What is the role of propranolol (beta-blocker) in the management of patients with severe burns?

Propranolol in Severe Burns

Propranolol should be administered to severely burned patients (>20% TBSA) at doses of 1-4 mg/kg/day (divided into 4-6 doses) titrated to reduce heart rate by approximately 20% from baseline, as it accelerates wound healing, reduces blood loss during grafting, and decreases the hypermetabolic response without increasing mortality or sepsis risk. 1, 2, 3

Evidence-Based Benefits

Wound Healing Acceleration

• Propranolol significantly reduces healing time for superficial burns (16.1 vs 21.5 days, P=0.004) and decreases time to readiness for skin grafting in deep burns (28.2 vs 33.5 days, P=0.007) 2
• The interval between serial grafting procedures is markedly shortened with propranolol (10 ± 5 days vs 17 ± 12 days, P=0.02), indicating faster donor site healing 3
• Propranolol reduces the total body surface area requiring skin grafting (13.75% vs 18.72% TBSA, P=0.006), suggesting improved spontaneous healing of partial-thickness burns 2

Perioperative Blood Conservation

• Propranolol improves perioperative hematocrit by 5-7% during grafting procedures covering 4,000-16,000 cm² compared to controls (P=0.002) 3
• Blood transfusion requirements are significantly reduced in adults receiving propranolol (MD -185.64 mL, 95% CI -331.06 to -40.43) 1
• This vasoconstriction effect occurs through unopposed α-adrenergic receptor activity, increasing peripheral vascular resistance and reducing wound bed hemorrhage 3

Metabolic Benefits

• Propranolol reduces supraphysiological thermogenesis, cardiac work, and resting energy expenditure in burn patients 4
• It increases efficiency of muscular protein synthesis and reduces peripheral lipolysis 4
• Heart rate is consistently reduced (MD -26.85 bpm, 95% CI -39.95 to -13.75) 1

Safety Profile

Mortality and Sepsis

• No significant difference in mortality between propranolol and placebo groups (RD -0.02,95% CI -0.06 to 0.02) 1
• No significant difference in sepsis rates (RD -0.03,95% CI -0.09 to 0.04) 1
• This safety profile supports propranolol use without concern for increased infectious or mortality risk 1

Dosing Algorithm

Initiation Criteria

• Begin propranolol within 48 hours of burn injury for patients with >20% TBSA burns 2, 3, 5
• Most burn centers (60.8%) use this 20% TBSA threshold as their initiation criterion 5

Dosing Strategy

• Adults: Start with 1-4 mg/kg/day divided into 4-6 doses (typical range 10-40 mg per dose) 2, 4, 5
• Pediatrics: 0.1-5 mg/kg/day divided into multiple doses 5
• Titration target: Reduce resting heart rate by approximately 20% from baseline admission values 2, 3, 4
• Maximum reported dose: 1.98 mg/kg/day in divided doses 2

Duration of Therapy

• Continue throughout acute hospitalization for adults (43% of centers) 5
• For pediatric patients, 17.6% of centers continue treatment up to 6 months post-discharge 5
• Maintain therapy through serial grafting procedures to maximize blood conservation and wound healing benefits 3

Clinical Implementation Considerations

Current Practice Patterns

• 60.5% of surveyed burn centers use propranolol in both adult and pediatric populations 5
• 82% of centers that use propranolol administer it to both age groups 5
• 56% of centers report improved outcomes with propranolol use 5

Evidence Strength Nuances

• Most high-quality evidence comes from pediatric populations, with adult data being more limited but consistently supportive 4, 5
• The 2017 systematic review included 1,236 participants across 10 studies, providing robust safety data 1
• Individual RCTs in adults demonstrate significant wound healing and blood conservation benefits 2, 3

Critical Pitfalls to Avoid

• Do not delay initiation beyond 48 hours post-burn, as early administration maximizes metabolic and wound healing benefits 3
• Do not use fixed dosing—always titrate to achieve 20% heart rate reduction from baseline to optimize therapeutic effect while maintaining safety 2, 3, 4
• Do not discontinue prematurely during the acute hospitalization phase, as benefits accumulate with continued use through serial grafting procedures 3, 5
• Monitor heart rate closely to avoid excessive bradycardia while ensuring adequate β-blockade 2, 3
• Be aware that hospital stay reduction was not consistently demonstrated across all studies (MD -0.37 days, 95% CI -4.52 to 3.78), though individual trials showed benefit 1, 2