Clinical scienceBeta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients
Section snippets
Methods
After approval by the institutional review board, we retrospectively reviewed all trauma patients admitted to the Los Angeles County + University of Southern California Medical Center surgical intensive care unit (SICU) from January 2000 to December 2008. Patients sustaining moderate to severe head injuries, defined as a head Abbreviated Injury Score (AIS) ≥ 3, were excluded.
Demographic and clinical information collected included age, gender, mechanism of injury (blunt vs penetrating), blood
Results
During the 9-year study period, 5,180 patients were admitted to the SICU. After the exclusion of 2,231 patients with moderate to severe head injuries (head AIS ≥ 3), 663 patients with ISS ≥ 25 and 2,286 patients with ISS < 25 were available for analysis (Fig. 1). Beta-blocker exposure was consistent across both populations, with 14.8% of patients with ISS ≥ 25 and 15.1% of those with ISS < 25 exposed during the first 30 days of SICU admission.
Table 1 compares the demographic and clinical injury
Comments
The role of catecholamines in critical illness was established in the early 1900s,27 and modulation of this response has been an area of intense research investigation in the past decade. Severe injury is associated with sympathetic hyperactivity due to an exaggerated catecholamine response that has been shown to have a positive relationship to ISS.6 Many deleterious effects of the catecholamine surge are mediated through the β-adrenergic receptor, regardless of the source of insult.27
Conclusions
Our study suggests that there is another trauma population that may benefit from β-adrenergic blockade. In patients sustaining severe injuries, as defined by ISS ≥ 25, in the absence of significant head injuries, β-blocker exposure appears to be associated with a mortality benefit and may offer a simple therapeutic intervention. The protective mechanism of β-blocker administration remains to be elucidated given the multiple systemic effects of catecholamines and their respective β-receptors.
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The effects of beta blockade and clonidine on persistent injury-associated anemia
2018, Journal of Surgical ResearchCitation Excerpt :Future research should seek to build on the trial performed by Bible et al.9 by enrolling more patients, quantifying operative and phlebotomy blood losses, and assessing the effects of clonidine as well as BB on anemia. Future studies should also investigate other mechanisms by which BB may improve outcomes among critically ill patients, a phenomenon which has been observed in the presence and absence of traumatic brain injury.25,26 Critically ill trauma patients who received BB or clonidine for ≥25% of their hospital stay had favorable Hb trends when accounting for OBL, PBL, and RBC transfusion.
Syndecan-1: A Quantitative Marker for the Endotheliopathy of Trauma
2017, Journal of the American College of SurgeonsCitation Excerpt :Endothelial glycocalyx breakdown and syndecan-1 shedding triggers neurohormonal overactivation, coagulopathy, endothelial dysfunction, and increased permeability.2,11,19,24,29 These systemic effects are potential therapeutic targets, which has prompted the study of interventions ranging from β-blockers to modulate the catecholamine surge to plasma to repair the endothelium.29-34 Therapies such as plasma-based resuscitation seem to re-establish syndecan-1 on the cell surface and reduce shedding, while also decreasing endothelial hyperpermeability and modulating inflammation.5,13,29,32,35,36
Coagulopathy, catecholamines, and biomarkers of endothelial damage in experimental human endotoxemia and in patients with severe sepsis: A prospective study
2013, Journal of Critical CareCitation Excerpt :We infer that endogenous heparinization through shedding of the glycocalyx, represents one of several mechanisms influenced by catecholamines that contributes to hypocoagulability in critical illness [8]. Given the widespread use of vasopressor/inotropic therapy in critically ill patients, including septic patients, and the ongoing debate on the balance between its associations with beneficial vs adverse events [4,61], including evidence for the potential beneficial effects of modulating the sympathoadrenal response in critical illness [62-69], there is a need for improved understanding of the effects of catecholamines, whether endogenous and exogenous, on the vascular system, the endothelium and whole blood hemostasis in particular. The present study has several limitations.
Advances in the Management of the Critically Injured Patient in the Operating Room
2013, Anesthesiology ClinicsCitation Excerpt :Beta blockade has been suggested to be protective in human studies in subjects with brain injuries. Retrospective database reviews indicated improved neurologic outcome and reduced morbidity and mortality in patients receiving peri-insult beta blockade.12–14 Beta blockade in head injuries was initially thought to be deleterious insofar as it may decrease mean arterial pressure (MAP).
Understanding Acquired Brain Injury: A Review
2022, BiomedicinesBeta-blockade is not associated with improved outcomes in isolated severe extracranial injury: an observational cohort study
2021, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine