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Kondo T, Tsuboi H, Nishiyama K, Takahashi G, Nishimura Y. Effects of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists in patients with severe burn injury. Burns 2024; 50:1621-1631. [PMID: 38604823 DOI: 10.1016/j.burns.2024.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 03/21/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
Rehabilitation treatments for patients with severe burn injury (SBI) are difficult owing to the lack of knowledge, skills, and experience among clinicians and physical and occupational therapists, resulting in serious patient disability. This study retrospectively evaluated the effectiveness of rehabilitation treatments jointly considered by physiatrists and rehabilitation therapists (Physiatrist and Registered therapist Operating rehabilitation: PROr) for patients with SBI admitted to our hospital's burn intensive care unit (BICU). Eligible patients were classified into the PROr and standard rehabilitation (SR) groups. Contents of the rehabilitation program in the BICU, the functional ambulation categories (FAC), and the Barthel index at the first rehabilitation, BICU discharge, and hospital discharge were collected. Of the 184 patients with severe burns admitted to the BICU, 29 (PROr group, n = 16; SR group, n = 13) met the eligibility criteria. The PROr group received more types of exercise interventions for a longer time than the SR group. No significant differences in the FAC and Barthel index scores at the first time of rehabilitation were found between the two groups; however, the scores of FAC and Barthel index at BICU and hospital discharges were higher in the PROr group than in the SR group. The PROr program may help in the functional improvement of patients with SBI.
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Affiliation(s)
- Takahito Kondo
- Department of Rehabilitation Medicine, Iwate Medical University, Japan; Rehabilitation Division, Iwate Medical University Hospital, Japan
| | - Hiroyuki Tsuboi
- Rehabilitation Division, Iwate Medical University Hospital, Japan
| | | | - Gaku Takahashi
- Department of Disaster and Emergency Medicine, Iwate Medical University, Japan
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2
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Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
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Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
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3
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Bordeanu-Diaconescu EM, Grosu-Bularda A, Frunza A, Grama S, Andrei MC, Neagu TP, Hariga CS, Lascar I. Venous Thromboembolism in Burn Patients: A 5-Year Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:258. [PMID: 38399545 PMCID: PMC10889946 DOI: 10.3390/medicina60020258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Burn patients manifest all components of Virchow's triad, amplifying the concern for venous thromboembolism (VTE). Routine prophylaxis for VTE remains a subject of debate, with the central concern being the occurrence of associated adverse events. Materials and Methods: We conducted a five-year retrospective study on burn patients admitted to our burn center. Demographic data, comorbidities, burn lesions characteristics, surgical interventions, anticoagulant medication, the need for transfusions, the presence of a central venous catheter, length of stay, complications, and mortality were recorded. Results: Of the overall number of patients (494), 2.63% (13 patients) developed venous thromboembolic complications documented through paraclinical investigations. In 70% of cases, thrombosis occurred in a limb with central venous catether (CVC). Every patient with VTE had a Caprini score above 8, with a mean score of 12 points in our study group. Conclusions: Considering each patient's particularities and burn injury characteristics, individualized approaches may be necessary to optimize thromboprophylaxis effectiveness. We suggest routinely using the Caprini Risk Assessment Model in burn patients. We recommend the administration of pharmacologic thromboprophylaxis in all patients and careful monitoring of patients with Caprini scores above 8, due to the increased risk of VTE. Additionally, ongoing research in this field may provide insights into new strategies for managing thrombotic risk in burn patients.
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Affiliation(s)
- Eliza-Maria Bordeanu-Diaconescu
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Andreea Grosu-Bularda
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Adrian Frunza
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Sabina Grama
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
| | - Mihaela-Cristina Andrei
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Tiberiu Paul Neagu
- Burn Centre, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania; (E.-M.B.-D.); (A.G.-B.)
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Cristian-Sorin Hariga
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
| | - Ioan Lascar
- Department of Plastic Surgery and Reconstructive Microsurgery, ”Carol Davila” University of Medicine and Pharmacy Bucharest, 010825 Bucharest, Romania (I.L.)
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Palmieri TL. Acute care for burn patients: fluids, surgery, and what else? Curr Opin Crit Care 2023; 29:696-701. [PMID: 37861199 DOI: 10.1097/mcc.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Recently published initiatives spanning the burn care spectrum have substantially changed the standard of care in burn care. The purpose of this article is to describe new impactful concepts in burn first aid, triage, resuscitation, and treatment as well as their impact on future research. RECENT FINDINGS First aid after burn injury traditionally consists of extinguishing the burn and applying dressings. Recent evidence suggests that applying 20 min of cool tap water to the burn wound in the first 3 h postburn mitigates burn injury extent. National burn center transfer criteria have been updated, impacting patient initial transfer and management. The adverse effects of hydroxocobalamin, a commonly used antidote for cyanide toxicity, have been delineated. Initial burn resuscitation recommendations for both volume and potentially fluid type are being reexamined. The emergence of innovative skin substitutes may improve burn survival by providing a physiologically stabilizing intermediate dressing. Finally, formal clinical practice guidelines for early mobility in the ICU after burn injury have been defined. SUMMARY These changes in burn care, triage, resuscitation, and treatment have challenged traditional burn care standards, created new standards, and are the basis for future prospective randomized trials.
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Affiliation(s)
- Tina L Palmieri
- Shriners Children's Northern California, University of California Davis, Sacramento, California, USA
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Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. Int J Mol Sci 2023; 24:16357. [PMID: 38003548 PMCID: PMC10671630 DOI: 10.3390/ijms242216357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.
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Affiliation(s)
- Elżbieta Radzikowska-Büchner
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Inga Łopuszyńska
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Wojciech Flieger
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4 Street, 20-090 Lublin, Poland;
| | - Michał Tobiasz
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Krasnystawska 52 Street, 21-010 Łęczna, Poland;
| | - Ryszard Maciejewski
- Faculty of Medicine, University of Warsaw, Żwirki i Wigury 101 Street, 02-089 Warszawa, Poland;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A Street, 20-093 Lublin, Poland
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Yelvington M, Whitehead C, Turgeon L. Special Considerations for Pediatric Burn Injuries. Phys Med Rehabil Clin N Am 2023; 34:825-837. [PMID: 37806700 DOI: 10.1016/j.pmr.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Burns are the fifth leading cause of non-fatal childhood injuries. Physiological differences between children and adults lead to unique considerations when treating young burn survivors. In addition to the physical and psychological concerns which must be considered in adult burn rehabilitation, pediatric burn rehabilitation must also consider the developmental stage of the child, preexisting developmental delays, and the impact of scaring on growth and motor skill attainment. Treatment of pediatric burn survivors requires a multidisciplinary approach centered around caring for not only the child but also for their parents, siblings, and other caregivers. For children who sustain burns early in life, long-term follow-up is essential and should be conducted under the guidance of a burn center for the early identification of needed interventions during periods of growth and development. This article considers pediatric-specific factors, which may present during the rehabilitation of a child with a burn injury.
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Affiliation(s)
- Miranda Yelvington
- Arkansas Children's Hospital, 1 Children's Way, Slot 104, Little Rock, AR 72202, USA.
| | | | - Lori Turgeon
- Shriners Children's Boston, 51 Blossom Street, Boston, MA 02114, USA
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O'Neil A, Hines D, Wirdzek E, Thornburg C, Murray D, Porter J. Early Mobilization, Early Ambulation, and Burn Therapy in the Acute Hospital Setting. Phys Med Rehabil Clin N Am 2023; 34:733-754. [PMID: 37806694 DOI: 10.1016/j.pmr.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Rehabilitation therapies in the burn acute care environment continue to evolve. Immediate access to therapy is considered standard, and therapy is a key component of the transprofessional care team. Early positioning, edema management, and therapy care in the intensive care unit (ICU) environment can limit later complications; mobility in the ICU can be engaged safely using a systems-based approach in the absence of nondirectable agitation. Later in the course of acute care, early ambulation is an appropriate intervention that can improve outcomes.
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Affiliation(s)
- Audrey O'Neil
- Burn Rehabilitation Services; Eskenazi Health, Richard M Fairbanks Burn Center, 720 Eskenazi Avenue, 4th Floor, Indianapolis, IN 46202, USA
| | - Danika Hines
- Burn Therapy, Valleywise, Valleywise Health, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
| | - Emily Wirdzek
- Burn Therapy, Valleywise, Valleywise Health, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
| | - Cody Thornburg
- Burn Therapy, Valleywise, Valleywise Health, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
| | - Derek Murray
- Burn Therapy, Valleywise, Valleywise Health, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA.
| | - John Porter
- Physiatry, Valleywise, Valleywise Health, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA; Trauma and Burn Services, Department of Surgery, University of Arizona, Creighton University, Phoenix, AZ, USA
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Arshad Z, Rehan M, Iqbal T, Waheed U, Zafar H, Pervaiz S, -Ain QU, Shais Khan M, Hassaan Tariq M. Treadmill Versus Overground Gait Training in Patients with Lower Limb Burn Injury: A Comparative Study. J Burn Care Res 2023; 44:1150-1153. [PMID: 36964917 DOI: 10.1093/jbcr/irad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Indexed: 03/27/2023]
Abstract
The primary goal of the rehabilitation services offered to patients with lower limb burns is to enhance gait function. Exercise on a treadmill and conventional overground gait training are the two most widespread gait-training methods. Numerous studies have been published in the literature that claim treadmill training helps people walk more easily. Therefore, it would be intriguing to investigate whether treadmill gait training affects the progress made by post-lower limb burn patients compared to traditional overground gait training. The goal of the current study was to compare the effectiveness of treadmill training and traditional physical therapy therapies for improving gait after lower limb burn injury. A comparative study was conducted between January to August 2022 at a burns care unit, in Islamabad. All the participants were informed about the study procedure and consent was taken before initiating the study. All the participants received the set standard of Burn Rehabilitation by the American Burn Association (ABA). The program consists of ROM exercises, mobilization, functional mobility, stretching, balance training, and resisted exercises for enhancing muscle power. Statistical analyses were performed using IBM SPSS 24.0 software. The study subjects selected were 30 burn patients, aged above 18 years, vitally stable, and had lower limb burn injuries with an average TBSA (total burn surface area) of 20-30%. The mean for the Experimental is 18.86 and for the control group is 21.13. Patients were randomly either assigned to an experimental group or a control group. The Experimental group had a lower Time Up and Go test score of 11.86 ± 3.58 (9.50-24.07) as compared to the control group's TUG score (of 12.78 ± 4.41 (6.30-24.07). Functional mobility significantly improved as the P < 0.05. The total mean scores calculated on the Tampa Kinesiophobia scale for the Experimental group were 35.66 ± 6.32 which was less compared with those of the control group 37.93 ± 6.36. It demonstrates that fear of movement was reduced for treadmill training participants. Comparison of pre-distance (350.9 ± 86.82), pre-velocity (62.78 ± 20.20), and post-distance (385.02 ± 32.29), post-velocity 40.48 ± 21.91 of the experimental group with the control group pre-distance (339.26 ± 98.17), pre-velocity (55.07 ± 22.63), post-distance (383.07 ± 36.914), and post-velocity (40.57 ± 21.95) showed significant changes in results. In contrast to traditional gait training, treadmill training significantly improves walking ability in burn patients with lower limb damage.
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Affiliation(s)
- Zunera Arshad
- Burn Care Centre (BCC), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad, Pakistan
| | - Muhammad Rehan
- Burns Surgery Department, BCC, PIMS, SZABMU, Islamabad, Pakistan
| | - Tariq Iqbal
- Head of Department, Burns Surgery Department, BCC, PIMS, SZABMU, Islamabad, Pakistan
| | | | - Hirza Zafar
- Burns Surgery Department, BCC, PIMS, SZABMU, Islamabad, Pakistan
| | - Sehrish Pervaiz
- Burn Care Centre (BCC), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad, Pakistan
| | - Qurat-Ul -Ain
- Burns Surgery Department, BCC, PIMS, SZABMU, Islamabad, Pakistan
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Cancio JM, Dewey WS. Critical Care Rehabilitation of the Burn Patient. Surg Clin North Am 2023; 103:483-494. [PMID: 37149384 DOI: 10.1016/j.suc.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Despite the fact that modern burn care has significantly reduced the mortality associated with severe burn injuries, the rehabilitation and community reintegration of survivors continues to be a challenge. An interprofessional team approach is essential for optimal outcomes. This includes early occupational and physical therapy, beginning in the intensive care unit (ICU). Burn-specific techniques (edema management, wound healing, and contracture prevention) are successfully integrated into the burn ICU. Research demonstrates that early intensive rehabilitation of critically ill burn patients is safe and effective. Further work on the physiologic, functional, and long-term impact of this care is needed.
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Affiliation(s)
- Jill M Cancio
- US Army Institute of Surgical Research, 3698 Chambers Pass Suite B, JBSA Fort Sam Houston, TX 78234-7767, USA.
| | - William S Dewey
- US Army Institute of Surgical Research, 3698 Chambers Pass Suite B, JBSA Fort Sam Houston, TX 78234-7767, USA
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Rousseau AF, Pantet O, Heyland DK. Nutrition after severe burn injury. Curr Opin Clin Nutr Metab Care 2023; 26:99-104. [PMID: 36892959 DOI: 10.1097/mco.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Severe burn injury causes significant metabolic changes and demands that make nutritional support particularly important. Feeding the severe burn patient is a real challenge in regard to the specific needs and the clinical constraints. This review aims to challenge the existing recommendations in the light of the few recently published data on nutritional support in burn patients. RECENT FINDINGS Some key macro- and micro-nutrients have been recently studied in severe burn patients. Repletion, complementation or supplementation of omega-3 fatty acids, vitamin C, vitamin D, antioxidant micronutrients may be promising from a physiologic perspective, but evidence of benefits on hard outcomes is still weak due to the studies' design. On the contrary, the anticipated positive effects of glutamine on the time to discharge, mortality and bacteremias have been disproved in the largest randomized controlled trial investigating glutamine supplementation in burns. An individualized approach in term of nutrients quantity and quality may proof highly valuable and needs to be validated in adequate trials. The combination of nutrition and physical exercises is another studied strategy that could improve muscle outcomes. SUMMARY Due to the low number of clinical trials focused on severe burn injury, most often including limited number of patients, developing new evidence-based guidelines is challenging. More high-quality trials are needed to improve the existing recommendations in the very next future.
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Affiliation(s)
- Anne-Françoise Rousseau
- Intensive Care Department and Burn Center, University Hospital of Liège, Liège University, Liège, Belgium
| | - Olivier Pantet
- Intensive Care Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey. Burns 2023; 49:42-54. [PMID: 36202684 DOI: 10.1016/j.burns.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM. METHODS A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists). RESULTS Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained. CONCLUSION Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.
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