Recently, to limit tachicardia in a septic shock patient I successfully administered beta-blocker after Dobutamine started (Norepinephrine was on continuous infusion since 24 hs, but the subject showed ultrasound worsening contractility, as he suffers from chronic heart ischemia, systolic blood pressure 85mmHg). After Dobutamine started heart rate rised from 95bpm to 120bpm (synus rhythm) with a worsening of blood pressure not responsive to Leg Rising Test (fluid load was already given). Metoprololo 3mg iv reduced the heart rate to 85-90bpm and blood pressure did ameliorate.
It was just only luck?
Hi Enrico,
I do not think it was just luck. There is growing evidence for the use of BB in sepsis (see the trial by A. Morelli in JAMA) and also it is worth nothing that in this study almost 50% of patients received levosimendan.
Moreover there is also at least one small study on milrinone associated to BB in sepsis. It is still far from being recommended in guidelines, but I strongly believe the use of BB in sepsis will probably grow over the next years.There are several reason for a haemodynaic improvement in reducing tachycardia. Also your patient had chronic heart ischemia and thus likely advanced diastolic dysfunction. Tachycardia does not help the filling especially in patients with diastolic dysfunction. Indeed a metanalysis I published on Int Care Med shows an association between diastolic dysfunction and mortality.
Best,
Filippo
Amiodarone plus dobutamine seems more reasonable to me. At least that´s what we normally do if patient´s too tachycardic
Although I have not any experience, it is reasonable to administration of beta-blocker to limit tachicardia due to dobutamine. Because, dobutamine causes tachicardia by beta receptors. Therefore, blocking these receptors may reduce the heart rate and ameliorate the blood pressure.
There is no reason to add a beta blocker to dobutamine (a beta stimulator + weak alpha) as at the end you just have the small alpha effect (the beta + and beta - neutralize each other).
The rise in blood pressure is just the effect of the alpha effect of dobutamine, but it would be wizer to just use norepinephrine.
Regarding heart rate control, the Jama paper should be looked up very cautiously as there was a 20% decrease in oxygen delivery (significant) in the esmolol group despite more frequent use of levosimendant in this group (more than 50% of the patients).
we are not using, and i dont feel its wise to start b agonist then get tachycardia and use the antagonist, if tachycardia is too much then just stop dobutamin and start something else, think norepi.
Norepinephrine, as I wrote was already on infusion, but ineffectively.
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