Factors that influence the recovery of physical function of adult patients with major burn injuries
Angelou, Irene Katherine
Background: Research focusing on patients with major burn injuries is limited, and this applies specifically to the physiotherapy aspects and functional outcomes relating to burns. This study was done so as to review the patients with major burn injuries, their outcomes and the effects of certain aspects of the hospital stay on physical function during the different periods of the hospital stay. Objectives: The objectives laid out were set to describe the demographic and clinical characteristics of patients with major burn injuries; to describe the changes in physical function of patients with major burn injuries from the respective stages starting with their Intensive Care Unit (ICU) admission until their discharge from hospital; to describe the number as well as the type of complications that patients with major burn injuries develop during their stay in the ICU; to determine whether the severity of injury is associated with physical function at discharge from the hospital; to determine whether there is an association between the complications developed in ICU and physical function at hospital discharge; to determine if the number of surgical procedures performed is associated with physical function at hospital discharge; and to determine if the length of stay is associated with physical function at hospital discharge. Design: A retrospective record review was conducted to meet the objectives of this research study. Methods: The study population included adults who had sustained major burn injuries. Information about these patients was sourced from a private hospital in Johannesburg, South Africa, which has a Level 1 Trauma Centre and a Burns Unit. The recorded data in the patients’ ICU charts, hospital files and physiotherapy notes were reviewed and only the information needed for this study was extracted. All of the records of patients admitted to the Burns Unit and who were subsequently transferred to a hospital ward were reviewed over a period of 36 months. Patients diagnosed with burns of a total body surface area (TBSA) of 20% or more (excluding superficial burns), with or without an inhalation injury (Gauglitz and Williams, 2016) were included. Records that were excluded from the study included the following cases: patients with complex lower limb injuries, patients with cognitive disorders, and patients who had died in hospital. Results and Discussion: Eighty-four patients were admitted to the hospital during the study period. Of these 84, 73 fitted the inclusion criteria. Though many of the results were incomplete, the following was found. The resulting majority of these patients were male, of black ethnicity, and with a median age of 38 (IQR:22). The most common mechanism of injury was of a thermal nature. The median TBSA burned was 31%, the most common body part to be injured being the upper iv limbs. The results of this study are comparable to those of others conducted in South Africa. According to the demographics and clinical characteristics, the majority of the study cohorts were males, of a black ethnicity, and the areas that were most frequently burned were the limbs (Den Hollander, et al. 2014). Injury to the limbs could be linked to injury on duty as there is evidence that burn injuries generally occur at work e.g. from flammable substances. Furthermore, it was noted that work-related injuries predominantly involve the extremities (Forjuoh, 2006; Hanekom, et al. 2015; WHO, 2019a). Burn injuries can also be sustained at home and during leisure-time activities. The median Injury Severity Score (ISS) was 16 (IQR:16) and the mean revised Baux score was 93 (SD:19.3). Taking into account the revised Baux score, it becomes evident that the majority of the study population (at least 50%) were found to be at risk of mortality, with some individuals potentially needing palliative care. Length of stay (LOS) ranged from seven days, with a maximum of 243 days. The most surgeries a patient underwent amounted to 29. The most common surgery was a debridement. The most common complication with 21.7% (n=15) of the sampled patients was oedema. Other complications included pyrexia (18.8%), low haemoglobin (15.9%), diarrhoea (14.5%), blisters and infection (11.6%). An extended LOS allows for rehabilitation in the hospital and healing after the surgeries (e.g. skin grafts) and from the mentioned complications. With regard to the surgeries, it is evident that the primary cause of surgery was for wound management. Oedema may be due to IV fluid overload, increased capillary permeability as well as blood flow slowing in that area. Pyrexia may be due to the disturbance in thermoregulation, increased metabolic response, systemic inflammation, or an infection. Low haemoglobin levels might have been due to blood loss through the wounds sustained at the time of the injury, multiple debridement procedures as part of wound care, and phlebotomy procedures performed in the ICU. The reasons for vomiting and diarrhoea were probably due to the medication given to the patients in the Burns Unit (e.g. opioids cause vomiting and constipation, and antibiotics cause diarrhoea). Of the study cohort, 43.8% (n=32) of the patients were intubated and ventilated and 45.2% (n=33) needed sedation. Mechanical ventilation is usually accompanied by sedation. Sedation is necessary for patient comfort in an ICU clinical setting, and was found to be essential in this patient population for pain management as a result of their injuries and particularly subsequent to painful surgeries (e.g. debridement). The injuries sustained and subsequent surgeries may affect the range of motion of the joints involved. Restriction of motion of the hand/wrist was noted as the most frequent consequence. The general trend for ROM seemed to improve over the hospital stay although limited ROM of the knees, ankles and feet for some patients were noted at hospital discharge. The possible reasons for v decreased ROM over the period ranging from ICU discharge to hospital discharge might have been due to the lack of patient compliance (not compliant with physiotherapy sessions or exercises that were to be done independently), the need for joint immobility and for multiple surgeries. Muscle strength also seemed to improve during the patients’ hospital stay. All patients received physiotherapy management during their hospital stay, and it is reasonable to conclude that they responded clinically to the rehabilitation received for regaining their muscle strength. The muscle length of the Achilles tendon was the most common of the two-joint muscles to be shortened. Distance walked, independent mobilisation, stair climbing and the Functional Status Score (FSSICU) seemed to improve throughout the hospital stay and can be attributed to the fact that patients received needs-based physiotherapy care. No associations were found between ISS, ICU LOS, number of theatre visits, and number of complications developed respectively, and non-independent physical function of patients. Since surgeries are conducted to improve the patient outcomes, it seems plausible that no associations were found between the number of surgeries and non-independent physical function of patients at hospital discharge. On the other hand, LOS might have improved physical function as the patient’s functional ability would have reached a certain level before he/she could be discharged from the hospital. Limitations of this study include: ▪ poor data recording, ▪ the non-recording of the number of times a single complication occurred, ▪ the non-recording of psychological aspects and level of pain, and ▪ the intervals between which the data were recorded were too great. Conclusion: This retrospective record review provides a general overview of the outcomes associated with patients recovering from major burn injuries. The findings should be interpreted with caution as the sample is small and some records were incomplete. Physical function at hospital discharge for this cohort does not seem to be associated with ISS, ICU LOS, hospital LOS, theatre visits number and number of complications developed respectively. Information obtained from this study provides a platform from which further research of a prospective nature can be conducted to investigate factors that might influence physical recovery of patients who survive major burn injuries.
A research project submitted fulfilment of the requirement for the degree of Master of Science in Physiotherapy to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2020