Esmolol Infusion for Patients With Septic Shock and Persistent Tachycardia

Phase 2

Completed

Conditions: Septic Shock

Interventions: Drug: Esmolol

Registration Number: NCT02841241

Lead Sponsor: Intermountain Health Care, Inc.

Brief Summary: This is a prospective, single arm, "roll-in" study of esmolol infusion for patients with septic shock with persistent tachycardia after adequate intravenous volume expansion. The study will evaluate the adequacy and efficiency of study protocols for the anticipated, main ECASSS study, which will have a separate entry in clinicaltrials.gov.

Detailed Description: PRIMARY OBJECTIVE:

To evaluate the adequacy and efficiency of study protocols for the anticipated, randomized, controlled ECASSS study. The primary clinical outcome is organ-failure free days at 28 days, with multiple secondary outcomes, including those relevant to function of and compliance with the study protocols.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 7

Inclusion Criteria

Age ≥ 18 years
Within 48 hours of admission to the ICU and septic shock (sepsis present at time of admission)

a. Septic shock defined by consensus criteria as i. At least two systemic inflammatory response syndrome (SIRS) criteria ii. Suspected or documented infection iii. Receiving vasopressors to treat hypotension after at least 20 ml/kg intravenous crystalloid volume expansion
Receiving vasopressors through a central venous catheter for more than 60 minutes.
Arterial catheter in place or expected to be placed imminently.
Heart rate > 90/min while receiving vasopressors for more than 60 minutes.
Adequately volume expanded, as manifest by any of the following, performed as part of routine clinical care (i.e., no study procedures will be performed before signed consent). If none of these measures are clinically available, the clinical attending must confirm that volume expansion is adequate. (After enrollment, a final safety check will confirm the adequacy of volume expansion.)
1. Central venous pressure (CVP) > 15 mm Hg.
2. Negative Passive-Leg Raise (PLR) maneuver (<10% increase in cardiac output after PLR).
3. No cardiac output response (<10% increase) after rapid infusion (<5 min) of 250 ml of IV crystalloid, i.e., a graded volume expansion challenge (GVEC).
4. For patients who happen to be breathing passively on a positive pressure mechanical ventilator delivering at least 8 ml/kg tidal volumes and in normal sinus rhythm, stroke volume variability <10% (such patients are acknowledged to be uncommon; the protocol does not recommend or require the induction of passive breathing).

Exclusion Criteria

Lack of informed consent.
Currently receiving ECMO (extracorporeal membrane oxygenation).
Known pregnancy or nursing.
Patient is a prisoner.
Patient on hospice (or equivalent comfort care approach) at or before the time of enrollment.
Known or current atrial fibrillation.
Previously enrolled in the trial.
Known allergy to esmolol or vehicle
Receipt of nodal blocking agents within three half lives
Hemoglobin < 7 gm/dl.
Cardiac arrest within 24 hours.
Pulmonary hypertension (moderate or severe), from documented history of prior right heart catheterization or current evidence on TTE (transthoracic echocardiography) of any of the following
- mPAP (mean pulmonary artery pressure) ≥ 35 mmHg
- SPAP (systolic pulmonary artery pressure)≥ 60 mmHg
Cardiovascular collapse, as manifested by inability to achieve a MAP (mean arterial pressure) of 65 mmHg with vasopressor therapy.
Cardiogenic shock, as defined by any of the following
- Cardiac index ≤ 2 L/min/m2
- Ejection fraction ≤ 25%
- ScvO2 ≤ 60%
- Current infusion of any dose of dobutamine, milrinone, or dopamine
- Current infusion of epinephrine for clinically diagnosed cardiogenic shock
Significant atrioventricular dysfunction
- Sick sinus syndrome
- PR interval (time from onset of P wave to start of QRS complex) > 200 msec
- Current evidence or prior history of Grade 2 or Grade 3 heart block
- Pacemaker or plans to place a pacemaker
Pheochromocytoma or status asthmaticus
Receiving clonidine, guanfacine, or moxonidine
Hemoglobin < 7 gm/dl
Cardiovascular collapse (failure to achieve MAP of 65mmHg)
Cardiac arrest within 24 hours
Worse than moderate aortic stenosis

• Known aortic stenosis, with any of (1) mean gradient ≥ 40 mmHg OR (2) maximum gradient ≥ 60mmHg OR (3) aortic valve area ≤ 1.0cm2 OR (4) aortic valve area index ≤ 0.85cm2/m2 body surface area.
Worse than mild mitral stenosis • Known mitral stenosis, with any of (1) valve area ≤ 1.5 cm2 OR mean gradient ≥ 5 mmHg.

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Esmolol	Esmolol	Esmolol infusion, started without bolus, with slow upward titration to a maximum infusion rate is protocolized, with a target heart rate of 80-90/min

Primary Outcome Measures

Name	Time	Method
Organ-failure-free Days	Day 28	As of day 28, the number of calendar days on which the patient receives none of (a) vasopressor therapy, (b) mechanical ventilation, or (c) renal replacement therapy. If the patients dies on or before day 28, they have -1 organ-failure-free days. The resulting point-based score combines the probability of death and the number of days without organ failure. Score of -1 = Death before day 28 (Lowest Score). Score of 28 = Patient has been successful at going 28 without any vasopressor therapy/mechanical ventilation/renal replacement therapy (Highest Score)

Secondary Outcome Measures

Name	Time	Method
All-cause Mortality	90 days
Left Ventricular Global Longitudinal Strain at 24 Hours	Day 1
Development of Heart Block	for duration of esmolol infusion, an expected average of 2 days
Peak Serum High-sensitivity Troponin	Troponin is measured on day 0 and day 1 (first day of esmolol infusion is day 0)	Measured after enrollment.