critically ill patients.

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.

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock: a pilot study

Background

Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns.

Methods

Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1–H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases.

Results

Esmolol was infused 9 (6.4–11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34–0.83) to 0.78 (0.3–1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110–125) to 100 (92–103) beats/min and a decrease in cardiac index from 4.2 (3.1–4.4) to 2.9 (2.5–3.7) l/min/m⁻². Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients.

Conclusion

In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287).

Monitoring coherence between the macro and microcirculation in septic shock

PURPOSE OF REVIEW

Currently, the treatment of patients with shock is focused on the clinical symptoms of shock. In the early phase, this is usually limited to heart rate, blood pressure, lactate levels and urine output. However, as the ultimate goal of resuscitation is the improvement in microcirculatory perfusion the question is whether these currently used signs of shock and the improvement in these signs actually correspond to the changes in the microcirculation.

RECENT FINDINGS

Recent studies have shown that during the development of shock the deterioration in the macrocirculatory parameters are followed by the deterioration of microcirculatory perfusion. However, in many cases the restoration of adequate macrocirculatory parameters is frequently not associated with improvement in microcirculatory perfusion. This relates not only to the cause of shock, where there are some differences between different forms of shock, but also to the type of treatment.

SUMMARY

The improvement in macrohemodynamics during the resuscitation is not consistently followed by subsequent changes in the microcirculation. This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.

Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation

Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.

Esmolol reduces myocardial injury induced by resuscitative endovascular balloon occlusion of the aorta (REBOA) in a porcine model of hemorrhagic shock

PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) causes myocardial injury from increased aortic afterload and supraphysiologic cardiac output. However, pharmacologic methods to attenuate high cardiac output and reduce myocardial injury have not been explored. We hypothesized that the use of esmolol during REBOA would reduce myocardial injury.

METHODS

Ten pigs were anesthetized and instrumented. Following 25% total blood volume hemorrhage, animals underwent 45 min of supraceliac (zone 1) REBOA with or without titration of esmolol to maintain heart rate between 80 and 100 beats per minute. Following the REBOA interventions, animals underwent 275 min of standardized critical care.

RESULTS

During REBOA, heart rate was significantly lower in the esmolol group compared to control animals (100 [88 - 112] vs 193 [172 - 203] beats/minute, respectively, p < 0.001) and the average mean arterial pressure (MAP) was lower in the esmolol group (88.0 [80.3-94.9] vs 135.1 [131.7-140.4] mmHg, respectively, p = 0.01). During the critical care phase, there were no differences in heart rate or MAP between groups. Animals in the intervention group received 237.9 [218.7-266.5] µg/kg of esmolol. There was a significant increase from baseline in serum troponins for the control group (p = 0.006) and significantly more subendocardial hemorrhage compared to animals treated with esmolol (3 [3 - 3] and 0 [0 - 0], p = 0.009, respectively).

CONCLUSION

In our porcine model of hemorrhagic shock, zone 1 REBOA was associated with myocardial injury. Pharmacologic heart rate titration with esmolol during occlusion may mitigate the deleterious effects of REBOA on the heart.

Microcirculation-guided protection strategy in hemodynamic therapy

Microcirculatory shock is a condition defined by the presence of tissue hypoperfusion despite the normalization of systemic and regional blood flow. Currently, more evidence shows that intrinsic septic shock is microcirculatory shock, which results in septic shock that is difficult to resuscitate. At present, treatments are aimed at recovering macro-circulation functions and include fluid resuscitation, vasoactive drugs, positive inotropic drugs, de-obstruction, and even mechanical assistance to improve oxygen delivery. However, the application of these treatments to more accurately improve microcirculation or avoid further microcirculatory damage is more important in clinics. In this article, we discuss the need for microcirculation protection and microcirculation-guided protection strategies in hemodynamic therapies.

Manipulating the Microcirculation in Sepsis - the Impact of Vasoactive Medications on Microcirculatory Blood Flow: A Systematic Review

BACKGROUND

Sepsis is life-threatening organ dysfunction because of a dysregulated host response to infection. Disturbed microvascular blood flow is associated with excess mortality and is a potential future target for interventions. This review addresses the evidence for pharmacological manipulation of the microcirculation in sepsis assessed by techniques that evaluate the sublingual microvasculature.

METHODS

Systematic review using a published protocol. Eligibility criteria were studies of septic patients published from January 2000 to February 2018. Interventions were drugs aimed at improving perfusion. Outcome was improvement in microvascular flow using orthogonal polarization spectral, sidestream dark field, or incident dark field imaging (Grades of Recommendation, Assessment, Development, and Evaluation criteria used).

RESULTS

Two thousand six hundred and six articles were screened and 22 included. (6 randomized controlled trials, 12 interventional, 3 observational, and 1 pilot, n = 572 participants). Multiple measurement techniques were described, including: automated analyses, subjective, and composite scoring systems. Norepinephrine was not found to improve microvascular flow (low-grade evidence, n = 6 studies); except in chronic hypertension (low, n = 1 study). Addition of arginine vasopressin or terlipressin to norepinephrine maintained flow while decreasing norepinephrine requirements (high, n = 2 studies). Neither dobutamine nor glyceryl trinitrate consistently improved flow (low, n = 6 studies). A single study (n = 40 participants) demonstrated improved flow with levosimendan (high). In a risk of bias assessment 16/16 interventional, pilot and observational studies were found to be high risk.

CONCLUSIONS

There is no robust evidence to date that any one agent can reproducibly lead to improved microvascular flow. Furthermore, no study demonstrated outcome benefit of one therapeutic agent over another. Updated consensus guidelines could improve comparable reporting of measurements and reduce bias, to enable meaningful comparisons around the effects of individual pharmacological agents.

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

OBJECTIVE

In the assessment and management of septic patients in the emergency department (ED), serum lactate is often measured to stratify severity to guide decision making. Increased adrenergic drive has been postulated as a contributory factor for hyperlactatemia in sepsis. We aim to prospectively evaluate the effect of chronic beta-blocker use on serum lactate levels in sepsis at initial presentation to the ED.

METHODS

We conducted a prospective observational study at the ED of a tertiary care academic medical center in Singapore. One hundred and ninety-five ED patients who fulfilled all of the following: (1) age 45 years and above, (2) tympanic temperature ≥ 37.8 °C or clinically suspected to have an infection, and (3) quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score ≥ 1 were included in the study. Serum venous lactate was sampled within two hours from presentation to the ED. The primary outcome measure was the difference in initial serum venous lactate concentration at presentation to the ED in patients on chronic beta-blockers versus patients without.

RESULTS

Seventy patients (35.9%) were on long-term beta-blocker therapy. The primary outcome of mean initial serum venous lactate concentration was similar between patients prescribed chronic beta-blocker therapy and patients without (1.78 mmol/L versus 1.70 mmol/L, p = .540). Chronic beta-blocker therapy also did not significantly affect mean initial serum venous lactate concentration across all subgroups of sepsis risk stratification.

CONCLUSIONS

Long-term beta-blocker therapy did not significantly affect initial serum venous lactate concentration in ED patients with suspected sepsis.

The association between premorbid beta blocker exposure and mortality in sepsis-a systematic review

BACKGROUND

The effect of premorbid β-blocker exposure on clinical outcomes in patients with sepsis is not well characterized. We aimed to examine the association between premorbid β-blocker exposure and mortality in sepsis.

METHODS

EMBase, MEDLINE, and Cochrane databases were searched for all studies of premorbid β-blocker and sepsis. The search was last updated on 22 June 2019. Two reviewers independently assessed, selected, and abstracted data from studies reporting chronic β-blocker use prior to sepsis and mortality. Main data extracted were premorbid β-blocker exposure, mortality, study design, and patient data. Two reviewers independently assessed the risk of bias and quality of evidence.

RESULTS

In total, nine studies comprising 56,414 patients with sepsis including 6576 patients with premorbid exposure to β-blockers were eligible. For the primary outcome of mortality, two retrospective studies reported adjusted odds ratios showing a reduction in mortality with premorbid β-blocker exposure. One study showed that premorbid β-blocker exposure decreases mortality in patients with septic shock. Another study showed that continued β-blockade during sepsis is associated with decreased mortality.

CONCLUSION

This systematic review suggests that β-blocker exposure prior to sepsis is associated with reduced mortality. There was insufficient data to conduct a bona fide meta-analysis. Whether the apparent reduction in mortality may be attributed to the mitigation of catecholamine excess is unclear.

TRIAL REGISTRATION

PROSPERO, CRD42019130558 registered June 12, 2019.

Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study

INTRODUCTION

Supraventricular arrhythmias contribute to haemodynamic compromise in septic shock. A retrospective study generated the hypothesis that propafenone could be more effective than amiodarone in achieving and maintaining sinus rhythm (SR). Certain echocardiographic parameters may predict a successful cardioversion and help in the decision on rhythm or rate control strategy.

METHODS AND ANALYSIS

The trial includes septic shock patients with new-onset arrhythmia, but without severe impairment of the left ventricular ejection fraction. After baseline echocardiography, the patient is randomised to receive a bolus and maintenance dose of either amiodarone or propafenone. The primary outcome is the proportion of patients that have achieved rhythm control at 24 hours after the start of the infusion. The secondary outcomes are the percentages of patients that needed rescue treatments (DC cardioversion or unblinding and crossover of the antiarrhythmics), the recurrence of arrhythmias, intensive care unit mortality, 28-day and 1-year mortality. In the posthoc analysis, we separately assess subgroups of patients with pulmonary hypertension and right ventricular dysfunction. In the exploratory part of the study, we assess whether the presence of a transmitral diastolic A wave and its higher velocity-time integral is predictive for the sustainability of mechanical SR and whether the indexed left atrial endsystolic volume is predictive of recurrent arrhythmia. Considering that the restoration of SR within 24 hours occurred in 74% of the amiodarone-treated patients and in 89% of the patients treated with propafenone, we plan to include 200 patients to have an 80% chance to demonstrate the superiority of propafenone at p=0.05.

ETHICS AND DISSEMINATION

The trial is recruiting patients according to its second protocol version approved by the University Hospital Ethical Board on the 6 October 2017 (No. 1691/16S-IV). The results will be disseminated through peer reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03029169.

Metabolic effects of beta-blockers in critically ill patients: A retrospective cohort study

BACKGROUND

Beta-blockers have potential protective features during critical illness. Heart rate reduction, with limited effect on blood pressure and beneficial effects on metabolism, organ function and inflammation have been reported. We examined metabolic effects of beta-blockers among ICU patients, to address the effect on the estimated energy expenditure, measured by carbon dioxide production (VCO₂). Furthermore, we investigated effects on organ function and inflammation.

METHODS

A retrospective study in adult patients admitted to our 17-beds mixed medical-surgical ICU from January 2013 to March 2016. Mechanically ventilated patients who commenced beta-blockers were eligible for inclusion. Exclusion criteria were: beta-blocker therapy in the 7 previous days, treatment duration <48 h, therapeutic hypothermia, and no VCO₂ measurements. Outcome parameters were obtained at 6 different time points from 24 h before until 48 h after beta-blocker commencement. Linear mixed models were used to evaluate trends.

RESULTS

In total 58 patients were included. Various types of beta-blockers were administered, with a median equivalent daily dose to metoprolol of 50.0 mg (IQR 25.0-62.5). The mean heart rate decreased from 103 ± 20 to 91 ± 19 beats per minute after 48 h (p < 0.001), with unaltered blood pressures. Metabolic and other parameters did not show significant differences over time, or parameter changes were due to trends that had already started before beta-blocker commencement.

CONCLUSIONS

No changes in VCO₂ after beta-blocker commencement were demonstrated suggesting no alterations in energy expenditure. Heart rates significantly decreased with unaltered blood pressures. Other parameters did not show trends that could be attributed to beta-blockers effects.

β-bloquants dans la prise en charge du choc septique

Les adrénorécepteurs α et en particulier β sont les principales cibles de l’adrénaline et de la noradrénaline libérées par le système sympathique activé. Durant le choc septique, la dysautonomie est une stimulation prolongée à un haut niveau d’intensité du système nerveux sympathique à l’origine d’une altération de la contractilité, de la vasoréactivité et d’une immunodépression. Ainsi, l’administration précoce d’un traitement β-bloquant lors du choc septique pourrait pondérer les effets délétères de cette surstimulation sympathique. Néanmoins, si les preuves expérimentales sont en faveur de cette approche, l’accumulation des preuves cliniques reste encore insuffisante.

Continuing chronic beta-blockade in the acute phase of severe sepsis and septic shock is associated with decreased mortality rates up to 90 days

Background

There is growing evidence that beta-blockade may reduce mortality in selected patients with sepsis. However, it is unclear if a pre-existing, chronic oral beta-blocker therapy should be continued or discontinued during the acute phase of severe sepsis and septic shock.

Methods

The present secondary analysis of a prospective observational single centre trial compared patient and treatment characteristics, length of stay and mortality rates between adult patients with severe sepsis or septic shock, in whom chronic beta-blocker therapy was continued or discontinued, respectively. The acute phase was defined as the period ranging from two days before to three days after disease onset. Multivariable Cox regression analysis was performed to compare survival outcomes in patients with pre-existing chronic beta-blockade.

Results

A total of 296 patients with severe sepsis or septic shock and pre-existing, chronic oral beta-blocker therapy were included. Chronic beta-blocker medication was discontinued during the acute phase of sepsis in 129 patients and continued in 167 patients. Continuation of beta-blocker therapy was significantly associated with decreased hospital (P=0.03), 28-day (P=0.04) and 90-day mortality rates (40.7% vs 52.7%; P=0.046) in contrast to beta-blocker cessation. The differences in survival functions were validated by a Log-rank test (P=0.01). Multivariable analysis identified the continuation of chronic beta-blocker therapy as an independent predictor of improved survival rates (HR = 0.67, 95%-CI (0.48, 0.95), P=0.03).

Conclusions

Continuing pre-existing chronic beta-blockade might be associated with decreased mortality rates up to 90 days in septic patients.

Hemodynamic response to β-blockers in severe sepsis and septic shock: A review of current literature

The administration of β-blockers in patients with sepsis is a trending topic in intensive care medicine since the landmark study by Morelli and colleagues, showing a striking decrease in 28-day mortality compared to standard care. While the available evidence suggests that the use of β-blockers in septic shock is safe, the effects on hemodynamics are controversial. In this paper, we review the effect of β-blockade in septic shock on hemodynamics from animal models to critically ill patients.

Landiolol in patients with septic shock resident in an intensive care unit (LANDI-SEP): study protocol for a randomized controlled trial

Background

In patients with septic shock, the presence of an elevated heart rate (HR) after fluid resuscitation marks a subgroup of patients with a particularly poor prognosis. Several studies have shown that HR control in this population is safe and can potentially improve outcomes. However, all were conducted in a single-center setting. The aim of this multicenter study is to demonstrate that administration of the highly beta1-selective and ultrashort-acting beta blocker landiolol in patients with septic shock and persistent tachycardia (HR ≥ 95 beats per minute [bpm]) is effective in reducing and maintaining HR without increasing vasopressor requirements.

Methods

A phase IV, multicenter, prospective, randomized, open-label, controlled study is being conducted. The study will enroll a total of 200 patients with septic shock as defined by The Third International Consensus Definitions for Sepsis and Septic Shock criteria and tachycardia (HR ≥ 95 bpm) despite a hemodynamic optimization period of 24–36 h. Patients are randomized (1:1) to receive either standard treatment (according to the Surviving Sepsis Campaign Guidelines 2016) and continuous landiolol infusion to reach a target HR of 80–94 bpm or standard treatment alone. The primary endpoint is HR response (HR 80–94 bpm), the maintenance thereof, and the absence of increased vasopressor requirements during the first 24 h after initiating treatment.

Discussion

Despite recent studies, the role of beta blockers in the treatment of patients with septic shock remains unclear. This study will investigate whether HR control using landiolol is safe, feasible, and effective, and further enhance the understanding of beta blockade in patients with septic shock.

Trial registration

EU Clinical Trials Register; EudraCT, 2017-002138-22. Registered on 8 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3024-6) contains supplementary material, which is available to authorized users.

The influence of esmolol on right ventricular function in early experimental endotoxic shock

The mechanism by which heart rate (HR) control with esmolol improves hemodynamics during septic shock remains unclear. Improved right ventricular (RV) function, thereby reducing venous congestion, may play a role. We assessed the effect of HR control with esmolol during sepsis on RV function, macrocirculation, microcirculation, end-organ-perfusion, and ventricular-arterial coupling. Sepsis was induced in 10 healthy anesthetized and mechanically ventilated sheep by continuous IV administration of lipopolysaccharide (LPS). Esmolol was infused after successful resuscitation of the septic shock, to reduce HR and stopped 30-min after reaching targeted HR reduction of 30%. Venous and arterial blood gases were sampled and the small intestines' microcirculation was assessed by using a hand-held video microscope (CytoCam-IDF). Arterial and venous pressures, and cardiac output (CO) were recorded continuously. An intraventricular micromanometer was used to assess the RV function. Ventricular-arterial coupling ratio (VACR) was estimated by catheterization-derived single beat estimation. The targeted HR reduction of >30% by esmolol infusion, after controlled resuscitation of the LPS induced septic shock, led to a deteriorated RV-function and macrocirculation, while the microcirculation remained depressed. Esmolol improved VACR by decreasing the RV end-systolic pressure. Stopping esmolol showed the reversibility of these effects on the RV and the macrocirculation. In this animal model of acute severe endotoxic septic shock, early administration of esmolol decreased RV-function resulting in venous congestion and an unimproved poor microcirculation despite improved cardiac mechanical efficiency.

Effects of esmolol on systemic hemodynamics and heart rate variability measured using the Analgesia/Nociception Index in resuscitated piglets with Pseudomonas aeruginosa septic shock

OBJECTIVE

To determine the effects of esmolol on hemodynamics and heart rate variability (HRV) in the early stage of sepsis.

DESIGN

Prospective, randomized, controlled, parallel trial.

SETTINGS

Veterinary research laboratory.

ANIMALS

Ten anesthetized piglets.

INTERVENTIONS

Septic shock was induced by infusing a suspension of live Pseudomonas aeruginosa IV in 10 anesthetized piglets. The piglets were resuscitated according to a standardized protocol using Ringer's lactate solution, norepinephrine, and milrinone. Once stabilized, the piglets were randomized to receive IV esmolol, titrated to a heart rate <90/min, or control, receiving saline. A pulmonary artery catheter and an arterial catheter were inserted for hemodynamic measurements. The Analgesia/Nociception Index (ANI) and the normalized HRV frequency domain parameters - high-frequency (HF), low frequency (LF), LF/HF ratio - were recorded using a proprietary monitor.

MEASUREMENTS AND MAIN RESULTS

A significant decrease in cardiac output and heart rate, and a significant increase in systemic vascular resistance were observed over time in the esmolol group in comparison to the control group. No other differences were observed in hemodynamic parameters. No significant differences were observed in ANI variations or HRV parameters over time between groups.

CONCLUSIONS

The administration of esmolol produced significant changes in hemodynamics with no change in ANI values or HRV parameters. Further study is needed to understand the effect of esmolol during sepsis.

Esmolol infusion in patients with septic shock and tachycardia: a prospective, single-arm, feasibility study

Background

High adrenergic tone appears to be associated with mortality in septic shock, while adrenergic antagonism may improve survival. In preparation for a randomized trial, we conducted a prospective, single-arm pilot study of esmolol infusion for patients with septic shock and tachycardia that persists after adequate volume expansion.

Methods

From April 2016 to March 2017, we enrolled patients admitted to an intensive care unit with sepsis who were receiving vasopressor infusion and were tachycardic despite adequate volume expansion. All patients received a continuous intravenous infusion of esmolol, targeted to heart rate 80–90/min, while receiving vasopressors. The feasibility outcomes were proportion of eligible patients consented, compliance with pre-infusion safety check, and compliance with the titration protocol. The primary clinical outcome was organ-failure-free days (OFFD) at 28 days.

Results

We enrolled 7 of 10 eligible patients. Mean age was 46 (± 19) years, and mean admission APACHE II was 28 (± 8). Median norepinephrine infusion rate at the initiation of esmolol infusion was 0.20 (0.14–0.23) μg/kg/min. Compliance with the safety check was 100%; compliance with components of the titration protocol was 98–100%. OFFD were 26 (24.5–26); all patients survived to day 90. Median peak esmolol infusion was 50 (25–50) μg/kg/min. Median peak norepinephrine infusion rate during esmolol infusion was 0.46 (0.13–0.50) μg/kg/min. Four patients achieved target heart rate. Protocol-defined stop events, suggesting possible intolerance to a given infusion rate, occurred in three patients, all of whom were receiving at least 50 μg/kg/min of esmolol.

Conclusions

In a pilot, single-arm study, we report the first published experience with esmolol infusion in tachycardic patients with septic shock in the United States. These findings support a phase 2 trial of esmolol infusion for septic shock. Lower infusion rates of esmolol infusion may be better tolerated and more feasible than higher infusion rates for such a trial.

Trial registration

This study was retrospectively registered at ClinicalTrials.gov (NCT02841241) on 19 July 2016.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0321-5) contains supplementary material, which is available to authorized users.

Monitoring microcirculation in critical illness

PURPOSE OF REVIEW

Critical illness includes a wide range of conditions from sepsis to high-risk surgery. All these diseases are characterized by reduced tissue oxygenation. Macrohemodynamic parameters may be corrected by fluids and/or vasoactive compounds; however, the microcirculation and its tissues may be damaged and remain hypoperfused. An evaluation of microcirculation may enable more physiologically based approaches for understanding the pathogenesis, diagnosis, and treatment of critically ill patients.

RECENT FINDINGS

Microcirculation plays a pivotal role in delivering oxygen to the cells and maintains tissue perfusion. Negative results of several studies, based on conventional hemodynamic resuscitation procedures to achieve organ perfusion and decrease morbidity and mortality following conditions of septic shock and other cardiovascular compromise, have highlighted the need to monitor microcirculation. The loss of hemodynamic coherence between the macrocirculation and microcirculation, wherein improvement of hemodynamic variables of the systemic circulation does not cause a parallel improvement of microcirculatory perfusion and oxygenation of the essential organ systems, may explain why these studies have failed.

SUMMARY

Critical illness is usually accompanied by abnormalities in microcirculation and tissue hypoxia. Direct monitoring of sublingual microcirculation using hand-held microscopy may provide a more physiological approach. Evaluating the coherence between macrocirculation and microcirculation in response to therapy seems to be essential in evaluating the efficacy of therapeutic interventions.

Neural pathways involved in infection-induced inflammation: recent insights and clinical implications

Although the immune and nervous systems have long been considered independent biological systems, they turn out to mingle and interact extensively. The present review summarizes recent insights into the neural pathways activated by and involved in infection-induced inflammation and discusses potential clinical applications. The simplest activation concerns a reflex action within C-fibers leading to neurogenic inflammation. Low concentrations of pro-inflammatory cytokines or bacterial fragments may also act on these afferent nerve fibers to signal the central nervous system and bring about early fever, hyperalgesia and sickness behavior. In the brain, the preoptic area and the paraventricular hypothalamus are part of a neuronal network mediating sympathetic activation underlying fever while brainstem circuits play a role in the reduction of food intake after systemic exposure to bacterial fragments. A vagally-mediated anti-inflammatory reflex mechanism has been proposed and, in turn, questioned because the major immune organs driving inflammation, such as the spleen, are not innervated by vagal efferent fibers. On the contrary, sympathetic nerves do innervate these organs and modulate immune cell responses, production of inflammatory mediators and bacterial dissemination. Noradrenaline, which is both released by these fibers and often administered during sepsis, along with adrenaline, may exert pro-inflammatory actions through the stimulation of β1 adrenergic receptors, as antagonists of this receptor have been shown to exert anti-inflammatory effects in experimental sepsis.

Use of a Short-Acting β1 Blocker During Endotoxemia May Reduce Cerebral Tissue Oxygenation if Hemodynamics are Depressed by a Decrease in Heart Rate

BACKGROUND

A decrease in heart rate (HR) using a short-acting β blocker has potential benefits in sepsis; however, depression of hemodynamics and reduction of cerebral oxygenation may also occur in endotoxemia.

METHODS

Seventeen swine were allocated to landiolol or control groups. In the landiolol group, the dose was sequentially changed from 0 to 40 to 200 μg kg min, and stopped. Hemodynamics, blood variables, and the cerebral tissue oxygenation index (TOI) were recorded by near infrared spectroscopy at each dose. Lipopolysaccharide (LPS) was then administered continuously at 1 μg kg h after a 100 μg bolus administration. After 30 and 150 min, as two severity stages of endotoxemia (endotoxemia 1 and 2), landiolol was administered as above and measurements were made. In the control group, landiolol was not administered, but measurements were made.

RESULTS

LPS increased HR and landiolol decreased HR, with similar effects in each endotoxemia stage. In endotoxemia 1, LPS decreased stroke volume (SV), but landiolol restored SV to a value similar to that before endotoxemia, and did not decrease cardiac output (CO), even at 200 μg kg min. In contrast, landiolol did not restore SV in endotoxemia 2, resulting in a decrease in CO and mean arterial pressure, accompanied with a dose-dependent decrease in TOI.

CONCLUSIONS

A short-acting β blocker has various hemodynamic effects in endotoxemia. Use of a short-acting β blocker during endotoxemia may reduce cerebral tissue oxygenation if hemodynamics are depressed by a decrease in HR.

Landiolol for managing atrial fibrillation in intensive care

Landiolol is an injectable ultrashort acting beta-blocker with high beta1 selectivity indicated for heart rate control of atrial fibrillation in the emergency and critical care setting. Accordingly, landiolol is associated with a significantly reduced risk of arterial hypotension and negative inotropic effects. Based on this particular profile along with the clinical experience in Japan for more than a decade landiolol represents a promising agent for the management of elevated heart rate and atrial fibrillation in intensive care patients even with catecholamine requirements. This article provides a review and perspective of landiolol for heart rate control in intensive care patients based on the current literature.