Combined milrinone and enteral metoprolol therapy in patients with septic myocardial depression.
Crit Care. 2008 Aug 4;12(4):R99
Authors: Schmittinger CA, Dunser MW, Haller M, Ulmer H, Luckner G, Torgersen C, Jochberger S, Hasibeder WR
ABSTRACT: INTRODUCTION: The multifactorial etiology of septic cardiomyopathy is not fully elucidated. Recently, high catecholamine levels have been suggested to contribute to impaired myocardial function. METHODS: This retrospective analysis summarizes our preliminary clinical experience with the combined use of milrinone and enteral metoprolol therapy in forty patients with septic shock and cardiac depression. Patients with other causes of shock or cardiac failure, patients with beta-blocker therapy initiated >48 hrs after shock onset and patients with pre-existent decompensated congestive heart failure were excluded. In all study patients, beta blockers were initiated only after stabilization of cardiovascular function (17.7+/-15.5 hrs after shock onset or intensive care unit admission) in order to decrease heart rate <95 bpm. Hemodynamic data and laboratory parameters were extracted from medical charts and documented before, 6, 12, 24, 48, 72, and 96 hours after the first metoprolol dosage. Adverse cardiovascular events were documented. Descriptive statistical methods and a linear mixed-effects model were used for statistical analysis. RESULTS: Heart rate control (65-95 bpm) was achieved in 97.5% of patients (n=39) within 12.2+/-12.4 hrs. Heart rate, central venous pressure, norepinephrine, arginine vasopressin and milrinone dosages decreased (all p<0.001). Cardiac index and cardiac power index remained unchanged, while stroke volume index increased (p=0.002). In two patients (5%) metoprolol was discontinued because of asymptomatic bradycardia. Norepinephrine and milrinone dosages were increased in nine (22.5%) and six (15%) patients, respectively. PH increased (p<0.001), while arterial lactate (p<0.001), serum C-reactive protein (p=0.001) and creatinine levels (p=0.02) decreased during the observation period. Twenty-eight day mortality was 33%. CONCLUSIONS: Low doses of enteral metoprolol in combination with phosphodiesterase inhibitors are feasible in patients with septic shock and cardiac depression but no overt heart failure. Future prospective controlled trials on the use of beta blockers for septic cardiomyopathy and their influence on pro-inflammatory cytokines are warranted.
PMID: 18680591 [PubMed - as supplied by publisher]