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?