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Beta-Blocker — Burns Hypermetabolism Pregnancy: Use with caution — may cause fetal bradycardia and IUGR; use only if benefit outweighs risk

Propranolol (Burns — Hypermetabolic Response)

Brand names: Inderal, Half-Inderal

Adult dose

Dose: 0.5–1 mg/kg every 6–8 hours; titrate to reduce resting HR by 15–20%
Route: Oral
Frequency: Every 6–8 hours
Max: 4 mg/kg/day
Started within 48–72 hours of major burns (>20% TBSA) and continued throughout acute hospitalisation and rehabilitation phase. Target: reduction in resting HR by 15–20% from baseline. Non-selective beta-blocker — attenuates catecholamine-driven hypermetabolism, reduces muscle wasting, and improves cardiac efficiency.

Paediatric dose

Dose: 0.5–1 mg/kg
Route: Oral
Frequency: Every 6–8 hours
Max: 4 mg/kg/day
Well-studied in paediatric burns (Galveston studies). 0.5–1 mg/kg every 6 hours — titrate to HR reduction. Start low and titrate.

Dose adjustments

Renal

No specific adjustment required.

Hepatic

Caution in severe hepatic impairment — reduced first-pass metabolism increases bioavailability.

Paediatric weight-based calculator

Well-studied in paediatric burns (Galveston studies). 0.5–1 mg/kg every 6 hours — titrate to HR reduction. Start low and titrate.

Clinical pearls

  • Herndon et al. landmark trials: propranolol reduces resting energy expenditure, reverses muscle wasting, reduces fatty infiltration of the liver, and decreases mortality in paediatric major burns
  • Non-selective beta-blockade preferred over selective — non-selective agents more effective at attenuating the full hypermetabolic response
  • Do NOT stop abruptly — taper over 1–2 weeks to avoid rebound tachycardia and increased metabolic rate

Contraindications

  • Cardiogenic shock
  • Severe bradycardia
  • 2nd/3rd degree AV block
  • Severe asthma/COPD
  • Uncontrolled heart failure

Side effects

  • Bradycardia
  • Hypotension
  • Bronchospasm (non-selective — avoid in asthma)
  • Fatigue
  • Cold extremities
  • Masking of hypoglycaemia
  • Worsening of Raynaud's

Interactions

  • Calcium channel blockers — verapamil/diltiazem (profound bradycardia)
  • Insulin/antidiabetics (masking of hypoglycaemia)
  • Clonidine (rebound hypertension if propranolol stopped first)
  • Adrenaline (hypertensive crisis — beta blockade leaves alpha effects unopposed)

Monitoring

  • Resting heart rate (target 15–20% reduction)
  • Blood pressure
  • Signs of bronchospasm
  • Blood glucose (masking)

Reference: BNFc; BNF 90; Herndon DN et al. NEJM 2001 (Propranolol in Paediatric Burns); BBA Hypermetabolic Response Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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