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Kopel J, Brower GL, Sorensen G, Griswold J. Application of beta-blockers in burn management. Proc AMIA Symp 2021; 35:46-50. [PMID: 34970031 PMCID: PMC8682851 DOI: 10.1080/08998280.2021.2002110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/24/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022] Open
Abstract
Severe burn injuries cause chronic inflammation, which produces a subsequent hypermetabolic response that starts immediately and persists for at least 3 years. The hypermetabolic state, which is thought to be due to postburn elevations of endogenous catecholamines and cortisol, is associated with a number of harmful physiologic derangements including immunosuppression, impaired wound healing, muscle catabolism, and hepatic dysfunction. Beta-blockers have become first line agents for reducing these adverse effects of hypermetabolism in severe burns. This review discusses the underlying pharmacological mechanisms demonstrated by clinical studies evaluating the safety and efficacy of beta-blockers in the management of burn injuries. A literature search was performed using the PubMed database to identify articles on beta-blockers and burn management. The review yielded 33 relevant results consisting of randomized controlled trials, original research articles, and meta-analyses in pediatric and adult burn patients. Propranolol administration reduced insulin resistance, lipolysis, proteolysis, cardiac work, and bone loss resulting from burn-associated hypermetabolism. Propranolol also effectively reduced myocardial stress, resting energy expenditure, and central deposition of fat. Recent studies have begun to evaluate incorporation of anabolic agents and rehabilitative exercise therapy. However, at this time propranolol continues to be the most effective therapy for reducing the hypermetabolic response and other morbidities resulting from burn injuries.
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Affiliation(s)
- Jonathan Kopel
- Foster School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Gregory L. Brower
- Foster School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Grant Sorensen
- Foster School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
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Palackic A, Suman OE, Porter C, Murton AJ, Crandall CG, Rivas E. Rehabilitative Exercise Training for Burn Injury. Sports Med 2021; 51:2469-2482. [PMID: 34339042 DOI: 10.1007/s40279-021-01528-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
Due to improvements in acute burn care over the last few decades, most patients with severe burns (up to 90% of the total body surface) survive. However, the metabolic and cardiovascular complications that accompany a severe burn can persist for up to 3 years post injury. Accordingly, there is now a greater appreciation of the need for strategies that can hasten recovery and reduce long-term morbidity post burn. Rehabilitation exercise training (RET) is a proven effective treatment to restore lean body mass, glucose and protein metabolism, cardiorespiratory fitness, and muscle strength in burn survivors. Despite this, very few hospitals incorporate RET in programs to aid the rehabilitation of patients with severe burns. Given that RET is a safe and efficacious treatment that restores function and reduces post-burn morbidity, we propose that a long-term exercise prescription plan should be considered for all patients with severe burns. In this literature review, we discuss the current understanding of burn trauma on major organ systems, and the positive benefits of incorporating RET as a part of the long-term rehabilitation of severely burned individuals. We also provide burn-specific exercise prescription guidelines for clinical exercise physiologists.
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Affiliation(s)
- Alen Palackic
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Oscar E Suman
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA
| | - Craig Porter
- Department of Pediatrics, Division of Developmental Nutrition, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Andrew J Murton
- Department of Surgery, Division of Surgical Sciences, Medical Branch, University of Texas, Galveston, TX, USA
| | - Craig G Crandall
- Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - Eric Rivas
- KBR, Human Physiology, Performance, Protection and Operations Laboratory, NASA Johnson Space Center, 2101 NASA Parkway, Houston, TX, 77058, USA.
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Gus EI, Shahrokhi S, Jeschke MG. Anabolic and anticatabolic agents used in burn care: What is known and what is yet to be learned. Burns 2019; 46:19-32. [PMID: 31852612 DOI: 10.1016/j.burns.2018.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/17/2018] [Accepted: 03/18/2018] [Indexed: 12/15/2022]
Abstract
Major thermal injury induces profound metabolic derangements secondary to an inflammatory "stress-induced" hormonal environment. Several pharmacological interventions have been tested in an effort to halt the hypermetabolic response to severe burns. Insulin, insulin growth factor 1, insulin growth factor binding protein 3, metformin, human growth hormone, thyroid hormones, testosterone, oxandrolone, and propranolol, among others, have been proposed to have anabolic or anticatabolic effects. The aim of this broad analysis of pharmacological interventions was to raise awareness of treatment options and to help establishing directions for future clinical research efforts. A PubMed search was conducted on the anabolic and anticatabolic agents used in burn care. One hundred and thirty-five human studies published between 1999 and 2017 were included in this review. The pharmacological properties, rationale for the treatments, efficacy considerations and side effect profiles are summarized in the article. Many of the drugs tested for investigational purposes in the severely thermally injured are not yet gold-standard therapies in spite of their potential benefit. Propranolol and oxandrolone have shown great promise but further evidence is still needed to clarify their potential use for anabolic and anticatabolic purposes.
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Affiliation(s)
- Eduardo I Gus
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada
| | - Shahriar Shahrokhi
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marc G Jeschke
- Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, D704, Toronto, ON M4N 3M5, Canada; Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Department of Immunology, University of Toronto, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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Rivas E, Sanchez K, Cambiaso-Daniel J, Gutierrez IL, Tran J, Herndon DN, Suman OE. Burn Injury May Have Age-Dependent Effects on Strength and Aerobic Exercise Capacity in Males. J Burn Care Res 2018; 39:815-822. [PMID: 29596612 PMCID: PMC6097589 DOI: 10.1093/jbcr/irx057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Whether burn injury affects boys and men differently is currently unknown. To test the hypothesis that burned boys have lower exercise capacity and exercise training-induced responses compared with burned men, 40 young boys (12 ± 4 years, 149 ± 20 cm, 46 ± 18 kg) were matched to 35 adult men (33 ± 9 years, 174 ± 10 cm, 84 ± 16 kg) based on extent of burn injury (total body surface area burned, boys 46 ± 14% vs men 47 ± 30, P = .85) and length of hospital stay (boys 33 ± 23 vs men 41 ± 32 days, P = .23). Strength (peak torque) and cardiorespiratory fitness (peak VO2) were normalized to kg of lean body mass for group comparisons. Each group was also compared with normative age-sex matched values at discharge and after an aerobic and resistance exercise training (RET) program. A two-way factorial analysis of covariance assessed interaction and main effects of group and time. We found that boys and men showed similar pre-RET to post-RET increases in total lean (~4%) and fat (7%) mass (each P ≤ .008). Both groups had lower age-sex matched norm values at discharge for peak torque (boys 36%; men 51% of normative values) and peak VO2 (boys: 44; men: 59%; each P ≤ .0001). Boys strength were 13-15 per cent lower than men at discharge and after RET (main effect for group, P < .0001). Cardiorespiratory fitness improved to a greater extent in men (19%) compared with boys (10%) after the RET (group × time interaction, P = .011). These results show that at discharge and after RET, burn injury may have age-dependent effects and should be considered when evaluating efficacy and progress of the exercise program.
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Affiliation(s)
- Eric Rivas
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, Texas
| | | | - Janos Cambiaso-Daniel
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Ileana L Gutierrez
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Joan Tran
- Shriners Hospitals for Children, Galveston, Texas
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Oscar E Suman
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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Rivas E, Herndon DN, Chapa ML, Cambiaso-Daniel J, Rontoyanni VG, Gutierrez IL, Sanchez K, Glover S, Suman OE. Children with severe burns display no sex differences in exercise capacity at hospital discharge or adaptation after exercise rehabilitation training. Burns 2018; 44:1187-1194. [PMID: 29429746 DOI: 10.1016/j.burns.2018.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/11/2018] [Accepted: 01/17/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Females have a 50% increased risk of death from burn injury compared to males. However, whether exercise capacity and exercise induced training adaptations differ between burned boys and girls is unknown. This project tested the hypothesis that girls with burns have lower exercise capacity and different exercise induced training adaptations. METHODS Twenty-five girls were matched to 26 boys (mean, 95%CI; years 13 [12,14], cm 151 [143,161], kg 54 [45,63]; each P>0.05) for burn injury (% total body surface area burn, 54 [45,62]; P=0.82). Lean body mass (LBM), strength (peak torque) and cardiorespiratory fitness (peak VO2) were normalized to kg LBM and compared as a percentage of age-sex matched non-burned children (n=26 boys, years 13 [12,14]; n=25 girls, years 13 [12,14]) at discharge (DC) and after aerobic and resistance rehabilitation exercise training (RET). RESULTS Using a 2-way factorial ANOVA (group×time), we found both groups had similar 11% change in LBM (87.3% of non-burned values [82.2,92.3]) and after the RET (92.8% [87.2,98.3]; main effect, time P<0.0001). Peak torque increased similarly by 16% in both groups (% of age-sex matched non-burned DC, 55.9 [51.3,60.5]; after RET, 77.5 [72.1,82.9]; main effect, time P<0.0001). Likewise, peak VO2 increased in both groups by 15% (% of age-sex matched non-burned DC, 56.8 [52.4,61.2] to RET, 72.2 [67.6,76.8]; main effect, time; P<0.0001). Burned children exercise at greater percentage of their peak VO2 and peak HR compared to non-burned children (Interaction, group×time, P<0.0001). CONCLUSION The burn injury does not have sex-dependent effects on LBM or exercise capacity in severely burn injured children. Differences in relative peak VO2 and peak HR suggest the need for burn specific exercise programs for improving the efficacy of a rehabilitation program.
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Affiliation(s)
- Eric Rivas
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Department of Kinesiology & Sport Management, Texas Tech University, Lubbock, TX, USA.
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Martha L Chapa
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Janos Cambiaso-Daniel
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Victoria G Rontoyanni
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Ileana L Gutierrez
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Kevin Sanchez
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Shauna Glover
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Oscar E Suman
- Shriners Hospitals for Children, Galveston, TX, USA; Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
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Cambiaso-Daniel J, Rivas E, Carson JS, Hundeshagen G, Lopez ON, Glover SQ, Herndon DN, Suman OE. Cardiorespiratory Capacity and Strength Remain Attenuated in Children with Severe Burn Injuries at Over 3 Years Postburn. J Pediatr 2018; 192:152-158. [PMID: 29246338 PMCID: PMC5739078 DOI: 10.1016/j.jpeds.2017.09.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/01/2017] [Accepted: 09/07/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To compare physical capacity and body composition between children with burn injuries at approximately 4 years postburn and healthy, fit children. STUDY DESIGN In this retrospective, case-control study, we analyzed the strength, aerobic capacity, and body composition of children with severe burn injuries (n = 40) at discharge, after completion of a 6- to 12-week rehabilitative exercise training program, and at 3-4 years postburn. Values were expressed as a relative percentage of those in age- and sex-matched children for comparison (n = 40 for discharge and postexercise; n = 40 for 3.5 years postburn). RESULTS At discharge, lean body mass was 89% of that in children without burn injuries, and exercise rehabilitation restored this to 94% (P < .01). At 3.5 years postburn, lean body mass (94%), bone mineral content (89%), and bone mineral density (93%; each P ≤ .02) remained reduced, whereas total body fat was increased (148%, P = .01). Cardiorespiratory fitness remained lower in children with burn injuries both after exercise training (75%; P < .0001) and 3.5 years later (87%; P < .001). Peak torque (60%; P < .0001) and average power output (58%; P < .0001) were lower after discharge. Although exercise training improved these, they failed to reach levels achieved in healthy children without burns (83-84%; P < .0001) but were maintained at 85% and 82%, respectively, 3.5 years later (P < .0001). CONCLUSIONS Although the benefits of rehabilitative exercise training on strength and cardiorespiratory capacity are maintained at almost 4 years postburn, they are not restored fully to the levels of healthy children. Although the underlying mechanism of this phenomenon remains elusive, these findings suggest that future development of continuous exercise rehabilitation interventions after discharge may further narrow the gap in relation to healthy adolescents.
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Affiliation(s)
- Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria,Janos Cambiaso-Daniel, M.D., Research Fellow, Shriners Hospital for Children Galveston, Department of Surgery, 815 market street, Galveston, TX 77550, United States, +43 660 399 7290, FAX: n.a.
| | - Eric Rivas
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX,Department of Kinesiology & Sport Management, Texas Tech University, Lubbock, TX,Janos Cambiaso-Daniel, M.D., Research Fellow, Shriners Hospital for Children Galveston, Department of Surgery, 815 market street, Galveston, TX 77550, United States, +43 660 399 7290, FAX: n.a.
| | - Joshua S. Carson
- Department of Surgery and Shands Burn Center, University of Florida, Gainesville, FL
| | - Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX
| | - Shauna Q. Glover
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX
| | - David N. Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX
| | - Oscar E. Suman
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX
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