A state-of-the-art review in Intensive Care Medicine, published in August 2026, examines beta-blockade as a way to temper the sustained adrenergic surge of critical illness. The authors list established benefit in acute myocardial infarction, tachyarrhythmias, hypertensive emergencies, thyroid storm and variceal bleeding prevention.
In septic shock, traumatic brain injury, acute heart failure and burns, the evidence is limited or conflicting. The concern is that blocking the sympathetic response can remove compensation, lowering cardiac output and perfusion in a patient who depends on it. Effects vary with drug, dose, timing, haemodynamic reserve, and whether the drug is being continued, restarted or newly started.
The practical upshot is caution and individualisation: there is no reliable marker of who will benefit, and an approach based on haemodynamic phenotype and physiology is suggested rather than a rule.
- Continue chronic beta-blockers in stable critically ill patients where possible, since abrupt withdrawal carries its own risk
- Withhold or reduce beta-blockers in patients who are hypotensive or need vasopressors
- Avoid starting beta-blockers for tachycardia in septic shock outside a trial or specialist protocol
- Use beta-blockers in thyroid storm and for rate control in hypertensive emergencies where indicated
- Reassess the indication daily as haemodynamics change
Why it matters
Interest in heart-rate control in sepsis is growing faster than the evidence for it.
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A narrative review cannot settle questions the trials have not; it maps the uncertainty.
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