Very Early Use of Esmolol in Hyperkinetic Septic Shock Patients With Persistent Tachycardia: A Randomized Controlled Pilot Study

Background : Although β-blockade for heart rate (HR) control in septic shock is conventionally initiated after 24 h of stabilization in most studies, we investigated whether esmolol could be safely and effectively administered immediately postinitial resuscitation in hyperkinetic septic shock patients with persistent tachycardia. Methods : In this randomized controlled pilot study, 24 hyperkinetic septic shock patients with sinus tachycardia (>95 bpm) after initial resuscitation were randomized to receive either esmolol (titrated for 10% HR reduction) as the treatment group or equal volume of normal saline as the control group. The primary endpoint was achievement of target HR reduction, with safety assessed through monitoring of tissue perfusion parameters and hemodynamic stability over 72 h. Results : Demographic and baseline characteristics were comparable between groups. The esmolol group achieved faster HR reduction (12/12 vs. 7/12 patients at 24 h, P = 0.037) with comparable hemodynamic stability. Despite initial decreases in cardiac index (4.5 ± 0.9 to 3.9 ± 0.6 L/min/m 2 , P = 0.009) and oxygen delivery index (585 ± 145 to 504 ± 132 mL, P = 0.040) at 1 h, tissue perfusion parameters remained stable. No significant between-group differences were observed in central venous oxygen saturation, CO 2 gap, microcirculation parameters, inflammatory markers, organ functions, or hospital mortality (42% vs. 42%, P = 1.000). Conclusion : This pilot study suggested that post-initial resuscitation early esmolol administration targeting modest HR reduction appears feasible and safe in hyperkinetic septic shock patients with persistent tachycardia, providing foundation for future large-scale investigations.