Journal Article

Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study

D’Egidio, A., Frati, G., Guarracino, F., Piscioneri, F., Singer, M., Orecchioni, A., Morelli, A., Biondi-Zoccai, G., Romano, S. M., Greco, E., Ranieri, V. M., Peruzzi, M., Mascia, L.

2016

Overview

Purpose Ventricular–arterial (V–A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV). Methods After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol. Results Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l −1 ), arterial d P /d t max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms −1 ), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p  < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg −1  min −1 , p  < 0.05). Conclusions HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V–A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.

• Publisher: Springer Berlin Heidelberg,Springer,Springer Nature B.V
• Subject: Adrenergic beta-1 Receptor Antagonists - administration & dosage / Adult / Aged / Analysis / Anesthesiology / Cardiac arrhythmia / Care and treatment / Critical Care Medicine / Echocardiography / Emergency Medicine / Esmolol / Female / Heart beat / Heart rate / Heart Rate - drug effects / Hemodynamics / Hemodynamics - drug effects / Humans / Intensive / Intensive care / Male / Medicine / Medicine & Public Health / Middle Aged / Norepinephrine - therapeutic use / Observational studies / Original / Pain Medicine / Pediatrics / Pneumology/Respiratory System / Propanolamines - administration & dosage / Prospective Studies / Pulmonary arteries / Pulmonary Artery - physiopathology / Remifentanil / Sepsis / Septic shock / Shock, Septic - physiopathology / Stroke Volume - drug effects / Tachycardia / Vasoconstrictor Agents - therapeutic use / Veins & arteries