Clinical science
Beta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients

https://doi.org/10.1016/j.amjsurg.2012.02.007Get rights and content

Abstract

Background

The effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries.

Methods

Critically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality.

Results

During the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients.

Conclusions

Beta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted.

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.

References (38)

  • R.G. Douglas et al.

    Metabolic response to sepsis and trauma

    Br J Surg

    (1989)
  • D.N. Herndon et al.

    Reversal of catabolism by beta-blockade after severe burns

    N Engl J Med

    (2001)
  • P.J. Devereaux et al.

    Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

    CMAJ

    (2005)
  • R.E. Barrow et al.

    The use of beta-adrenergic blockade in preventing trauma-induced hepatomegaly

    Ann Surg

    (2006)
  • D.P. Cioca et al.

    Apoptosis of peripheral blood lymphocytes is induced by catecholamines

    Jpn Heart J

    (2000)
  • D.T. Mangano et al.

    Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery

    N Engl J Med

    (1996)
  • A. Wallace et al.

    Prophylactic atenolol reduces postoperative myocardial ischemia

    Anesthesiology

    (1998)
  • D. Poldermans et al.

    The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery

    N Engl J Med

    (1999)
  • D.N. Herndon et al.

    Effect of propranolol administration on hemodynamic and metabolic responses of burned pediatric patients

    Ann Surg

    (1988)
  • Cited by (0)

    View full text