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The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection?

The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically... Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 ORIGINAL ARTICLE The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection? †,‡ Beth A. Shields, MS, RDN, CNSC,* Jennifer N. Carpenter, MS, RDN, Brenda D. Bustillos, DrPH, ‡ ,|| MS, RDN, Alicia N. Jordan, PT, DPT,* Kyle B. Cunningham, PT, DPT,* Saul J. Vega, BS,* ‡ ,# ,$ James K. Aden, PhD, Matthew P. Rowan, PhD,* Julie A. Rizzo, MD,* William S. Dewey, PT, CHT,* Jennifer M. Gurney, MD,* Craig R. Ainsworth MD,* and Leopoldo C. Cancio, MD* The purpose of this project was to evaluate the relationships between nutrition, physical activity levels (PALs), severity of illness (SOI), and survival in critically ill burn patients. We conducted a retrospective evaluation of consecutively admitted adult patients who had an intensive care unit stay ≥8 days after ≥20% TBSA burns. Linear regression was used to assess the association between SOI (sequential organ failure assessment scores) and PALs as well as between SOI and nutritional intake. After univariate analysis comparing survivors and nonsurvivors, factors with P < .10 were analyzed with multiple logistic regression. Characteristics of the 45 included patients were: 42 ± 15 years old, 37 ± 17% TBSA burns, 22% mortality. Factors independently associated with survival were burn size (negatively) (P = .018), height (positively) (P = .006), highest PAL during the first eight intensive care unit days (positively) (P = .016), and kcal balance during the fifth through the eighth intensive care unit days (positively) (P = .012). Sequential organ failure assessment scores had a significant (P < .001) but weak association with nutrition 2 2 intake (R  = 0.05) and PALs (R  = 0.25). Higher nutritional intake and activity were significantly associated with lower mortality in critically ill burn patients. Given the weak associations between both nutritional intake and PALs with SOI, the primary barrier in achieving nutrition and activity goals was not SOI. We recommend that physical rehabilitation and nutritional intake be optimized in an effort to improve outcomes in critically ill burn patients. Nutrition and physical rehabilitation are fundamental even after autografting of the lower extremities (with the use components in the care of critically ill burn patients. The of splinting or casting to protect the graft). However, they 2016 guidelines from the Society of Critical Care Medicine noted a lack of evidence for the timing, duration, and in- and the American Society for Parenteral and Enteral tensity of specific exercises and, therefore, could not make Nutrition support efforts to initiate enteral nutrition (EN) recommendations on these. Critically ill patients often un- within 4–6 hours of burn and to provide critically ill adult dergo periods of prolonged bed rest, which can result in patients who are at high nutrition risk with at least 80% of a significant decrease in lean body mass, subsequently 1 7 energy goals within 48–72 hours of hospitalization. Despite resulting in increased length of stay, increased mortality, and these recommendations, underfeeding is highly prevalent in decreased physical function and quality of life following dis- critically ill patients in the United States and is associated charge. Research has shown that physical rehabilitation can with severe weight loss, increased infection rates, decreased be delivered safely to intubated patients despite barriers to 9–11 wound healing, increased pressure ulcer development, mobilization. Early physical activity improves pulmonary 2–4 increased rates of pneumonia, and death. function, strength, and lean body mass retention in critically The 2008 Burn Rehabilitation and Research Consensus ill burn patients and these have the potential to decrease mor- Summit recommended that critically ill, mechanically tality and improve long-term functional outcomes. ventilated burn patients be mobilized as soon as possible, In our clinical practice, we have observed an association be- tween improved outcomes in patients with severe burns and both the provision of a higher percentage of the nutrition goal From the *U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, and achieving higher physical activity levels (PALs) early in the 27th Engineer Battalion (Airborne), Fort Bragg, North Carolina; Texas; intensive care unit (ICU) course. However, severity of illness ‡ || Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; Navy $ (SOI) can result in interruptions of nutritional and rehabilita- Uniformed Medicine Operational Training Center, Penacola, Florida; Deceased. Services University of Health Sciences, Bethesda, Maryland; tion therapies. The purpose of this project was to evaluate the Funding. None declared. achievement of nutrition goals and PALs along with SOI and Conflict of interest statement. The authors declare no conflict of interest. survival in patients with severe burns. Address correspondence to Beth A. Shields, MS, RDN, LD, CNSC, U.S. Army Institute of Surgical Research Burn Center, 3698 Chambers Pass, JBSA Fort Sam Houston, Texas 78234. Email: beth.a.shields6.civ@mail.mil METHODS Published by Oxford University Press on behalf of the American Burn Association 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US. This descriptive performance improvement project was approved by our Research Regulatory Compliance Division doi:10.1093/jbcr/irz126 936 Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 937 and involved a retrospective review of the electronic med- the lower ranked PALs were also considered to be achieved. ical records of adult (≥18 years of age) patients consecutively The MOVEO XP (DJO Global, Dallas, TX) is a graded exer- admitted with ≥20% TBSA burns to our burn ICU between cise platform utilized at our burn center to enable patients who January 2014 and September 2015. Patients with an ICU are unable to ambulate the ability to perform partial squats to length of stay with at least 8 days were included in this anal- improve lower extremity functional strength. ysis. Patients of limb amputations and those admitted a week Early excision and grafting is our standard of care. or more after injury were excluded. Postoperative immobilization after autografting can vary at our facility, based on the autograft location and the type of postoperative dressing used, as well as the patients’ overall Clinical Care cognitive and medical status and healing ability. Our standard The Registered Dietitian Nutritionist assessed the admission for rehabilitation coordination is to collaborate with the phy- nutrition status through physical examination, nutritional in- sician during surgery and during interdisciplinary rounds to take prior to injury, and body weight history. Usual dry body discuss required immobilization and activity clearance based weight was used to calculate calorie (kcal) goals with the Milner on the surgical and medical ramifications of the activity type 12,13 equation, and when feasible, indirect calorimetry was used that is anticipated. to reassess caloric requirements throughout the hospitalization. Clinically, an activity factor of 1.4 was used in the Milner equa- Data Collection tion to account for increases in metabolism above the resting energy expenditure (from pain, physical activity, anxiety, etc.), Data were collected from the medical record and included age, in an attempt to minimize weight loss and has been found to sex, burn size, inhalation injury, height, pre-injury dry body result in weight maintenance at our facility. The activity factor weight, hours from admission to EN initiation, parenteral nu- was decreased to 1 in the Milner equation temporarily when trition use, daily kcal goal, daily kcal intake, daily MaxPALs, patients were chemically paralyzed. As part of standard of care, daily sequential organ failure assessment (SOFA) scores, ICU the Registered Dietitian Nutritionist monitored kcal intake days, hospital days, and mortality. Daily data were collected for from EN, parenteral nutrition, intravenous fluids, and oral in- the first eight full ICU days. The SOFA score quantifies the take. The cumulative kcal balance (kcal intake − kcal goal) was SOI by scoring the degree of organ dysfunction over time and calculated and monitored in an effort to avoid severe weight has been correlated with mortality in critically ill and severely 14–16 loss. Avoiding weight loss over 10% of the usual dry body burned patients. Daily SOFA scores were calculated ac- weight was a clinical goal, as this level of weight loss has been cording to established guidelines, with two adjustments: the 2–4 found to be associated with increased mortality. Additional renal portion was counted as a score of 4 on each continuous nutrition goals for patients with ≥30% TBSA burns and patients renal replacement therapy day and vasopressin was used in place who were not expected to be able to meet their nutrition goals of dopamine. Mortality was collected as the clinical endpoint. with oral intake alone included initiating EN within 24 hours of admission and achieving the EN goal rate within 48 hours. The Statistics standard EN formula was Promote (Abbott Nutrition, Lake Statistical analyses were conducted using JMP (Version Bluff, Illinois), with a concentration of 1 kcal/ml and 25% 13.0.0; SAS Institute, Inc., Cary, NC). Descriptive statis- of kcal from protein. In order to promote a positive nitrogen tics, including percent, mean ± standard deviation, or median balance, the initial nutrition prescription included boluses of with interquartile range (IQR), were calculated. Chi-square 6  g of modular whey protein every 3 hours. Adjustments in or Fisher’s exact tests were used to evaluate the relationships modular protein provisions were made based on assessments of between categorical variables. Mann–Whitney U and Kruskal– healing and nitrogen balance. Patients received glutamine sup- Wallis tests were used to analyze continuous variables against plementation at 0.5 g/kg during this time period unless they categorical variables. Linear regression was performed to de- had preexisting renal failure or developed severe transaminitis. termine the correlation between daily MaxPAL, %kcal goal EN was provided until the time of surgery in patients who were achieved, and SOFA scores. A  two-way repeated-measures being fed into the intestine and then restarted at the previously analysis of variance (ANOVA) was conducted to compare the tolerated rate when hemodynamically stable after surgery. The relationship of time and mortality on SOFA scores. EN rate was increased before and after surgery in an effort to Characteristics were examined with univariate analysis to achieve kcal goals. determine which factors were significantly different between Physical rehabilitation treatment goals included minimizing survivors and nonsurvivors. Multiple logistic regressions the risk of burn scar contracture, maximizing mobility and inde- were conducted, including all possible predictors of mortality pendence in performing activities of daily living, and ultimately, having P < .10, removing the characteristic with the highest preparing patients for discharge from the hospital. Physical and P-value at each step until all factors remaining achieved sta- Occupational Therapists determined daily physical rehabilita- tistical significance. Odds ratio (OR), 95% Wald confidence tion treatment plans according to patients’ medical status and limits, and P-values were reported. Statistical significance was therapeutic needs. The daily maximum PAL (MaxPAL), a nu- accepted at P < .05. merical score developed by our group to aid in communication of PALs for each patient, were ranked as follows: (0) no activity, (1) performing range of motion, (2) sitting in the total lift chair RESULTS (TLC), (3) tilt-table positioning, (4) sitting at the edge of the bed (EOB), (5) squatting on a graded exercise platform, (6) During the evaluation period, 53 patients met the inclusion standing, and (7) ambulating. If a higher PAL was achieved, criteria for this analysis. However, six patients were excluded Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 938 Shields et al November/December 2019 due to limb amputations and two patients were admitted adjusted for burn size, height, and highest MaxPAL achieved over a week after injury. The remaining 45 patients were 42 ± during the first eight full ICU days with logistic regression, 15  years old, had 37  ± 17% TBSA burns, and experienced achieving at least 50% of kcal goal on average over the first eight 22% mortality. Patient characteristics are reported in Table 1. full ICU days and at least 80% of kcal goal on average over the These patients were in the ICU for 21 days (IQR: 14–35) and fifth through the eighth full ICU days were individually associ- in the hospital for 32 days (IQR: 21–46). Patients who died ated with lower mortality (P = .005 and P = .046, respectively). were older (53 ± 20 vs 39 ± 13 years, P = .025) with larger In order to better describe the timing of individual MaxPALs TBSA burns (53  ± 25% vs 32  ± 10%, P  =  .013) and higher associated with lower mortality rates, mortality and daily in- SOFA scores over the first eight full ICU days (8 ± 3 vs 5 ± 3, dividual MaxPALs achieved during the first eight full ICU P = .018) (Figure 1). days were evaluated with a univariate analysis (Figure 3). The Table 2 shows patient interventions during the first 8 days daily individual MaxPALs with P < .10 were then adjusted for in the ICU. On average, survivors received 84 ± 15% of kcal burn size, height, and kcal balance from the fifth through the goal and nonsurvivors received 74 ± 20% of kcal goal during eighth full ICU days using logistic regression. The following this time (P = .081); the kcal balance over the first 8 days in timing of MaxPALs were individually associated with lower the ICU did not reach statistical significance (nonsurvivors: mortality when adjusted for other significant factors: MaxPAL −6861 kcal [IQR: −4457 to −12,285] vs survivors: −4703 kcal score of ≥2 (positioning in the TLC) by the first (P = .011) or [IQR: −1938 to −6776], P = .081). Based on Figure 2, the second (P = .003) full ICU days, MaxPAL score of ≥4 (sitting ICU days were separated to better describe the kcal balance, as EOB) by the fourth through the sixth (P = .019) or the sev- both groups had a worsening kcal balance over the first 4 ICU enth (P = .017) or eighth full ICU days (P = .007), MaxPAL days, but on day 5, survivors’ kcal balance began to improve. score of ≥5 (squatting on the graded exercise platform) by There was no difference in the kcal balance during first 4 full the seventh (P  =  .030) or eighth (P  =  .012) full ICU days, ICU days (nonsurvivors: −6860 [IQR: −4760 to −8036] vs MaxPAL score of ≥6 (standing) by the seventh (P = .030) or survivors: −6296 [IQR: −4188 to −8059], P  =  .702). The eighth (P  =  .012) full ICU days, and MaxPAL score of ≥7 kcal balance during the fifth through the eighth full ICU days (ambulating) by the eighth full ICU day (P = .038). achieved a P-value less than .10, allowing for use in logistic Repeated-measures ANOVA revealed no interaction regression (nonsurvivors: +261 [IQR: −4780 to +1335] vs (P = .124) between SOFA scores of survivors vs nonsurvivors survivors: +1880 [IQR: +300 to +2913], P = .063). during the first eight full days in the ICU (Figure 1). When Multiple logistic regression analysis was conducted for mor- linear regression was performed on the variables collected tality using age, burn size, height, weight, time (hours) from each day during the first eight full days in the ICU to eval- admission to initiation of EN, average SOFA score during the uate the relationship between SOI and MaxPAL and then first eight full ICU days, highest MaxPAL achieved during SOI and %kcal goal, both daily MaxPALs and daily %kcal goal the first eight full ICU days, and kcal balance during the fifth achieved matched with daily SOFA scores had significant but through the eighth full ICU days. The four factors independ- weak associations, with R values of 0.25 and 0.05, respec- ently associated with mortality in the final model (Table 3) tively (both P < .001). were burn size (OR = 1.088, P = .018), height (OR = 0.601, P = .006), highest MaxPAL achieved during the first eight full DISCUSSION ICU days (OR = 0.425, P = .016), and kcal balance during the fifth through the eighth full ICU days (OR = 0.691, P = .012). We found a significant relationship between both nutritional In order to better describe the timing and amount of nutrition intake and physical activity, and mortality, in critically ill associated with lower mortality rates, patients were separated burn patients during the first 8  days after admission. These into groups by the %kcal goal achieved (see Tables 4 and 5). relationships can now provide guidance for our clinical prac- Achieving at least 50% of kcal goal on average over the first eight tice, including the following quantifiable goals: full ICU days and at least 80% of kcal goal on average during the fifth through the eighth full ICU days were associated with 1. Achieve ≥50% of kcal goal* on average over the first lower mortality (P  =  .007 and P  =  .031, respectively). When eight full ICU days Table 1.  Patient characteristics Nonsurvivors Characteristic All (n = 45) Survivors (n = 35) (n = 10) P Women 9 (20%) 7 (20%) 2 (20%) >.999 Age (yr) 42 (32–52) 36 (31–47) 56 (37–68) .025* TBSA burns (%) 32 (26–42) 30 (24–37) 45 (28–79) .013* Inhalation injury 11 (24%) 7 (20%) 4 (40%) .228 Height (inches) 69 (67–72) 70 (68–72) 67 (65–70) .044* Weight (kg) 85 (72–103) 92 (73–105) 74 (67–100) .096 BMI (kg/m ) 28 (24–31) 28 (24–32) 26 (23–31) .530 BMI, body mass index; TBSA, total body surface area. *P = significant. The bold indicates the value with significant differences. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 939 Survivors Non-Survivors 12 34 56 78 Day Figure 1. Sequential organ failure assessment (SOFA) scores over time. Table 2.  Patient interventions over the first eight full ICU days Treatment All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P Hours to EN initiation 21 (14–32) 20 (13–27) 34 (19–43) .049* Parenteral nutrition 10 (22%) 6 (17%) 3 (30%) .423 %Kcal goal achieved 83 (74–94) 86 (77–94) 77 (64–83) .081 MaxPAL 3 (3–7) 3 (3–7) 3 (3-3) .026* EN, enteral nutrition; ICU, intensive care unit; MaxPAL, maximum physical activity level. *P < .05. The bold indicates the value with significant differences. 2. Achieve ≥80% of kcal goal* on average over the fifth gastrointestinal dysfunction, which impede these efforts but through the eighth full ICU days which are not adequately measured by SOFA. 3. Achieve positioning in the TLC by the first full ICU day Our results agree with previous studies that have associ- 4. Achieve sitting EOB by the fourth full ICU day ated suboptimal feeding with detrimental clinical outcomes. 5. Achieve squatting on the graded exercise platform by Villet et al found that the energy deficit accumulated during the seventh full ICU day the first 7  days was associated with increased infectious 6. Achieve standing by the seventh full ICU day complications in surgical ICU patients. Similarly, Dvir 7. Achieve ambulation by the eighth full ICU day et  al found that negative energy balance during the ICU stay was associated with increased incidence of acute respi- *Kcal goal as calculated by the Milner equation with activity ratory distress syndrome, sepsis, renal failure, pressure ulcer factor of 1.4 (decreased to 1 during chemical paralysis). development, and total complication rates. Although we It should be noted that these levels of nutrition and phys- did not evaluate the development of these complications ical activity found to be significantly associated with mor- as outcomes in our analysis, we did evaluate mortality and tality were from a small sample size. Larger sample sizes found a negative kcal balance during the first eight full ICU may result in statistical significance in mortality for earlier days to be significantly associated with a higher mortality achievement of specific MaxPALs and higher achievement of rate (P < .001), even when adjusted for burn size, height, kcal goals. Therefore, these goals would be considered the and MaxPALs. minimum goals. Lorente et al observed that mortality was associated with Further study is required to prospectively validate these higher SOFA scores during the first 4  days postburn. In goals and establish causality; however, the weak relationship the present evaluation, there was no interaction over time between SOFA scores, PALs, and nutrition goals is very sug- for SOFA scores during the first eight full ICU days be- gestive that SOI is not the primary barrier in achieving higher tween sur vivors and nonsur vivors (Figure 1, P = .124). Due PALs and nutrition goals. However, we do not discount the to the potential relationship of SOI on achieving kcal and possibility that failure to achieve activity and nutrition goals PAL goals, we investigated the relationship between SOFA also points to underlying problems, such as cognitive or scores, %kcal goal achieved, and MaxPALs. Using linear Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 940 Shields et al November/December 2019 -2000 Survivors Non-Survivors -3000 -4000 -5000 -6000 -7000 -8000 -9000 -10000 -11000 12 3456 78 Day Figure 2. Cumulative calorie balance over time. Table 3. Odds ratio estimations for mortality Effect Odds Ratio 95% Wald Confidence Limits P TBSA burns (%) 1.088 (0.998, 1.186) .018* Height (inches) 0.601 (0.379, 0.955) .006* Highest MaxPAL achieved by day 8 0.425 (0.174, 1.040) .016* Kcal balance during the fifth through the 0.691 (0.495, 0.965) .012* eighth full ICU days (per 1000 kcal) ICU, intensive care unit; kcal, calories; MaxPAL, maximum physical activity level; TBSA, total body surface area. *P < .05. Table 4.  Patients grouped by survival and percent calorie goal achieved during the fifth through the eighth full ICU days % Calorie Goal All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P ≥100% achieved 35 (78%) 29 (83%) 6 (60%) .125 ≥90% achieved 39 (87%) 32 (91%) 7 (70%) .104 ≥80% achieved 40 (89%) 33 (94%) 7 (70%) .031* ICU, intensive care unit. *P < .05. The bold indicates the value with significant differences. Table 5.  Patients grouped by survival and percent calorie goal achieved during the first eight full ICU days % Calorie Goal All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P ≥100% achieved 5 (11%) 4 (11%) 1 (10%) .899 ≥90% achieved 15 (33%) 13 (37%) 2 (20%) .311 ≥80% achieved 27 (60%) 23 (66%) 4 (40%) .143 ≥70% achieved 37 (82%) 29 (83%) 8 (80%) .835 ≥60% achieved 40 (89%) 32 (91%) 8 (80%) .311 ≥50% achieved 43 (96%) 35 (100%) 8 (80%) .007* ICU, intensive care unit. *P = significant. The bold indicates the value with significant differences. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 941 Figure 3. Maximum physical activity levels achieved by each full intensive care unit (ICU) day. Highlighted days show timing for activity levels found to be independent factors associated with mortality after adjustments for all other significant factors (burn size, height, and calorie balance from the fifth through the eighth full ICU days). regression, we found significant but weak correlations be- does not allow for determining causation; however, there tween daily SOFA scores and %kcal goal achieved (P < .001, does appear to be a weak relationship between SOFA R  = 0.05) as well as daily SOFA scores and MaxPALs (P < scores, the amount of nutrition delivered, and achieving .001, R   =  0.25). The retrospective nature of our project higher PALs. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 942 Shields et al November/December 2019 The primary limitation of this project is that we were REFERENCES unable to assess all daily ICU practices and reasons for 1. 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The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection?

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Copyright © 2022 American Burn Association
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1559-047X
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1559-0488
DOI
10.1093/jbcr/irz126
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Abstract

Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 ORIGINAL ARTICLE The Interplay of Nutrition, Physical Activity, Severity of Illness, and Mortality in Critically Ill Burn Patients: Is There a Connection? †,‡ Beth A. Shields, MS, RDN, CNSC,* Jennifer N. Carpenter, MS, RDN, Brenda D. Bustillos, DrPH, ‡ ,|| MS, RDN, Alicia N. Jordan, PT, DPT,* Kyle B. Cunningham, PT, DPT,* Saul J. Vega, BS,* ‡ ,# ,$ James K. Aden, PhD, Matthew P. Rowan, PhD,* Julie A. Rizzo, MD,* William S. Dewey, PT, CHT,* Jennifer M. Gurney, MD,* Craig R. Ainsworth MD,* and Leopoldo C. Cancio, MD* The purpose of this project was to evaluate the relationships between nutrition, physical activity levels (PALs), severity of illness (SOI), and survival in critically ill burn patients. We conducted a retrospective evaluation of consecutively admitted adult patients who had an intensive care unit stay ≥8 days after ≥20% TBSA burns. Linear regression was used to assess the association between SOI (sequential organ failure assessment scores) and PALs as well as between SOI and nutritional intake. After univariate analysis comparing survivors and nonsurvivors, factors with P < .10 were analyzed with multiple logistic regression. Characteristics of the 45 included patients were: 42 ± 15 years old, 37 ± 17% TBSA burns, 22% mortality. Factors independently associated with survival were burn size (negatively) (P = .018), height (positively) (P = .006), highest PAL during the first eight intensive care unit days (positively) (P = .016), and kcal balance during the fifth through the eighth intensive care unit days (positively) (P = .012). Sequential organ failure assessment scores had a significant (P < .001) but weak association with nutrition 2 2 intake (R  = 0.05) and PALs (R  = 0.25). Higher nutritional intake and activity were significantly associated with lower mortality in critically ill burn patients. Given the weak associations between both nutritional intake and PALs with SOI, the primary barrier in achieving nutrition and activity goals was not SOI. We recommend that physical rehabilitation and nutritional intake be optimized in an effort to improve outcomes in critically ill burn patients. Nutrition and physical rehabilitation are fundamental even after autografting of the lower extremities (with the use components in the care of critically ill burn patients. The of splinting or casting to protect the graft). However, they 2016 guidelines from the Society of Critical Care Medicine noted a lack of evidence for the timing, duration, and in- and the American Society for Parenteral and Enteral tensity of specific exercises and, therefore, could not make Nutrition support efforts to initiate enteral nutrition (EN) recommendations on these. Critically ill patients often un- within 4–6 hours of burn and to provide critically ill adult dergo periods of prolonged bed rest, which can result in patients who are at high nutrition risk with at least 80% of a significant decrease in lean body mass, subsequently 1 7 energy goals within 48–72 hours of hospitalization. Despite resulting in increased length of stay, increased mortality, and these recommendations, underfeeding is highly prevalent in decreased physical function and quality of life following dis- critically ill patients in the United States and is associated charge. Research has shown that physical rehabilitation can with severe weight loss, increased infection rates, decreased be delivered safely to intubated patients despite barriers to 9–11 wound healing, increased pressure ulcer development, mobilization. Early physical activity improves pulmonary 2–4 increased rates of pneumonia, and death. function, strength, and lean body mass retention in critically The 2008 Burn Rehabilitation and Research Consensus ill burn patients and these have the potential to decrease mor- Summit recommended that critically ill, mechanically tality and improve long-term functional outcomes. ventilated burn patients be mobilized as soon as possible, In our clinical practice, we have observed an association be- tween improved outcomes in patients with severe burns and both the provision of a higher percentage of the nutrition goal From the *U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, and achieving higher physical activity levels (PALs) early in the 27th Engineer Battalion (Airborne), Fort Bragg, North Carolina; Texas; intensive care unit (ICU) course. However, severity of illness ‡ || Brooke Army Medical Center, JBSA Fort Sam Houston, Texas; Navy $ (SOI) can result in interruptions of nutritional and rehabilita- Uniformed Medicine Operational Training Center, Penacola, Florida; Deceased. Services University of Health Sciences, Bethesda, Maryland; tion therapies. The purpose of this project was to evaluate the Funding. None declared. achievement of nutrition goals and PALs along with SOI and Conflict of interest statement. The authors declare no conflict of interest. survival in patients with severe burns. Address correspondence to Beth A. Shields, MS, RDN, LD, CNSC, U.S. Army Institute of Surgical Research Burn Center, 3698 Chambers Pass, JBSA Fort Sam Houston, Texas 78234. Email: beth.a.shields6.civ@mail.mil METHODS Published by Oxford University Press on behalf of the American Burn Association 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US. This descriptive performance improvement project was approved by our Research Regulatory Compliance Division doi:10.1093/jbcr/irz126 936 Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 937 and involved a retrospective review of the electronic med- the lower ranked PALs were also considered to be achieved. ical records of adult (≥18 years of age) patients consecutively The MOVEO XP (DJO Global, Dallas, TX) is a graded exer- admitted with ≥20% TBSA burns to our burn ICU between cise platform utilized at our burn center to enable patients who January 2014 and September 2015. Patients with an ICU are unable to ambulate the ability to perform partial squats to length of stay with at least 8 days were included in this anal- improve lower extremity functional strength. ysis. Patients of limb amputations and those admitted a week Early excision and grafting is our standard of care. or more after injury were excluded. Postoperative immobilization after autografting can vary at our facility, based on the autograft location and the type of postoperative dressing used, as well as the patients’ overall Clinical Care cognitive and medical status and healing ability. Our standard The Registered Dietitian Nutritionist assessed the admission for rehabilitation coordination is to collaborate with the phy- nutrition status through physical examination, nutritional in- sician during surgery and during interdisciplinary rounds to take prior to injury, and body weight history. Usual dry body discuss required immobilization and activity clearance based weight was used to calculate calorie (kcal) goals with the Milner on the surgical and medical ramifications of the activity type 12,13 equation, and when feasible, indirect calorimetry was used that is anticipated. to reassess caloric requirements throughout the hospitalization. Clinically, an activity factor of 1.4 was used in the Milner equa- Data Collection tion to account for increases in metabolism above the resting energy expenditure (from pain, physical activity, anxiety, etc.), Data were collected from the medical record and included age, in an attempt to minimize weight loss and has been found to sex, burn size, inhalation injury, height, pre-injury dry body result in weight maintenance at our facility. The activity factor weight, hours from admission to EN initiation, parenteral nu- was decreased to 1 in the Milner equation temporarily when trition use, daily kcal goal, daily kcal intake, daily MaxPALs, patients were chemically paralyzed. As part of standard of care, daily sequential organ failure assessment (SOFA) scores, ICU the Registered Dietitian Nutritionist monitored kcal intake days, hospital days, and mortality. Daily data were collected for from EN, parenteral nutrition, intravenous fluids, and oral in- the first eight full ICU days. The SOFA score quantifies the take. The cumulative kcal balance (kcal intake − kcal goal) was SOI by scoring the degree of organ dysfunction over time and calculated and monitored in an effort to avoid severe weight has been correlated with mortality in critically ill and severely 14–16 loss. Avoiding weight loss over 10% of the usual dry body burned patients. Daily SOFA scores were calculated ac- weight was a clinical goal, as this level of weight loss has been cording to established guidelines, with two adjustments: the 2–4 found to be associated with increased mortality. Additional renal portion was counted as a score of 4 on each continuous nutrition goals for patients with ≥30% TBSA burns and patients renal replacement therapy day and vasopressin was used in place who were not expected to be able to meet their nutrition goals of dopamine. Mortality was collected as the clinical endpoint. with oral intake alone included initiating EN within 24 hours of admission and achieving the EN goal rate within 48 hours. The Statistics standard EN formula was Promote (Abbott Nutrition, Lake Statistical analyses were conducted using JMP (Version Bluff, Illinois), with a concentration of 1 kcal/ml and 25% 13.0.0; SAS Institute, Inc., Cary, NC). Descriptive statis- of kcal from protein. In order to promote a positive nitrogen tics, including percent, mean ± standard deviation, or median balance, the initial nutrition prescription included boluses of with interquartile range (IQR), were calculated. Chi-square 6  g of modular whey protein every 3 hours. Adjustments in or Fisher’s exact tests were used to evaluate the relationships modular protein provisions were made based on assessments of between categorical variables. Mann–Whitney U and Kruskal– healing and nitrogen balance. Patients received glutamine sup- Wallis tests were used to analyze continuous variables against plementation at 0.5 g/kg during this time period unless they categorical variables. Linear regression was performed to de- had preexisting renal failure or developed severe transaminitis. termine the correlation between daily MaxPAL, %kcal goal EN was provided until the time of surgery in patients who were achieved, and SOFA scores. A  two-way repeated-measures being fed into the intestine and then restarted at the previously analysis of variance (ANOVA) was conducted to compare the tolerated rate when hemodynamically stable after surgery. The relationship of time and mortality on SOFA scores. EN rate was increased before and after surgery in an effort to Characteristics were examined with univariate analysis to achieve kcal goals. determine which factors were significantly different between Physical rehabilitation treatment goals included minimizing survivors and nonsurvivors. Multiple logistic regressions the risk of burn scar contracture, maximizing mobility and inde- were conducted, including all possible predictors of mortality pendence in performing activities of daily living, and ultimately, having P < .10, removing the characteristic with the highest preparing patients for discharge from the hospital. Physical and P-value at each step until all factors remaining achieved sta- Occupational Therapists determined daily physical rehabilita- tistical significance. Odds ratio (OR), 95% Wald confidence tion treatment plans according to patients’ medical status and limits, and P-values were reported. Statistical significance was therapeutic needs. The daily maximum PAL (MaxPAL), a nu- accepted at P < .05. merical score developed by our group to aid in communication of PALs for each patient, were ranked as follows: (0) no activity, (1) performing range of motion, (2) sitting in the total lift chair RESULTS (TLC), (3) tilt-table positioning, (4) sitting at the edge of the bed (EOB), (5) squatting on a graded exercise platform, (6) During the evaluation period, 53 patients met the inclusion standing, and (7) ambulating. If a higher PAL was achieved, criteria for this analysis. However, six patients were excluded Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 938 Shields et al November/December 2019 due to limb amputations and two patients were admitted adjusted for burn size, height, and highest MaxPAL achieved over a week after injury. The remaining 45 patients were 42 ± during the first eight full ICU days with logistic regression, 15  years old, had 37  ± 17% TBSA burns, and experienced achieving at least 50% of kcal goal on average over the first eight 22% mortality. Patient characteristics are reported in Table 1. full ICU days and at least 80% of kcal goal on average over the These patients were in the ICU for 21 days (IQR: 14–35) and fifth through the eighth full ICU days were individually associ- in the hospital for 32 days (IQR: 21–46). Patients who died ated with lower mortality (P = .005 and P = .046, respectively). were older (53 ± 20 vs 39 ± 13 years, P = .025) with larger In order to better describe the timing of individual MaxPALs TBSA burns (53  ± 25% vs 32  ± 10%, P  =  .013) and higher associated with lower mortality rates, mortality and daily in- SOFA scores over the first eight full ICU days (8 ± 3 vs 5 ± 3, dividual MaxPALs achieved during the first eight full ICU P = .018) (Figure 1). days were evaluated with a univariate analysis (Figure 3). The Table 2 shows patient interventions during the first 8 days daily individual MaxPALs with P < .10 were then adjusted for in the ICU. On average, survivors received 84 ± 15% of kcal burn size, height, and kcal balance from the fifth through the goal and nonsurvivors received 74 ± 20% of kcal goal during eighth full ICU days using logistic regression. The following this time (P = .081); the kcal balance over the first 8 days in timing of MaxPALs were individually associated with lower the ICU did not reach statistical significance (nonsurvivors: mortality when adjusted for other significant factors: MaxPAL −6861 kcal [IQR: −4457 to −12,285] vs survivors: −4703 kcal score of ≥2 (positioning in the TLC) by the first (P = .011) or [IQR: −1938 to −6776], P = .081). Based on Figure 2, the second (P = .003) full ICU days, MaxPAL score of ≥4 (sitting ICU days were separated to better describe the kcal balance, as EOB) by the fourth through the sixth (P = .019) or the sev- both groups had a worsening kcal balance over the first 4 ICU enth (P = .017) or eighth full ICU days (P = .007), MaxPAL days, but on day 5, survivors’ kcal balance began to improve. score of ≥5 (squatting on the graded exercise platform) by There was no difference in the kcal balance during first 4 full the seventh (P  =  .030) or eighth (P  =  .012) full ICU days, ICU days (nonsurvivors: −6860 [IQR: −4760 to −8036] vs MaxPAL score of ≥6 (standing) by the seventh (P = .030) or survivors: −6296 [IQR: −4188 to −8059], P  =  .702). The eighth (P  =  .012) full ICU days, and MaxPAL score of ≥7 kcal balance during the fifth through the eighth full ICU days (ambulating) by the eighth full ICU day (P = .038). achieved a P-value less than .10, allowing for use in logistic Repeated-measures ANOVA revealed no interaction regression (nonsurvivors: +261 [IQR: −4780 to +1335] vs (P = .124) between SOFA scores of survivors vs nonsurvivors survivors: +1880 [IQR: +300 to +2913], P = .063). during the first eight full days in the ICU (Figure 1). When Multiple logistic regression analysis was conducted for mor- linear regression was performed on the variables collected tality using age, burn size, height, weight, time (hours) from each day during the first eight full days in the ICU to eval- admission to initiation of EN, average SOFA score during the uate the relationship between SOI and MaxPAL and then first eight full ICU days, highest MaxPAL achieved during SOI and %kcal goal, both daily MaxPALs and daily %kcal goal the first eight full ICU days, and kcal balance during the fifth achieved matched with daily SOFA scores had significant but through the eighth full ICU days. The four factors independ- weak associations, with R values of 0.25 and 0.05, respec- ently associated with mortality in the final model (Table 3) tively (both P < .001). were burn size (OR = 1.088, P = .018), height (OR = 0.601, P = .006), highest MaxPAL achieved during the first eight full DISCUSSION ICU days (OR = 0.425, P = .016), and kcal balance during the fifth through the eighth full ICU days (OR = 0.691, P = .012). We found a significant relationship between both nutritional In order to better describe the timing and amount of nutrition intake and physical activity, and mortality, in critically ill associated with lower mortality rates, patients were separated burn patients during the first 8  days after admission. These into groups by the %kcal goal achieved (see Tables 4 and 5). relationships can now provide guidance for our clinical prac- Achieving at least 50% of kcal goal on average over the first eight tice, including the following quantifiable goals: full ICU days and at least 80% of kcal goal on average during the fifth through the eighth full ICU days were associated with 1. Achieve ≥50% of kcal goal* on average over the first lower mortality (P  =  .007 and P  =  .031, respectively). When eight full ICU days Table 1.  Patient characteristics Nonsurvivors Characteristic All (n = 45) Survivors (n = 35) (n = 10) P Women 9 (20%) 7 (20%) 2 (20%) >.999 Age (yr) 42 (32–52) 36 (31–47) 56 (37–68) .025* TBSA burns (%) 32 (26–42) 30 (24–37) 45 (28–79) .013* Inhalation injury 11 (24%) 7 (20%) 4 (40%) .228 Height (inches) 69 (67–72) 70 (68–72) 67 (65–70) .044* Weight (kg) 85 (72–103) 92 (73–105) 74 (67–100) .096 BMI (kg/m ) 28 (24–31) 28 (24–32) 26 (23–31) .530 BMI, body mass index; TBSA, total body surface area. *P = significant. The bold indicates the value with significant differences. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 939 Survivors Non-Survivors 12 34 56 78 Day Figure 1. Sequential organ failure assessment (SOFA) scores over time. Table 2.  Patient interventions over the first eight full ICU days Treatment All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P Hours to EN initiation 21 (14–32) 20 (13–27) 34 (19–43) .049* Parenteral nutrition 10 (22%) 6 (17%) 3 (30%) .423 %Kcal goal achieved 83 (74–94) 86 (77–94) 77 (64–83) .081 MaxPAL 3 (3–7) 3 (3–7) 3 (3-3) .026* EN, enteral nutrition; ICU, intensive care unit; MaxPAL, maximum physical activity level. *P < .05. The bold indicates the value with significant differences. 2. Achieve ≥80% of kcal goal* on average over the fifth gastrointestinal dysfunction, which impede these efforts but through the eighth full ICU days which are not adequately measured by SOFA. 3. Achieve positioning in the TLC by the first full ICU day Our results agree with previous studies that have associ- 4. Achieve sitting EOB by the fourth full ICU day ated suboptimal feeding with detrimental clinical outcomes. 5. Achieve squatting on the graded exercise platform by Villet et al found that the energy deficit accumulated during the seventh full ICU day the first 7  days was associated with increased infectious 6. Achieve standing by the seventh full ICU day complications in surgical ICU patients. Similarly, Dvir 7. Achieve ambulation by the eighth full ICU day et  al found that negative energy balance during the ICU stay was associated with increased incidence of acute respi- *Kcal goal as calculated by the Milner equation with activity ratory distress syndrome, sepsis, renal failure, pressure ulcer factor of 1.4 (decreased to 1 during chemical paralysis). development, and total complication rates. Although we It should be noted that these levels of nutrition and phys- did not evaluate the development of these complications ical activity found to be significantly associated with mor- as outcomes in our analysis, we did evaluate mortality and tality were from a small sample size. Larger sample sizes found a negative kcal balance during the first eight full ICU may result in statistical significance in mortality for earlier days to be significantly associated with a higher mortality achievement of specific MaxPALs and higher achievement of rate (P < .001), even when adjusted for burn size, height, kcal goals. Therefore, these goals would be considered the and MaxPALs. minimum goals. Lorente et al observed that mortality was associated with Further study is required to prospectively validate these higher SOFA scores during the first 4  days postburn. In goals and establish causality; however, the weak relationship the present evaluation, there was no interaction over time between SOFA scores, PALs, and nutrition goals is very sug- for SOFA scores during the first eight full ICU days be- gestive that SOI is not the primary barrier in achieving higher tween sur vivors and nonsur vivors (Figure 1, P = .124). Due PALs and nutrition goals. However, we do not discount the to the potential relationship of SOI on achieving kcal and possibility that failure to achieve activity and nutrition goals PAL goals, we investigated the relationship between SOFA also points to underlying problems, such as cognitive or scores, %kcal goal achieved, and MaxPALs. Using linear Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 940 Shields et al November/December 2019 -2000 Survivors Non-Survivors -3000 -4000 -5000 -6000 -7000 -8000 -9000 -10000 -11000 12 3456 78 Day Figure 2. Cumulative calorie balance over time. Table 3. Odds ratio estimations for mortality Effect Odds Ratio 95% Wald Confidence Limits P TBSA burns (%) 1.088 (0.998, 1.186) .018* Height (inches) 0.601 (0.379, 0.955) .006* Highest MaxPAL achieved by day 8 0.425 (0.174, 1.040) .016* Kcal balance during the fifth through the 0.691 (0.495, 0.965) .012* eighth full ICU days (per 1000 kcal) ICU, intensive care unit; kcal, calories; MaxPAL, maximum physical activity level; TBSA, total body surface area. *P < .05. Table 4.  Patients grouped by survival and percent calorie goal achieved during the fifth through the eighth full ICU days % Calorie Goal All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P ≥100% achieved 35 (78%) 29 (83%) 6 (60%) .125 ≥90% achieved 39 (87%) 32 (91%) 7 (70%) .104 ≥80% achieved 40 (89%) 33 (94%) 7 (70%) .031* ICU, intensive care unit. *P < .05. The bold indicates the value with significant differences. Table 5.  Patients grouped by survival and percent calorie goal achieved during the first eight full ICU days % Calorie Goal All (n = 45) Survivors (n = 35) Nonsurvivors (n = 10) P ≥100% achieved 5 (11%) 4 (11%) 1 (10%) .899 ≥90% achieved 15 (33%) 13 (37%) 2 (20%) .311 ≥80% achieved 27 (60%) 23 (66%) 4 (40%) .143 ≥70% achieved 37 (82%) 29 (83%) 8 (80%) .835 ≥60% achieved 40 (89%) 32 (91%) 8 (80%) .311 ≥50% achieved 43 (96%) 35 (100%) 8 (80%) .007* ICU, intensive care unit. *P = significant. The bold indicates the value with significant differences. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research Volume 40, Number 6 Shields et al 941 Figure 3. Maximum physical activity levels achieved by each full intensive care unit (ICU) day. Highlighted days show timing for activity levels found to be independent factors associated with mortality after adjustments for all other significant factors (burn size, height, and calorie balance from the fifth through the eighth full ICU days). regression, we found significant but weak correlations be- does not allow for determining causation; however, there tween daily SOFA scores and %kcal goal achieved (P < .001, does appear to be a weak relationship between SOFA R  = 0.05) as well as daily SOFA scores and MaxPALs (P < scores, the amount of nutrition delivered, and achieving .001, R   =  0.25). The retrospective nature of our project higher PALs. Downloaded from https://academic.oup.com/jbcr/article/40/6/936/5531681 by DeepDyve user on 19 July 2022 Journal of Burn Care & Research 942 Shields et al November/December 2019 The primary limitation of this project is that we were REFERENCES unable to assess all daily ICU practices and reasons for 1. 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Journal

Journal of Burn Care & Research – Oxford University Press

Published: Oct 16, 2019

Keywords: physical activity; calories; burns; critical illness; intensive care unit; mortality; science of nutrition; severity of illness; sequential organ failure assessment scores; periarterial lymphatic sheath; pediatric advanced life support; papillon-lefevre disease; survivors; physical rehabilitation; linear regression

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