Datta Priyankar K, Sathe Prachee, Roy Avishek, Baronia Tanima, Bhattacharjee Anirban, Kundu Riddhi
Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.
Department of Critical Care Medicine, Ruby Hall Hospital, Pune, Maharashtra, India.
Indian J Crit Care Med. 2024 Dec;28(12):1170-1179. doi: 10.5005/jp-journals-10071-24849. Epub 2024 Nov 30.
Heart rate control using beta-blockers in sepsis has traditionally been avoided because of concerns with worsening cardiac index and organ perfusion. Recent studies has explored the possible beneficial effects of targeted heart rate control in patients with septic shock who have tachycardia despite initial resuscitation. We performed a systematic review and meta-analysis to explore the effects of heart rate control in septic shock patients.
A systematic review and meta-analysis was conducted searching for studies from PubMed, Cochrane Central, and Embase registers for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with targeted rate control. The literature search was done to include studies from January 2013 to December 2023. Two independent researchers independently assessed the studies and included RCTS in which adult patients (>18 years of age) with septic shock were treated with targeted heart rate control vs placebo after initial resuscitation due to persistent tachycardia. The study data was extracted by two independent researchers. A random effects model was used to present the results. A trial sequential analysis (TSA) was performed for the primary outcome of 28-day mortality.
A total of 9 studies with a pooled sample size of 807 participants were included in the analysis.Eight of the included studies with a pooled sample size of 766 reported 28-day mortality. Targeted heart rate control was associated with a trend toward lower 28-day mortality [risk ratio (RR): 0.78; 95% CI: 0.62-0.99; = 0.04; = 48%]. Trial sequential analysis showed the cumulative effect lying within the zone of uncertainty, with diversity-adjusted required information size of 1,756 and pooled effect size of the pooled RR 0.78 (alpha-spending adjusted 95% CI: 0.53-1.15). There was a statistically significant lower heart rate associated with rate control (MD: -16.66; 95% CI: -23.89 to -9.42; -value < 0.001) but no difference in mean arterial pressure. cardiac index, lactate levels, norepinephrine (NE) requirements, and ICU length of stay (LOS) in between the groups.
Targeted heart rate control in patients with septic shock may be tolerated from a hemodynamic standpoint. However, the beneficial effect on mortality is less certain than was reported in the initial studies.
Datta PK, Sathe P, Roy A, Baronia T, Bhattacharjee A, Kundu R. The Clinical Utility of Targeted Heart Rate Control in Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials with Trial Sequential Analysis. Indian J Crit Care Med 2024;28(12):1170-1179.
由于担心会使心脏指数和器官灌注恶化，传统上一直避免在脓毒症中使用β受体阻滞剂进行心率控制。最近的研究探讨了在尽管经过初始复苏仍存在心动过速的感染性休克患者中进行目标心率控制可能产生的有益效果。我们进行了一项系统评价和荟萃分析，以探讨心率控制对感染性休克患者的影响。
进行了一项系统评价和荟萃分析，在PubMed、Cochrane Central和Embase数据库中检索比较接受目标心率控制治疗的脓毒症和感染性休克患者死亡率的随机对照试验（RCT）。文献检索纳入了2013年1月至2023年12月的研究。两名独立研究人员独立评估这些研究，并纳入RCT，其中成年（>18岁）感染性休克患者在因持续性心动过速进行初始复苏后接受目标心率控制与安慰剂治疗。研究数据由两名独立研究人员提取。采用随机效应模型呈现结果。对28天死亡率这一主要结局进行了试验序贯分析（TSA）。
分析共纳入9项研究，汇总样本量为807名参与者。纳入的8项研究汇总样本量为766名，报告了28天死亡率。目标心率控制与28天死亡率降低的趋势相关[风险比（RR）：0.78；95%置信区间：0.62 - 0.99；P = 0.04；I² = 48%]。试验序贯分析表明累积效应处于不确定性区间内，多样性调整后的所需信息量为1756，汇总RR的汇总效应量为0.78（α消耗调整后的95%置信区间：0.53 - 1.15）。与心率控制相关的心率在统计学上显著降低（MD：-16.66；95%置信区间：-23.89至-9.42；P值<0.001），但两组间平均动脉压、心脏指数、乳酸水平、去甲肾上腺素（NE）需求量和重症监护病房住院时间（LOS）无差异。
从血流动力学角度来看，感染性休克患者进行目标心率控制可能是可以耐受的。然而，对死亡率的有益影响不如最初研究所报道的那么确定。
Datta PK, Sathe P, Roy A, Baronia T, Bhattacharjee A, Kundu R. 目标心率控制在感染性休克中的临床应用：一项包含试验序贯分析的随机对照试验的系统评价和荟萃分析。《印度重症监护医学杂志》2024；28(12):1170 - 1179。
