The Efficacy and Safety of Esmolol for Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Effect of ultrashort-acting β-blockers on 28-day mortality in patients with sepsis with persistent tachycardia despite initial resuscitation: a meta-analysis of randomized controlled trials and trial sequential analysis

Purpose

This meta-analysis aims to identify whether patients with sepsis who have persistent tachycardia despite initial resuscitation can benefit from ultrashort-acting β-blockers.

Materials and methods

Relevant studies from MEDLINE, the Cochrane Library, and Embase were searched by two independent investigators. RevMan version 5.3 (Cochrane Collaboration) was used for statistical analysis.

Results

A total of 10 studies were identified and incorporated into the meta-analysis. The results showed that the administration of ultrashort-acting β-blockers (esmolol/landiolol) in patients with sepsis with persistent tachycardia despite initial resuscitation was significantly associated with a lower 28-day mortality rate (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.57-0.93; and p˂0.01). Subgroup analysis showed that the administration of esmolol in patients with sepsis was significantly associated with a lower 28-day mortality rate (RR, 0.68; 95% CI, 0.55-0.84; and p˂0.001), while there was no significant difference between the landiolol and control groups (RR, 0.98; 95% CI, 0.41-2.34; and p = 0.96). No significant differences between the two groups were found in 90-day mortality, mean arterial pressure (MAP), lactate (Lac) level, cardiac index (CI), and troponin I (TnI) at 24 h after enrollment.

Conclusion

The meta-analysis indicated that the use of esmolol in patients with persistent tachycardia, despite initial resuscitation, was linked to a notable reduction in 28-day mortality rates. Therefore, this study advocates for the consideration of esmolol in the treatment of sepsis in cases where tachycardia persists despite initial resuscitation.

Esmolol's Role in Hemodynamic Management During Pheochromocytoma Surgery: A Comprehensive Review

Pheochromocytoma (PCC) surgery presents significant challenges due to the hemodynamic instability induced by catecholamine release. Effective perioperative management is essential to minimize complications and ensure optimal outcomes. This comprehensive review examines the role of esmolol, a short-acting beta-blocker, in hemodynamic stabilization during PCC surgery. We provide an overview of the pathophysiology of PCC, highlighting the cardiovascular effects of excessive catecholamines. Challenges in perioperative management and the need for effective hemodynamic control are discussed. The pharmacology and mechanisms of action of esmolol are outlined, along with evidence from clinical studies supporting its use in PCC surgery. Comparative analyses with other hemodynamic agents are presented, along with recommendations for optimizing esmolol administration and monitoring. Key findings include the ability of esmolol to attenuate catecholamine-induced hypertension and tachycardia, thereby promoting hemodynamic stability and reducing the risk of intraoperative cardiovascular crises. Implications for clinical practice include the incorporation of esmolol into perioperative management protocols and the importance of multidisciplinary collaboration. Future research directions include further elucidating optimal dosing regimens, comparative effectiveness studies, and exploring novel therapeutic approaches. Collaboration among clinicians, researchers, and pharmaceutical companies is essential to advance the care of patients undergoing surgery for PCC.

Beyond the Surviving Sepsis Campaign Guidelines: a systematic review of interventions affecting mortality in sepsis

INTRODUCTION

Sepsis-related mortality is decreasing over time after the introduction of "Surviving Sepsis Campaign" Guidelines in 2004. The last Guidelines version collects 93 recommendations, but several interventions supported by randomized evidence of mortality reduction are not included.

EVIDENCE ACQUISITION

We performed a systematic review of all randomized controlled trials reporting a statistically significant mortality reduction in septic patients and compared the identified studies to the Surviving Sepsis Campaign Guidelines 2021 to highlight discrepancies.

EVIDENCE SYNTHESIS

We identified 83 randomized controlled trials (58 interventions) influencing mortality in sepsis. Only 9/58 of these interventions were included in the Guidelines: lactate measurement and lactate-guided hemodynamic management, procalcitonin-guided antibiotics discontinuation, balanced crystalloids as first choice fluids, albumin infusion, avoidance of starches, noradrenaline as first line vasopressor, vasopressin as an adjunctive vasopressor to noradrenaline, neuromuscular blocking agents in moderate-severe sepsis-associated acute respiratory distress syndrome, and corticosteroids use. Only 11/93 Guidelines recommendations were supported by randomized evidence with mortality difference. Five of the interventions with survival benefit in literature (vitamin C, terlipressin, polymyxin B, liberal transfusion strategy and immunoglobulins) were recommended to avoid in the Guidelines, while 44 interventions were not mentioned, including three interventions (esmolol, omega 3, and external warming) with at least two randomized controlled trials with a documented survival benefit.

CONCLUSIONS

Several discrepancies exist between the randomized controlled trials with mortality difference in septic patients and the latest Surviving Sepsis Campaign Guidelines. This systematic review can be of help for improving future guidelines and may guide research on specific promising topics.

The influence of metoprolol in patients with sepsis-induced cardiomyopathy: A retrospective study

OBJECTIVES

To focus on evaluating the clinical influence of metoprolol on sepsis-induced cardiomyopathy (SICM).

METHODS

A total of 90 patients with SICM was enrolled from December 2018 to February 2021 and divided into 2 groups according to the use of metoprolol during hospitalization in Suzhou Municipal Hospital in Suzhou, China. We compared them with the cardiac function, sequential organ failure assessment score, and clinical outcomes.

RESULTS

Between the 2 groups, the oxygenation indices and Glasgow coma scale in the metoprolol group were higher on the first day of treatment, with Glasgow coma scale higher on the third day of treatment. However, the doses of norepinephrine in patients with metoprolol showed no significant differences with the control group. The all-causemortality at 28 days in the metoprolol group was lower, and the time of removing from ventilator support as well as the number of failured organs also significantly differed between the 2 groups.

CONCLUSION

Metoprolol can reduce the 28-day mortality and shorten the duration of mechanical ventilation in SICM. It can also reduce the number of organ failures and improve the oxygenation index and Glasgow coma scale of these patients. Meanwhile, metoprolol did not affect the norepinephrine dose in patients with SICM.

Benefits of esmolol in adults with sepsis and septic shock: An updated meta-analysis of randomized controlled trials

BACKGROUND

Sepsis affects millions of patients annually, resulting in substantial health and economic burdens globally. The role of esmolol potentially plays in the treatment of sepsis and septic shock in adult patients remains controversial.

METHODS

We undertook a systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from their inception to May 12, 2022, for randomized controlled trials that evaluated the efficacy of esmolol for sepsis and septic shock. A random-effects meta-analysis was performed. Two investigators independently screened articles, extracted data, and assessed the quality of included studies.

RESULTS

Eight studies from 7 randomized controlled trials were included in our meta-analysis of 503 patients with sepsis and/or septic shock. Compared with standard treatment, esmolol significantly decreased 28-day mortality (risk ratio 0.68, 95% confidence interval [CI] 0.52-0.88; P = .004), heart rate (standardized mean difference [SMD] -1.83, 95% CI -2.95 to -0.70, P = .001), tumor necrosis factor-a (SMD -0.48, 95% CI -0.94 to -0.02, P = .04), and the troponin I level (SMD -0.59, 95% CI -1.02 to -0.16, P = .008) 24 hours after treatment. No significant effect was found in terms of length of intensive care unit stay; mean arterial pressure, lactic acid, central venous pressure, or central venous oxygen saturation, interleukin 6, or white blood cell levels; stroke volume index; or the PaO2/FiO2 ratio.

CONCLUSIONS

Esmolol treatment may be safe and effective in decreasing 28-day mortality, controlling heart rate, and providing cardioprotective function, but has no effect on lung injury in patients with sepsis or septic shock after early fluid resuscitation. Improvement in cardiac function may be related to changes in serum inflammatory mediators. No significant adverse effects on tissue perfusion and oxygen utilization were observed.