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Manzano-Nunez R, García-Perdomo HA, Ferrada P, Ordoñez Delgado CA, Gomez DA, Foianini JE. Safety and effectiveness of propranolol in severely burned patients: systematic review and meta-analysis. World J Emerg Surg 2017; 12:11. [PMID: 28265298 PMCID: PMC5335497 DOI: 10.1186/s13017-017-0124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective of this systematic review was to determine the effectiveness and safety of propranolol compared to placebo or usual care for improving clinical relevant outcomes in severely burned patients (TBSA >20%). METHODS Relevant articles from randomized controlled trials were identified by a literature search in MEDLINE, EMBASE, and CENTRAL. We included trials involving patients with a severe burn (>20% of total body surface area affected). Trials were eligible if they evaluated propranolol and compared to usual care or placebo. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for the final analysis. We conducted a meta-analysis using a random-effects model. RESULTS We included ten studies in our systematic review. These studies randomized a total of 1236 participants. There were no significant differences between propranolol and placebo with respect to mortality (RD -0.02 [95% CI -0.06 to 0.02]), sepsis (RD -0.03 [95% CI -0.09 to 0.04]), and the overall hospital stay (MD -0.37 [-4.52 to 3.78]). Propranolol-treated adults had a decrease in requirements of blood transfusions (MD -185.64 [95% CI -331.06 to -40.43]) and a decreased heart rate (MD -26.85 [95% CI -39.95 to -13.75]). CONCLUSIONS Our analysis indicates that there were no differences in mortality or sepsis in severely burned patients treated with propranolol compared with those who had usual care or placebo. However, the use of propranolol in these patients resulted in lower requirements of blood transfusion and lower values of heart rate. The evidence synthesized in this systematic review is limited to conclude that propranolol reduces the length of hospital stay among severely burned patients. Future trials should assess the impact of propranolol on clinically relevant outcomes such as mortality and adverse events.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
- UROGIV Research Group, Universidad Del Valle, Cali, Colombia
| | | | - Paula Ferrada
- Surgical Critical Care, Virginia Commonwealth University, Richmond, VA USA
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Tiwari P, Pandey V, Gangopadhyay AN, Sharma SP, Gupta DK. Role of propranolol in ulcerated haemangioma of head and neck: a prospective comparative study. Oral Maxillofac Surg 2016; 20:73-77. [PMID: 26481918 DOI: 10.1007/s10006-015-0528-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 09/14/2015] [Indexed: 06/05/2023]
Abstract
PURPOSE Infantile haemangiomas comprise the majority of vascular anomalies and are considered the predominant vascular tumour type 1. We performed this prospective study to evaluate the therapeutic response and propranolol tolerance in infants with ulcerated infantile haemangioma of head and neck region. METHODS Sixty-four patients with ulcerated infantile haemangiomas (IHs) of head and neck region, without any prior treatment and with age older than 1 month, were included in the study, after informed consent was obtained, and were randomly divided into groups A and B. Group A patients were given oral propranolol at a dose of 2 mg/kg per day in three divided doses as outpatients. Group B patients were given oral ibuprofen at a dose of 10 mg/kg 8-hourly and paracetamol at dose of 16.2 mg/kg 8-hourly. Documentation of gender, age, haemangioma location, duration of ulceration and pain was measured on the second and fifth day after commencement of treatment in both groups using the Children's Hospital of Eastern Ontario Pain Scale. RESULTS There was no difference in pain score between the two groups (P value 0.074). Mean duration of healing of ulceration in group A was 17.93 ± 2.22 days and in group B was 27.71 ± 2.33 days (P value <0.001). In group A, out of 28 patients, 8 (28.5 %) were complete responders, 16 (57.1 %) were partial responders and 4 (14.2 %) were non-responders. CONCLUSION Propranolol is a valuable therapeutic alternative for treatment of ulcerated haemangiomas and effectively reduces pain.
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Affiliation(s)
- Preeti Tiwari
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, India.
| | - Vaibhav Pandey
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, India
| | - Ajay N Gangopadhyay
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, India
| | - Shiv P Sharma
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, India
| | - Dinesh K Gupta
- Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences, IMS, BHU, Varanasi, India
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Moodley ST, Hudson DA, Adams S, Adams KG. Shouldn't Propranolol Be Used to Treat All Haemangiomas? Aesthetic Plast Surg 2015; 39:963-7. [PMID: 26377820 DOI: 10.1007/s00266-015-0557-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/07/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Infantile haemangioma is the most common childhood tumour. These tumours can cause significant functional and cosmetic problems. While there are many treatment modalities, propranolol is increasingly being recognised as the first-line treatment of problematic haemangiomas. This study investigates the use of oral propranolol for the treatment of all haemangiomas at a tertiary children's hospital. METHOD This is a retrospective study evaluating 15 children (3 boys and 12 girls) presenting at a tertiary children's hospital with infantile haemangioma during a 24-month period. The protocol consisted of pre-treatment ultrasonic evaluation of the lesion, followed by the commencement of propranolol therapy (2 mg/kg orally in two divided doses), with repeat imaging performed at 16-24 weeks in order to document the dimensional changes. Adverse effects of propranolol were documented. Intralesional bleomycin was utilised as a second-line modality of treatment for large or problematic haemangiomas with inadequate regression in size after oral propranolol therapy. RESULT Fifteen (15) patients with a mean age of 7 months (Range: 3-14 months) presented with haemangiomas. Ten patients presented with lesions affecting the head and neck region (67%). Three patients presented with an ulcerated haemangioma, which responded to propranolol and simple dressings and all healed completely. The average decrease in size between the ultrasonography procedures was 48.87%. Only one patient showed no improvement. No side effects were reported. Concomitant bleomycin treatment was reserved for large problematic haemangiomas and proved successful at speeding up the involution process. CONCLUSION This study suggests that propranolol become the first-line treatment of choice for all haemangiomas. It has proven to be effective and safe for reducing the size of all haemangiomas during the proliferative phase. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Release of insulin from PLGA-alginate dressing stimulates regenerative healing of burn wounds in rats. Clin Sci (Lond) 2015; 129:1115-29. [PMID: 26310669 DOI: 10.1042/cs20150393] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/26/2015] [Indexed: 12/21/2022]
Abstract
Burn wound healing involves a complex set of overlapping processes in an environment conducive to ischaemia, inflammation and infection costing $7.5 billion/year in the U.S.A. alone, in addition to the morbidity and mortality that occur when the burns are extensive. We previously showed that insulin, when topically applied to skin excision wounds, accelerates re-epithelialization and stimulates angiogenesis. More recently, we developed an alginate sponge dressing (ASD) containing insulin encapsulated in PLGA [poly(D,L-lactic-co-glycolic acid)] microparticles that provides a sustained release of bioactive insulin for >20 days in a moist and protective environment. We hypothesized that insulin-containing ASD accelerates burn healing and stimulates a more regenerative, less scarring healing. Using heat-induced burn injury in rats, we show that burns treated with dressings containing 0.04 mg insulin/cm(2) every 3 days for 9 days have faster closure, a higher rate of disintegration of dead tissue and decreased oxidative stress. In addition, in insulin-treated wounds, the pattern of neutrophil inflammatory response suggests faster clearing of the burned dead tissue. We also observe faster resolution of the pro-inflammatory macrophages. We also found that insulin stimulates collagen deposition and maturation with the fibres organized more like a basket weave (normal skin) than aligned and cross-linked (scar tissue). In summary, application of ASD-containing insulin-loaded PLGA particles on burns every 3 days stimulates faster and more regenerative healing. These results suggest insulin as a potential therapeutic agent in burn healing and, because of its long history of safe use in humans, insulin could become one of the treatments of choice when repair and regeneration are critical for proper tissue function.
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Ali A, Herndon DN, Mamachen A, Hasan S, Andersen CR, Grogans RJ, Brewer JL, Lee JO, Heffernan J, Suman OE, Finnerty CC. Propranolol attenuates hemorrhage and accelerates wound healing in severely burned adults. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:217. [PMID: 25936635 PMCID: PMC4432824 DOI: 10.1186/s13054-015-0913-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/08/2015] [Indexed: 12/03/2022]
Abstract
Introduction Propranolol, a nonselective β-blocker, exerts an indirect effect on the vasculature by leaving α-adrenergic receptors unopposed, resulting in peripheral vasoconstriction. We have previously shown that propranolol diminishes peripheral blood following burn injury by increasing vascular resistance. The purpose of this study was to investigate whether wound healing and perioperative hemodynamics are affected by propranolol administration in severely burned adults. Methods Sixty-nine adult patients with burns covering ≥30% of the total body surface area (TBSA) were enrolled in this IRB-approved study. Patients received standard burn care with (n = 35) or without (control, n = 34) propranolol. Propranolol was administered within 48 hours of burns and given throughout hospital discharge to decrease heart rate by approximately 20% from admission levels. Wound healing was determined by comparing the time between grafting procedures. Blood loss was determined by comparing pre- and postoperative hematocrit while factoring in operative graft area. Data were collected between first admission and first discharge. Results Demographics, burn size, and mortality were comparable in the control and propranolol groups. Patients in the propranolol group received an average propranolol dose of 3.3 ± 3.0 mg/kg/day. Daily average heart rate over the first 30 days was significantly lower in the propranolol group (P <0.05). The average number of days between skin grafting procedures was also lower in propranolol patients (10 ± 5 days) than in control patients (17 ± 12 days; P = 0.02), indicative of a faster donor site healing time in the propranolol group. Packed red blood cell infusion was similar between groups (control 5.3 ± 5.4 units vs. propranolol 4.4 ± 3.1 units, P = 0.89). Propranolol was associated with a 5 to 7% improvement in perioperative hematocrit during grafting procedures of 4,000 to 16,000 cm2 compared to control (P = 0.002). Conclusions Administration of propranolol during the acute hospitalization period diminishes blood loss during skin grafting procedures and markedly improves wound healing in severely burned adults. As burn patients require serial surgical interventions for motor and cosmetic repair, restricting blood loss during operative intervention is optimal.
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Affiliation(s)
- Arham Ali
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ashish Mamachen
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Samir Hasan
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Clark R Andersen
- Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Ro-Jon Grogans
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jordan L Brewer
- School of Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Jamie Heffernan
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA.
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA. .,Shriners Hospitals for Children, 815 Market Street, Galveston, TX, 77550, USA. .,Institute for Translational Sciences and the Sealy Center for Molecular Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX, 77555, USA.
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Yoshimoto K, Okuma Y, Nakamura T, Mita T, Mitsumoto A, Yamasaki N, Tobimatsu Y, Akai M. Limb fitting for quadruple amputees: report of two cases of symmetrical peripheral gangrene caused by pneumococcal purpura fulminans. Prosthet Orthot Int 2013; 37:489-94. [PMID: 23558402 DOI: 10.1177/0309364613481797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We report our experiences of prosthetic fitting in quadruple amputees. Two patients underwent quadruple amputation after suffering from disseminated intravascular coagulation in conjunction with pneumococcemia with purpura fulminans. CASE DESCRIPTION AND METHODS The first patient, a 52-year-old man, underwent bilateral transradial, left transtibial, and right transfemoral amputation, and the second patient, a 62-year-old man, underwent bilateral transradial and bilateral transfemoral amputation, both for symmetrical peripheral gangrene subsequent to septic shock. FINDINGS AND OUTCOMES The amputations were accompanied by skin damage due to ischemic tissue changes both on the stumps and on the nose and/or lips. The combination of the intensive prosthetic rehabilitation program and supportive medical care led to completely independent functioning, including driving a car, with the use of four prosthetic limbs and a wheelchair in both cases. CONCLUSION Early initiation of a multidisciplinary approach can properly address impairments and minimize future disability.
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Affiliation(s)
- Kenji Yoshimoto
- 1Department of Rehabilitation Medicine, Hospital for National Rehabilitation Center, Tokorozawa, Japan
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Abstract
PURPOSE OF REVIEW To update critical care practitioners on the recent advancements in burn care. RECENT FINDINGS Particular topics discussed include airway management, acute resuscitation, issues within the intensive care unit, nutrition, and wound management. SUMMARY This is a concise review of the recent burn literature tailored to the critical care practitioner. Criteria for extubation of burn patients are examined, as is the need for cuffed endotracheal tubes in pediatric burn patients. Strategies to avoid over-resuscitation are discussed, including use of colloid, as well as nurse-driven and computer-guided resuscitation protocols. New data regarding common ICU issues such as insulin therapy, delirium, and preferred intravenous access are reviewed. The importance of nutrition in the burn patient is emphasized, particularly early initiation of enteral nutrition, continuation of nutrition during surgical procedures, and use of adjuncts such as immunonutrition and beta blockade. Finally, both short-term and long-term wound issues are addressed via sections on laser Doppler assessment of burns and pressure garment therapy to prevent long-term scarring.
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