Esmolol and Norepi

[Cvepo]

I'd like to get some ICU nurse opinions here. I have 3 years of ICU experience, but I'm confused about this event. I was supporting a newer nurse recently with a post-surgical Type B dissection repair from OR. The patient arrived with esmolol for rate control and norepinephrine for BP control due to a baseline poor renal perfusion. When I worked MICU a few years ago, we would rarely (but occasionally) use esmolol in sepsis for HR control, but if we encountered hypotension, we would use phenylephrine for its alpha response rather than norepinephrine. I know norepinephrine also can stimulate alpha receptors, but it does have a beta adrenergic response, which we are subsequently blocking with the esmolol infusion.

Basically, I spoke up and asked the fellow (who by the way, we are currently having a MYRIAD of problems with on our unit) why not switch to a phenylephrine drip instead. He validated my knowledge and said that phenylephrine would also be a good choice, but that norepinephrine was still an appropriate drug as well. I asked for further clarification, because, hey, I'd like to learn, but his response was wishy-washy and he started citing studies than phenylephrine leads to increased mortality in sepsis patients. Great. But this isn't a sepsis patient. I could tell that he wasn't going to change the drip package, so despite my advocacy for the patient and my coworker, I dropped it.

Long story short, everything turned out OK, but the patient remained on both esmolol and norepinephrine (and eventually CRRT) for roughly 24 hours until parameters were widened so that the drips could be turned off. I've taken the time to do some research, but can so far only find articles of esmolol usage in sepsis AFTER hemodynamic stabilization. Am I wrong or missing something that using a beta blocker (appropriate) but then counteracting the hypotension with a beta agonist, doesn't make sense when we have a readily available pressor like phenylephrine?

[offlabel]

Esmolol is a selective beta 1 antagonist. NE is an alpha 1, beta 1 and beta 2 agonist, so the esmolol mitigates the potential bump in HR of NE and just slows the heart down, as you're clearly aware. But what NE has that neo doesn't have is that beta 2 stimulation that improves myocardial perfusion and contractility to some extent. So you get a little better bump in cardiac output and therefore end organ perfusion with NE as opposed to phenylepherine.

You'd probably need to use a higher dose of esmolol with NE than phenylepherine though, but the pay off is, like I said, the potential for a better cardiac output.

[Pheebz777, BSN, RN]

Plus the B2 stimulation promotes better perfusion through the pulmonary vasculature. Esmolol is primarily a B1 antagonist which has very minimal effect on B2 receptors.

[hockeynpolo]

an interesting potential side effect of Neo is reflex bradycardia so this patient could have had the alpha 1 agonist of neo for Bp support and count on some reflex bradycardia for rate control. I work in the transport world so when we pick up AAAs, they are usually hypertensive so pain meds and esmolol is usually all we need to bring the HR and BP down. If they are hypotensive, we give fluids and blood and fly quickly. Interesting case you had needing to keep the rate down to decrease the shearing effect of the HR, but then also need a little extra SVR support for the kidneys.