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After severe burns there is an initial phase of hypoperfusion followed by a postinjury response of fever, hyperdynamic circulation, and protein catabolism. Muscle proteolysis continues for 9 months or more. The underlying mechanisms are complex and multifactorial but include increased secretion of catecholamines. Management includes supplemental nutrition, maintenance of hydration, mechanical ventilation as necessary, pain control, and early wound excision and closure. Now researchers in Texas (David N Herndon and colleagues. New England Journal of Medicine 2001;345:1223–9; see also editorial, ibid: 1271–2) have shown that treatment with propranolol reduces hypermetabolism and reverses muscle breakdown.
Twenty-five children (mean age 7 years) with severe burns (> 40% of body surface area) were randomised to propranolol via nasogastric tube (dose adjusted to achieve 20% fall in heart rate; average eventual dose 1.05 mg/kg every 4 hours) or no propranolol, beginning about 2 weeks after injury. In the next 4 weeks the decrease in heart rate and resting energy expenditure was significantly greater in the propranolol group. Muscle protein balance was assessed from the rate of incorporation of labelled phenylalanine, in sequential muscle biopsies and increased by 82% over baseline values in the propranolol group but decreased by 27% in the control group. Fat-free mass, measured by whole-body potassium scanning, stayed constant in the treated group but fell by a mean of 9% in the control group.
Long term treatment with a beta blocker may benefit severely burned children by reversing muscle protein catabolism.