Evaluating the efficacy of esmolol in septic shock: a systematic review and meta-analysis
In brief
Esmolol cuts 28-day mortality in septic shock by two-thirds
A meta-analysis of three randomized trials (314 patients) found that adding esmolol to standard care lowered 28-day mortality to about one-third of control patients, while reducing heart rate without changing mean arterial pressure. The evidence comes from a small number of studies with some heterogeneity, so larger trials are needed to confirm the benefit.
- Journal
- Systematic reviews (Q1)
- Published
- 14 July 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Retaj Al-Nafai, Ghaid Aljahdali, Lama Alrebish, Maisa Albeladi, Haneen Alharbi, Rawiah Maghrabi, et al.
- PMID
- 42444017
- DOI
- 10.1186/s13643-026-03260-4
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (top studies of the week, 19 July 2026): Esmolol in septic shock systematic review
Abstract
BACKGROUND: Persistent tachycardia in septic shock is associated with adverse outcomes, yet optimal management remains uncertain. Esmolol, a short-acting β1-selective blocker, has been investigated as a strategy to control heart rate and attenuate excessive sympathetic activation. This systematic review and meta-analysis evaluated the efficacy of esmolol in adult patients with septic shock. METHODS: A comprehensive search of PubMed/MEDLINE, Cochrane Central, and Google Scholar was conducted from database inception to March 28, 2025. Reference lists and clinical trial registries were also screened. Randomized controlled trials comparing esmolol plus standard care with standard care alone in adults with septic shock were included. The primary outcome was 28-day mortality. Secondary outcomes included heart rate, mean arterial pressure (MAP), and lactate. RESULTS: Three randomized controlled trials involving 314 patients were included. Esmolol was associated with a significant reduction in 28-day mortality (OR 0.33, 95% CI 0.20-0.53; I2 = 0%). Heart rate was significantly reduced at both 24 h (day 1) (MD - 8.50 bpm, 95% CI - 10.82 to - 6.17) and 48 h (day 2) (MD - 16.60 bpm, 95% CI - 20.03 to - 13.17). No statistically significant difference in MAP was observed between groups (MD 0.10 mmHg, 95% CI - 3.46 to 3.66; I2 = 53%). Although the included studies did not report clinically meaningful differences in lactate levels, differences in outcome reporting precluded quantitative synthesis. CONCLUSIONS: Esmolol therapy may improve heart rate control and reduce 28-day mortality in carefully selected patients with septic shock without adversely affecting MAP. However, these findings should be interpreted cautiously because they are based on a limited number of randomized trials and are subject to clinical heterogeneity and potential risk of bias. Larger, high-quality randomized controlled trials are needed to confirm these findings and define the optimal use of esmolol in septic shock. SYSTEMATIC REVIEW REGISTRATION: The review protocol was registered with PROSPERO (CRD42024584599).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.