(1768) Effects of Propranolol Administration on Sedative and Analgesia Requirements in TBI Patients

Introduction: Propranolol may reduce secondary injury from paroxysmal sympathetic hyperactivity (PSH) and catecholamine surges in traumatic brain injury (TBI) patients by decreasing circulating catecholamine levels and resting metabolic rate. Catecholamine surges and PSH are linked to higher mortality and long-term disability in TBI patients, making surge management crucial. Propranolol, a non-selective β1 and β2 adrenergic receptor inhibitor, is preferred due to its lipophilic profile, which allows for blood-brain barrier penetration. Despite existing literature on propranolol’s impact on TBI outcomes, its effect on sedative and analgesic requirements remains unexplored. This study aims to address this gap by evaluating how propranolol affects sedative and analgesia requirements.

Methods: This was a retrospective, multicenter observational study conducted at four Level I Trauma Centers. Patients with moderate to severe TBI (Glasgow Coma Scale [GCS] 3-12) who received at least 48 hours of propranolol within the first 3 days of ICU admission with concurrent sedative and/or analgesic therapy were enrolled. Medical records between November 1, 2017, and February 28, 2023, were reviewed. The primary outcome was the effect of propranolol on 24-hour propofol and dexmedetomidine dosing requirements. Secondary outcomes included propranolol’s effect on 48-hour requirements for propofol and dexmedetomidine, as well as 24- and 48-hour requirements for opioids.

Results: Ninety-six patients were enrolled in the study. Propofol requirements at 24 hours decreased from 18.3 mcg/kg/min to 12.7 mcg/kg/min (p = 0.0329), while dexmedetomidine requirements increased from 0 mcg/kg/hr to 0.07 mcg/kg/hr (p = 0.047). At 48 hours, propofol requirements decreased to 7.6 mcg/kg/min (p = 0.003 for comparison from baseline), while dexmedetomidine requirements increased to 0.32 mcg/kg/hr (p = 0.002 for comparison from baseline). Opioid requirements at 48 hours post-propranolol initiation decreased from 120 mg/day IV morphine equivalents to 85 mg/day (p = 0.025).

Conclusions: The results of the study suggest that propranolol administration within 3-days after moderate-to-severe TBI may help facilitate the transition from deeper sedative agents to less sedating agents in the ICU setting.