Is lactate lower in septic patients who are prescribed beta blockers? Retrospective cohort study of an intensive care population

Abstract

Objective Elevated serum lactate has long been considered an important marker of sepsis severity. Increasing evidence supports catecholamine‐stimulated aerobic glycolysis being a major contributor to the hyperlactataemia seen in sepsis. Beta‐blockade may blunt such catecholamine mediated rise in lactate analogous to the way it can mask tachycardia. This could impact the way we evaluate sepsis severity and adequacy of initial treatment. The objective of this study is to investigate whether septic patients who were on beta‐blocker treatment at presentation have lower serum lactate level. Methods Using a retrospective cohort design we gathered data on patients admitted to our base hospital intensive care unit with APACHE III diagnosis of sepsis and septic shock during the 2017 calendar year. Serum lactate, current medications, presenting vital signs, illness severity scores, laboratory data and mortality outcome were extracted from patients' medical record and the unit's clinical database. Results Of 189 records analysed, 49 patients were concurrently prescribed beta‐blockers. More beta‐blocked patients were male, beta‐blocked patients were older, and a greater proportion of beta blocked patients had their first lactate measured as an inpatient. After regression to correct for identified significant covariates mean serum lactate was 0.87 (95% confidence interval 0.05–1.69) mmol/L lower in those prescribed beta blockers. Conclusions In our cohort pre‐existing beta blocker treatment was associated with lower serum lactate measurements in patients presenting with sepsis. Pre‐existing beta blocker treatment may reduce serum lactate at presentation in patients with sepsis.

Premorbid beta blockade in sepsis is associated with a lower risk of a lactate concentration above the lactate threshold, a retrospective cohort study

“…The papers which found no effect analysed cohorts with an average initial lactate of ≤ 2 mmol/L 40 , 42 ; we did not identify any association for premorbid beta blockade with the probability of lactate being ≥ 2 mmol/L. The three other studies which demonstrated an effect of beta blockade when looking at cohorts with higher average lactates 39 , 41 , 43 . Our proposed mechanism to explain the findings seen in our study, while hypothetical, offers a unifying explanation for the current heterogeneity of evidence in this area.…”

“…We used unpublished data from previous work where 25% fewer patients who were prescribed beta blockers in the community had an initial lactate > 4 mmol/L when compared with those not prescribed beta blockers (20% vs 45%). The study was powered under the assumptions that there would be the same proportion of beta blocked patients in the population and the proportions of patients with lactate > 4 mmol/L would be the same as in our previous work 41 . Under these assumptions, our study was > 80% powered at and alpha of 0.05 with 180 patient records included in the analysis.…”

“…Five observational studies have assessed the effect of pre-morbid beta-blockade on lactate levels in patients presenting with sepsis 39 – 43 . Three trials found a significant reduction in lactate levels with beta-blockade 39 , 41 , 43 , while two showed no difference 40 , 42 . A recent meta-analysis of these studeis found lactate levels to be lower in patients on beta-blockers 44 .…”

Effect of Premorbid Beta-Blockers on Mortality in Patients With Sepsis: A Systematic Review and Meta-Analysis

“…10,20,22,25 There were no significant differences in the ICU LOS (SMD, 0.05; 95% CI, −0.07-0.18; P = .38; I 2 = 68%) and need for mechanical ventilation (OR, 1.14; 95% CI, 0.69-1.90; P = .61; I 2 = 80%). Five studies reported the HR on admission 9,21,[23][24][25] and lactate levels on admission. 9,10,20,23,24 HR on admission (SMD, −0.33; 95% CI, −0.50-0.16; P < .001; I 2 = 66%) and lactate level on admission (SMD, −0.25; 95% CI, −0.36-0.13; P < .001; I 2 = 49%.)…”

Beta-blockers in septic shock: What is new?

“…68% ( P = 0.529) NS for lactate level, hospital length of stay, norepinephrine use Pham et al. [45] Retrospective cohort study Premorbid BB exposure vs . not in sepsis on serum lactate level 189 Mean serum lactate level was 0.87 (0.05–1.65); lower under BB NA Chan et al.…”