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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

Ley, Eric, J., MD; Leonard, Samuel, D.; Barmparas, Galinos, MD; Dhillon, Navpreet, K., MD; Inaba, Kenji, MD; Salim, Ali, MD; O'Bosky, Karen, R., MD; Tatum, Danielle, PhD; Azmi, Hooman, MD; Ball, Chad, G., MD, MSc; Engels, Paul, T., MD; Dunn, Julie, A., MD; Carrick, Matthew, M., MD; Meizoso, Jonathan, P., MD, MSPH; Lombardo, Sarah, MD, MSc; Cotton, Bryan, A., MD, MPH; Schroeppel, Thomas, J., MD; Rizoli, Sandro, MD, PhD; Chang, David S., J.; de León, Luis, Alejandro, MD; Rezende-Neto, Joao, MD; Jacome, Tomas, MD; Xiao, Jimmy, MD, PhD; Mallory, Gina, RN; Rao, Krishnamurti, MD, MPH; Widdel, Lars, MD; Godin, Samuel; Coates, Angela, MEd; Benedict, Leo, Andrew, MD; Nirula, Raminder, MD, MPH; Kaul, Sanjeev, MD; Li, TongThe Beta Blockers TBI Study Group Collaborators

Journal of Trauma and Acute Care Surgery: February 2018 - Volume 84 - Issue 2 - p 234–244
doi: 10.1097/TA.0000000000001747
AAST 2017 Podium Paper
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BACKGROUND Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers.

METHODS The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration.

RESULTS From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003).

CONCLUSION Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial.

LEVEL OF EVIDENCE Therapeutic/care management, level III.

From the Cedars-Sinai Medical Center, Department of Surgery, Division of Trauma and Critical Care (E.J.L., G.B., N.K.D., T.L.), Los Angeles, California; University of Texas at Houston, Department of Surgery, Division of Acute Care Surgery (S.D.L., B.A.C.), Houston, Texas; Los Angeles County and USC Medical Center, Department of Surgery, Division of Trauma and Critical Care (K.I., L.A.d.L.), Los Angeles, California; Brigham and Women's Hospital, Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care (A.S., L.A.B.), Boston, Massachusetts; Loma Linda University and Medical Center, Department of Surgery, Division of Acute Care Surgery (K.R.O., D.S.J.C.), Loma Linda, California; Our Lady of the Lake Regional Medical Center, Trauma Specialist Program (D.T., T.J.), Baton Rouge, Louisiana; Hackensack University Medical Center, Department of Neurosurgery (H.A., S.K.), Hackensack, New Jersey; University of Calgary, Foothills Medical Centre, Department of Surgery (C.G.B., J.X.), Calgary, Alberta; McMaster University/Hamilton General Hospital, Department of Surgery (P.T.E., A.C.), Hamilton, Ontario, Canada; Medical Center of the Rockies, Department of Trauma and Acute Care Surgery (J.A.D., L.W.), Loveland, Colorado; Medical City Plano, Trauma Services Department (M.M.C., G.M.), Plano, Texas; Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery (J.P.M., K.R.), University of Miami/Jackson Memorial Medical Center, Miami, Florida; Division of General Surgery, University of Utah (S.L., R.N.), Salt Lake City, Utah; Memorial Hospital, Department of Surgery (T.J.S., S.G.), Colorado Springs, Colorado; and St. Michael's Hospital, Department of Trauma and Acute Care Surgery (S.R., J.R.-N.), Toronto, ON, Canada.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

This article was a podium presentation at the 76th Annual Meeting of the American Association for the Surgery of Trauma, September 13–16, 2017 in Baltimore MD.

Address for reprints: Eric J. Ley, MD, Cedars-Sinai Medical Center Department of Surgery 8700 Beverly Blvd, Suite 8215NT Los Angeles, CA 90048; email: Eric.Ley@cshs.org.

© 2018 Lippincott Williams & Wilkins, Inc.