β受体阻滞剂在创伤性脑损伤重症患者中的应用：一项多中心、前瞻性、观察性美国创伤外科学会研究的结果。
Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study.
机构信息
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.
出版信息
J Trauma Acute Care Surg. 2018 Feb;84(2):234-244. doi: 10.1097/TA.0000000000001747.
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.
背景
β受体阻滞剂是一类抑制内源性儿茶酚胺与β肾上腺素能受体相互作用的药物，常用于创伤性脑损伤（TBI）后住院的患者。我们检验了这样一个假设，即 TBI 后使用β受体阻滞剂与死亡率降低相关，其次比较了普萘洛尔和其他β受体阻滞剂。
方法
美国创伤外科学会临床试验组进行了一项多机构、前瞻性、观察性试验，比较了需要入住重症监护病房的成年 TBI 患者基于β受体阻滞剂使用的情况。
结果
2015 年 1 月至 2017 年 1 月，从美国和加拿大的 15 个创伤中心分析了 2252 例患者，其中 49.7%接受了β受体阻滞剂治疗。大多数患者（56.3%）在入院第 1 天接受了首次β受体阻滞剂剂量。接受β受体阻滞剂治疗的患者年龄较大（56.7 岁 vs. 48.6 岁，p<0.001），头部损伤严重程度评分较高（3.6 分 vs. 3.4 分，p<0.001）。比较性别、入院时低血压、平均损伤严重程度评分和平均格拉斯哥昏迷量表时，也观察到了相似的情况。未校正死亡率在接受β受体阻滞剂治疗的患者中较低（13.8% vs. 17.7%，p=0.013）。多变量回归确定β受体阻滞剂与死亡率降低相关（调整优势比，0.35；p<0.001），普萘洛尔优于其他β受体阻滞剂（调整优势比，0.51，p=0.010）。使用时变变量的 Cox 回归模型显示，接受β受体阻滞剂治疗的患者有生存获益（调整危险比，0.42，p<0.001），普萘洛尔优于其他β受体阻滞剂（调整危险比，0.50，p=0.003）。
结论
TBI 后β受体阻滞剂的使用与存活率提高相关，在调整治疗队列中观察到的更严重损伤后，这种相关性仍然存在。本研究对β受体阻滞剂对 TBI 结局的影响进行了强有力的评估，支持开展多机构随机对照试验。
证据水平
治疗/护理管理，III 级。
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