Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study

Ej, Ley; Sd, Leonard; Barmparas, Galinos; Nk, Dhillon; Inaba, Kenji; Salim, Ali; Kr, OʼBosky; Tatum, Danielle; Azmi, Hooman; Cg, Ball; Pt, Engels; Ja, Dunn; Mm, Carrick; Jp, Meizoso; Lombardo, Sarah; Ba, Cotton; Schroeppel, Thomas J.; Rizoli, Sandro; Dsj, Chang; La, de León; Rezende-Neto, João; Jacome, Tomas; Jian-yun, Xiao; Mallory, Grant W.; K, Rao; Widdel, Lars; Godin, Samuel; Coates, Alan S.; La, Benedict; Nirula, Raminder; Kaul, Sanjeev; T, Li

doi:10.1097/ta.0000000000001747

Cited by 70 publications

(75 citation statements)

References 40 publications

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“…Accordingly, cardiovascular adverse events are the most common extracranial causes of death in TBI patients [10,14]. Several studies have shown an association between beta-blocker use and decreased mortality in patients suffering from TBI [30][31][32], leading to a recommendation for this therapy in this population by the Eastern Association for the Surgery of Trauma [33]. This finding has been attributed to the cardioprotective effect of beta-blockers in response to the hyperadrenergic state often seen in this patient population.…”

Section: Discussionmentioning

confidence: 99%

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

Forssten

Bass

Scheufler

et al. 2021

Eur J Trauma Emerg Surg

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Purpose Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. Methods All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. Results 259,399 patients met the study’s inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01–1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05–1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11–1.90), p = 0.006], compared to RCRI 0. Conclusion An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

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Section: Discussionmentioning

confidence: 99%

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

Forssten

Bass

Scheufler

et al. 2021

Eur J Trauma Emerg Surg

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“…13,14 These various implications may culminate in end organ damage and explain why beta blockers appear to confer a survival advantage. 8,13…”

Section: Discussionmentioning

confidence: 99%

“…Attenuation of this catecholamine response by beta-adrenergic receptor blockers was associated with lower mortality in a prospective multicenter trial, with propranolol, a nonselective beta blocker which is able to cross the blood brain barrier, conferring the best survival advantage. 8 What is not clear is if mitigating the catecholamine response has any implications for alterations in coagulation after trauma.…”

Section: Introductionmentioning

confidence: 99%

Early Propranolol Is Associated With Lower Risk of Venous Thromboembolism After Traumatic Brain Injury

Dhillon

Hashim

Conde

et al. 2021

The American Surgeon

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Background Traumatic brain injury (TBI) results in an elaborate systemic cascade of secondary injury elicited in part by an intrinsic catecholamine response, which ultimately leads to changes in inflammation and coagulopathy. Attenuation of this catecholamine response with agents such as propranolol confers a survival advantage. The related impact of propranolol on venous thromboembolism (VTE) after TBI is largely unknown. Study Design A single institution retrospective review was conducted of all TBI patients requiring intensive care unit (ICU) admission with an injury severity scale (ISS) ≥ 25 from January 2013 to May 2015. Patients who received at least one dose of propranolol within 24 hours of admission (PROP) were compared to patients who did not receive any doses of propranolol (NPROP) during their hospitalization. Results Of the 131 patients analyzed, 31 (23.7%) patients received propranolol. The PROP cohort was more severely injured overall (ISS 29 vs 26.5, P = .02). While unadjusted VTE rates were similar (16.1% vs 19.0%, P = .72), the adjusted VTE rate was lower in the PROP cohort (AOR 0.20 (95% CI 0.04-0.97), adjusted P-value < .05). Conclusion Propranolol use in TBI patients who have sustained critical injuries may mitigate the risk of VTE. The mechanism by which this outcome is achieved requires further investigation.

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“…In 2018, to build on the optimistic findings of these small single-center trials, the American Association for the Surgery of Trauma (AAST) conducted a multi-institutional, prospective observational trial (Ley et al, 2018). After analysis of 2,252 patients, the trial concluded that patients who received βB after TBI had a significantly lower adjusted (adjusted OR 0.35; p < 0.001) and unadjusted mortality rate (13.8 vs. 17.7%; p 0.013) in congruence with the 2017 EAST guideline recommendation.…”

Section: Traumatic Brain Injurymentioning

confidence: 99%

Beta-Adrenergic Blockade in Critical Illness

et al. 2021

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Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.

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Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study

Abstract: Therapeutic/care management, level III.

Cited by 70 publications

References 40 publications

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

Early Propranolol Is Associated With Lower Risk of Venous Thromboembolism After Traumatic Brain Injury

Beta-Adrenergic Blockade in Critical Illness

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