beta-blockers AND norepinephrine in septic shock

[Nick8]

If a patient has a septic shock requiring norepinefrine infusion and his HR is 130 can I use beta blockers? In general can we use beta-agonists and beta-blockers at the same time?

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[jdh71]

If a patient has a septic shock requiring norepinefrine infusion and his HR is 130 can I use beta blockers? In general can we use beta-agonists and beta-blockers at the same time?

norepi shouldn't have a lot of activity at the beta-receptor

the real question you should be asking yourself is why you'd want to lower the blood pressure and decrease appropriate cardiac responses to septic shock, as long as it's sinus tach, let him tach. People don't go into sinus tach as a result of a deficiency in beta-blocker - run through your differential for sinus tach, treat what needs treating, in this case, patient probably needs fluid.

hold the beta blocker

 

[Hernandez]

If a patient has a septic shock requiring norepinefrine infusion and his HR is 130 can I use beta blockers? In general can we use beta-agonists and beta-blockers at the same time?

If sinus tach....why? Treat the underlying cause
If a-fib, should you consider dig/amio/electricity?

 

[Bostonredsox]

I actually encounter this frequently. Septic shock with an SVR in the toilet, pumping saline and still can't get a MAP above 60 so I have levophed rolling and often additional peripheral help with neo, but they're taching away at 150-160. However, I agree with above posters, it is almost never ST unless they have an underlying PE. Its most always AF with RVR in which case I do use Esmolol/metoprolol or sometimes diltiazem to drop the Hr down to 130. It allows for increased ventricular filling times and improves CO, often resulting in a slight bump in my abysmal MAP. But again, rarely ST. And even if it is, ST is always physiologic and a rate less than 130 we rarely intervene on.

 

[jdh71]

I actually encounter this frequently. Septic shock with an SVR in the toilet, pumping saline and still can't get a MAP above 60 so I have levophed rolling and often additional peripheral help with neo, but they're taching away at 150-160. However, I agree with above posters, it is almost never ST unless they have an underlying PE. Its most always AF with RVR in which case I do use Esmolol/metoprolol or sometimes diltiazem to drop the Hr down to 130. It allows for increased ventricular filling times and improves CO, often resulting in a slight bump in my abysmal MAP. But again, rarely ST. And even if it is, ST is always physiologic and a rate less than 130 we rarely intervene on.

amio, try the amio first before using a beta-blocker or diltiazem, or give them some juice if it's really affecting BP that much

 

[sluggs]

In sinus tach and septic shock there is no rationale for BB, and it will drop the BP and kill the patient. In a-fib and septic shock there is a physiologic rationale for BB, but DON'T DO IT because it will still kill the patient. Dig load and cardiovert if you have to, but stay away from BB and CCB. Bad news!!

 

[souljah1]

Sinus tachycardia in the setting of septic shock is a compensatory mechanism to account for either an under filled ventricle combined with a low SVR OR sepsis-induced cardiomyopathy. Do not beta block sinus tach.

If you have an SVT in the setting of septic shock and your patient is on levophed, you can try to transition to neo to see if the cardiac excitation abates. If it persists then you can use Amiodarone, which has a side effect of nodal blockade (without a drop in BP). If I am meeting my resuscitation goals during septic shock and SVT leads to significant hypotension - they get shocked.

A prior poster suggested routine use of both leveophed and neo. That doesn't make a lot of sense at all given that both will be competing for the alpha receptor. Personally, I don't use more than two pressors. I usually use levo +/- vasopression OR neo +/- vasopressin (if tachyarrythmias are present) OR epi +/- vasopressin (RV failure)..This general approach does not take into account using inotropes like milrinone or dobutamine.

 

[Jagleaso]

If you have an SVT in the setting of septic shock and your patient is on levophed, you can try to transition to neo to see if the cardiac excitation abates. If it persists then you can use Amiodarone, which has a side effect of nodal blockade (without a drop in BP). If I am meeting my resuscitation goals during septic shock and SVT leads to significant hypotension - they get shocked.

Agree with this completely.

 

[redy]

Sinus tachycardia in the setting of septic shock is a compensatory mechanism to account for either an under filled ventricle combined with a low SVR OR sepsis-induced cardiomyopathy. Do not beta block sinus tach.

If you have an SVT in the setting of septic shock and your patient is on levophed, you can try to transition to neo to see if the cardiac excitation abates. If it persists then you can use Amiodarone, which has a side effect of nodal blockade (without a drop in BP). If I am meeting my resuscitation goals during septic shock and SVT leads to significant hypotension - they get shocked.

A prior poster suggested routine use of both leveophed and neo. That doesn't make a lot of sense at all given that both will be competing for the alpha receptor. Personally, I don't use more than two pressors. I usually use levo +/- vasopression OR neo +/- vasopressin (if tachyarrythmias are present) OR epi +/- vasopressin (RV failure)..This general approach does not take into account using inotropes like milrinone or dobutamine.

If patient is in PSVT and on levophed does it not then become unstable PSVT by definition and require cardioversion? Also what would be the role of adenosine in that scenario if cardioversion is not the option?

 

[Hernandez]

If patient is in PSVT and on levophed does it not then become unstable PSVT by definition and require cardioversion? Also what would be the role of adenosine in that scenario if cardioversion is not the option?

Yes...no.....depends on the scenario and how stable your pt is. Levophed can induce arrhythmias, it's not as common as with dopamine, but it does happen, IF you think the Levo is causing the SVT you can back down while increasing Neo if you think it's the beta activity from the Levo causing the issues.

 

[PlutoBoy]

I don't use beta blockers in shock. I don't chase sinuch tach. If A-fib is a problem I go with amio or cardioversion.

 

[Intensivist]

l think he/she meant, that by definition, patient on levo is unstable for PSVT standards....

 

[glorfindel]

This thread is better than I thought it would be.

I initially thought the OPs question was absurd, because I assumed sinus tach in a septic shock pt, and thought, "only place they'd get beta blockers would be at Outside Hospital."

EDIT: @ 1:36. Treat with lasix and metoprolol....

[YOUTUBE]http://www.youtube.com/watch?v=xskFo75Wdhs[/YOUTUBE]

 

[souljah1]

That video is from my hospital. Was done by residents as a spoof years ago. It is classic

 

[Bostonredsox]

your advise worked nicely. Picked up a pt tonight that is a septic shock 2/2 PNA/Flu+, hypotensive without any sedation but difficult to sedate. apparently been going in and out of SVT and Parox AF with RVR. Looks like last night they gave cardizem, pressure plummeted so they stopped sedation and bolused a **** ton. AM cardiologist stopped the dilt. Tonight pt dysynchronus with the vent and popped into AF RVR at 160. Pushed 150 amio and started some PO viat his OGT and a nice sinus rhythm at 90 from then on out. Still ended up needing to precedex and fentanyl him to get him inline with the vent and then added some neo to keep a map at goal, was hovering 58-66 anyway. Did quite nicely. cheers