Ying Ren, Qun-fei Yu, Fei Lu, Yao-jing Ma, Xiu-qin Feng

Nursing Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China

Burns often happen unexpectedly and have the potential to cause death, lifelong disfigurement and dysfunction.[1]According to the depth of the burn wound and extent of affected burned body surface area, burns are classified as mild or severe.Mild burns usually refer to burns that encompass less than 10% of the total body surface area (TBSA), mainly superficial burns.Severe burns are defined as TBSA >10% in elderly patients,TBSA>20% in adults, and TBSA>30% in children.[2]Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure.[3]Therefore, burn care providers face many challenges,including acute and critical care management, long-term care, and rehabilitation.Here, we report a 94-year-old patient with severe burns who recovered well and was discharged from the hospital in a wheelchair.

CASE

A 94-year-old man with severe burns caused by an explosion of a fuel tank was transferred from a local hospital to our hospital at 24 h after the injury.Prior to admission, the patient was initially resuscitated at the local hospital.On admission, the patient was conscious,with a Glasgow Coma Score of 13 and body mass index(BMI) of 21.63.He had severe burns (TBSA 52%).His blood pressure was 106/59 mmHg (1 mmHg=0.133 kPa),with a heart rate of 106 beats/min, a respiratory rate of 19 breaths/min, and a body temperature of 36.6 °C.He was able to respond to painful stimuli.Physical examination showed coarse breath sounds in both lungs and no murmurs with regular rhythm.The abdomen was soft,without tenderness or rebound.Laboratory tests indicated acute kidney injury.After admission, his blood pressure fluctuated at 78–106/42–56 mmHg.Norepinephrine was continuously infused at a rate of 0.02 g/(kg·min)to support blood pressure.He was resuscitated with alternate colloid or crystal fluid to prevent poor wound healing, hypovolemic shock, and even death.The patient was intubated, and tracheotomy was subsequently performed.In addition, nutritional supplements(carbohydrates, lipids, proteins, and vitamins) were provided through a feeding tube to enhance immunity and accelerate wound healing.To prevent secondary infection, we removed necrotic tissue, wrapped the wound with sterile material, used antibacterial drugs, and strictly adhered to quarantine and disinfection rules.To minimize discomfort and acute gastroduodenal diseases,analgesics and antacids were given.Since day 4, a total of seven operations had been performed, including the removal and debridement of necrotic tissue, skin grafting, and closed negative pressure drainage.On day 57, he was transferred to a rehabilitation unit where he was successfully extubated on day 69.

For severely burned patients in the intensive care unit (ICU), early mobility and recovery (EMR) is more challenging than that for other patients due to multiple and extensive burn wounds, wound dressings, and limited mobility after skin grafting.[4]During an early stage, routine positioning was adopted for the patient.The upper limb was abducted by 90° with the fossa fully exposed.The elbow joint was abducted and maintained at a flexion of 5° to 10°, with the forearm and wrist joints in a neutral position.The thumb was positioned in the opposite position of the metacarpal bone, and the metacarpophalangeal joints of the adjacent four fingers were maintained at approximately 0°to 90°.The hip joint was abducted by 10° to 15°.The knee joint was straight and maintained a flexion of 3° to 5°.The ankle joint was in an anatomical position of 90°, preventing foot drop.

Additionally, passive joint movements were performed twice daily for 20 min each time.On hospital day 45, the patient was required to carry out active exercise, starting with simple eye and mouth closure and arm lifting and abduction.As the patient gradually improved, he was directed to perform elbow and wrist flexion and extension, forearm forward and backward rotation, fist grip, and finger extension movements to improve joint mobility, avoid joint contracture, and improve muscle strength.The intensity of exercise was tailored to the patient’s comfort and tolerance.The day after the patient was transferred to the rehabilitation ward, he was trained to stand up with the aid of an electric stand-up bed for 30 min each time.The standing angle gradually increased from 30° to 85°, with an increase of 5° to 10° per day.During the training, the nurses and rehabilitation doctors stood on both sides of the patient for safety and closely monitored the patient’s heart rate, blood pressure, posture, and facial condition.If symptoms such as dizziness, nausea, panic, or cold sweats occurred, they immediately lowered the bed to 0°and loosened the straps and collar.In a standing position,the nurse assisted the patient in drinking 5 mL of water every 5 minutes to exercise swallowing function.On hospital day 63, nurses and rehabilitation doctors assisted the patient in walking on the ground, gradually increasing the walking distance from 5 m to 25 m.Swallowing exercises were performed, and the patient was assisted in eating yogurt and rice.After implementing the rehabilitation treatment, the patient could walk 25 m with support and eat food without choking and coughing.

The patient recovered well after 74 days of hospitalization and was discharged in a wheelchair.

DISCUSSION

ICU patients suffer from ICU-acquired weakness,cognitive impairment, and psychological disturbance due to long-term bed rest, fixation, and mechanical ventilation.[5,6]EMR is believed to avoid these complications and alleviate the adverse effects of postintensive care syndrome.Compared with other patients,acute critical burn patients have unique needs for analgesia,sedation, and skin grafting, which makes EMR-targeted measures more difficult to implement.[7]Obstacles to implementing EMR-targeted measures include excessive sedation, risk of various tube malfunctions, obesity,cognitive impairment, and endotracheal intubation.The initiation of EMR-targeted measures for ICU severe burn patients would cause additional risks and difficulties.The scar contracture caused by wound healing can easily lead to large joint dysfunction, seriously affecting quality of life and social function.[8,9]

In our patient, a treatment team was composed of experts from multidisciplinary services from the ICU,burn, and trauma.A burn department nurse and an ICU nurse formed a nursing team, cooperating with the physician team to carry out prescribed functional exercises, nutritional support, and other treatments.Multidisciplinary team rounds were conducted every day, and treatment and care plans were adjusted based on the current condition.Due to our close monitoring and predictive risk mitigation, no adverse events occurred,such as decreased oxygen saturation, orthostatic hypotension, or catheter malfunction.

Funding:This study was supported by a Major Science and Technology Project on Health of Zhejiang Province (WKJ-ZJ-2123).

Ethical approval:Written informed consent for publication was obtained from the patient for publication of this study.

Conflicts of interests: All authors have disclosed no Conflicts of interest.

Contributors:All authors contributed equally to this study.YR and FL drafted the manuscript.QFY contributed to the manuscript revision.All authors read and approved the final manuscript.