Aba Quemaduras

ABA GUIDELINES
Clinical Practice Guideline: Early Mobilization and

Rehabilitation of Critically Ill Burn Patients
Robert Cartotto, MD, FRCS(C),* Laura Johnson, MD, FACS, FCCM,† Jody M. Rood, RN, BSN,‡
David Lorello, BT-C, DPT,|| Annette Matherly, MS, RN, CCRN,$ Ingrid Parry, MS, PT, BT-C,¶
Kathleen Romanowski, MD, FACS,** Shelley Wiechman, PhD, ABPP,†† Amanda Bettencourt, RN,
PhD, CCRN-K, ACCNS-P, APRN,‡‡ Joshua S. Carson, MD, FACS,|||| Henry T. Lam, MLS,$$ and
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Bernadette Nedelec, PhD, BSc, BT-C,¶¶ for the Clinical Practice Guideline ad hoc Committee of the
American Burn Association
This Clinical Practice Guideline addresses early mobilization and rehabilitation (EMR) of critically ill adult burn
patients in an intensive care unit (ICU) setting. We defined EMR as any systematic or protocolized intervention
that could include muscle activation, active exercises in bed, active resistance exercises, active side-to-side
turning, or mobilization to sitting at the bedside, standing, or walking, including mobilization using assistance
with hoists or tilt tables, which was initiated within at least 14 days of injury, while the patient was still in an
ICU setting. After developing relevant PICO (Population, Intervention, Comparator, Outcomes) questions,
a comprehensive literature search was conducted with the help of a professional medical librarian. Available
literature was reviewed and systematically evaluated. Recommendations were formulated through the consensus
of a multidisciplinary committee, which included burn nurses, physicians, and rehabilitation therapists, based on
the available scientific evidence. No recommendation could be formed on the use of EMR to reduce the duration
of mechanical ventilation in the burn ICU, but we conditionally recommend the use of EMR to reduce ICU-
acquired weakness in critically ill burn patients. No recommendation could be made regarding EMR’s effects on the
development of hospital-acquired pressure injuries or disruption or damage to the skin grafts and skin substitutes.
We conditionally recommend the use of EMR to reduce delirium in critically ill burn patients in the ICU.
American Burn Association Clinical Practice literature, on the use of early rehabilitation and mobilization
Guideline Ad hoc Committee interventions in critically ill burn patients. In this CPG, the
In October 2020, the Board of Trustees of the American Burn term “early” refers to the first 14 days postburn injury, while
Association (ABA) created an ad hoc committee to develop the patient is critically ill and in an intensive care unit (ICU)
and maintain current clinical practice guidelines for burn setting. While positioning, passive stretching, and splinting
care. The committee members were selected from the ABA’s are fundamental standards of early burn rehabilitation care,
membership and include providers from many burn care sub- these were not the interventions of interest in this CPG.
specialties. This committee includes all the listed authors for Rather, we were interested in the use of any systematic or
this clinical practice guideline. protocolized interventions that could include muscle activa-
tion, active exercises in bed, active resistance exercises, active
side-to-side turning, or mobilization to sitting at the bedside,
Purpose
standing, or walking, including mobilization using assistance
The purpose of this Clinical Practice Guideline (CPG) is to with hoists or tilt tables.
make recommendations, based on the available scientific We recognized that while early mobilization and rehabil-
itation (EMR) has been extensively studied in the non-burn
From the *Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, ICU population,1 the literature on this topic involving crit-
University of Toronto, Ontario, Canada; †Burns and Trauma, MedStar
Washington Hospital Center, Georgetown University, Washington, DC, USA;
ically ill burn patients would be limited. We recognized the
‡
Regions Hospital Burn Center, St. Paul, Minneapolis, USA; ||Arizona Burn importance of carefully considering whether EMR practices in
Center, Glendale, Arizona, USA; $University of Utah Health Burn Center, non-burn ICU patients could be translated to the specialized
Salt Lake City, Utah, USA; ¶Shriners Hospital for Children, Northern
California, University of California at Davis, Sacramento, California, burn population which has unique analgesia, sedation, and
USA; **Firefighters Burn Institute Regional Burn Center, University surgical needs during the acute critical illness phase of treat-
of California at Davis, Sacramento, California, USA; ††Regional Burn ment. We also wished to review any specific safety concerns
Center at Harborview, University of Washington, Seattle, Washington, USA;
‡‡
University of Michigan Trauma Burn Center; ||||Loyola Burn Center, related to EMR of critically ill burn patients.
Maywood, Illinois, USA; $$Sunnybrook Health Sciences Centre, Toronto,
Ontario, Canada; ¶¶McGill Un iversity, Montréal, Quebec, Canada
Users
Address correspondence to Robert Cartotto, MD FRCS(C), 2075 Bayview Ave.
Toronto, ON, Canada M4N 3M5. Email: [email protected] This CPG will be of most use to nurses, physicians, and reha-
© American Burn Association 2022. All rights reserved. For permissions, please bilitation therapists who provide care to critically ill patients
e-mail: [email protected]. in the burn-ICU. The teamwork between burn nurses and
https://doi.org/10.1093/jbcr/irac008 rehabilitation therapists is highly important; mobilization
1
Journal of Burn Care & Research
2 Cartotto et al January/February 2023
interventions must be fit into the busy hour-to-hour ICU care included RCTs1, 10, 12 and had low overall confidence in the
plan, and nurses frequently are asked to assist the therapists literature.10
with mobilization. Mobilization should also be one of the Nonetheless, many professional societies and organizations
items on the checklist during daily burn team rounds in the have published clinical practice guidelines that recommend
burn ICU. As such, this CPG will be of interest to members of early mobilization of ICU patients.15–19 Finally, while early
the burn team who participate in these daily rounds. mobilization of patients in the ICU is generally considered to
be safe and feasible,20 one systematic review had low certainty
Clinical Problem and Scientific Background in the scientific evidence on the risk of adverse events.10
We would anticipate that the problem of prolonged bedrest
Critically ill patients in the ICU are subjected to prolonged
and immobilization leading to ICUAW, prolonged ventilatory
bedrest and immobilization. This results from the severe na-
support, and PICS would be especially problematic among
ture of critical illness itself, sedation and analgesia medications,
burn patients in the ICU. Many factors act together to cause
and the use of invasive monitors and devices. Consequently,
progressive weakness and deconditioning in critically ill burn
the cardiovascular system becomes deconditioned, skeletal
patients: The hypermetabolic response after a major burn

muscles atrophy, and the respiratory muscles and diaphragm
features catabolic erosion of the skeletal muscles and wasting
progressively weaken during controlled mechanical ventila-
of the lean body mass which may persist for years after the in-
tion (MV). Additionally, the bedridden critically ill patient
jury.21, 22 Bedrest is frequently prolonged because of lengthy
experiences anxiety, isolation, and an inability to communi-
critical illness, extensive wounds, pain, and multiple surgeries.
cate. As a result, ICU survivors may face a variety of both
Pain, stiffness, bulky dressings, postoperative restrictions on
short- and long-term morbidity from bedrest and immobi-
movement after skin grafting, and the often large amounts
lization. The duration of MV may be lengthened. Delirium
of analgesics and anxiolytics that are required can all inter-
may develop while the patient is still in the ICU. Profound
fere with the patient’s ability to mobilize and actively exercise.
generalized muscle weakness (termed ICU-acquired weakness
Critically ill burn patients are also subject to short- and long-
[ICUAW])2 can develop rapidly and may persist well after
term pulmonary dysfunction from smoke inhalation injury,
hospital discharge. Even as late as 5 years after ICU discharge,
pulmonary inflammation, and repetitive lung infections.23,
many survivors have not regained normal physical function 24
Prolonged cardiac stress characterized by tachycardia and
and suffer from ongoing physical problems, psychological
increased myocardial oxygen consumption, lasting for years
complaints, and the overall diminished physical and mental
after the burn injury, is another problem encountered among
quality of life.3 In fact, post-intensive care syndrome (PICS)
severely burned patients.25 Finally, numerous staged opera-
has been recognized as a distinct constellation of poor phys-
tions to excise and skin graft burn wounds under general anes-
ical, functional, and cognitive outcomes lasting years after the
thesia raise the risks of postoperative cognitive dysfunction and
patient left the ICU.4, 5
delirium.26 Therefore, the critically ill burn patient is exposed
Among non-burn ICU patients, there has been concen-
to multiple insults which could potentially increase the risk of
trated interest in the use of systematic early mobilization to
progressive weakness, deconditioning, and cognitive decline
prevent or lessen the adverse effects of prolonged bedrest
that will ultimately lead to not only acute problems, such as
and immobilization. It is thought that active mobilization
ICUAW and prolonged MV, but also post-discharge func-
interrupts the pathophysiology of ICUAW, for example, which
tional limitations and diminished health-related quality of life.
is thought to involve muscle injury from systemic inflamma-
So far, these problems have not been well studied in burn
tion, and muscle atrophy and deconditioning from disuse.6, 7
survivors.
Exercise and muscle activation maintain muscle strength and
Later exercise rehabilitation programs that focus on skel-
appear to help reduce inflammation.8
etal muscle strengthening, and cardiovascular reconditioning,
Several systematic reviews and meta-analyses of randomized
initiated at hospital discharge, have shown benefits among se-
controlled trials (RCTs) of systematic early mobilization
verely burned patients, including improved lean body mass,
in ICU patients have been conducted.1, 9–14 While some of
strength, fitness, and endurance.27–29 However, relatively
these systematic reviews concluded that early mobilization
little is known about the effects of instituting active exercise
lessened ICU-acquired muscle weakness or improved some
training early after burn injury while the patient is still in the
measures of physical function,9, 11, 12, 14 shortened the dura-
burn ICU. Many high-volume burn centers institute early
tion of MV,14 and improved health-related quality of life fol-
mobilization along with resistive and aerobic exercise training
lowing hospital discharge,14 others were either inconclusive
for patients in the burn ICU, but the approaches are hetero-
or found no consistent effect of early mobilization on these
geneous and no standardized guidelines exist.30
outcomes,1, 10, 12, 13 including the development of delirium or
other mental health sequelae.11 There are several reasons for
these varying findings. First, the timing of the mobilization METHODS
intervention appears to be important1 and differs between
studies. Second, the early mobilization intervention (eg, For the development of this guideline, the CPG Committee
method, dose, and intensity), the comparator (eg, no mobili- met virtually on several occasions and communicated elec-
zation, “standard” mobilization, and non-protocolized reha- tronically. Through discussion and consensus, the committee
bilitation), and the timing of the outcome measurement vary identified clinically important questions and definitions
considerably between studies. Finally, the study populations pertaining to the topic of “early rehabilitation and mobiliza-
are heterogeneous. Furthermore, some systematic reviews and tion in critically ill burn patients”. The questions were designed
meta-analyses identified a high risk of bias among many of the using a PICO approach (Patient: the patient population to
Volume 44, Number 1 Cartotto et al 3
whom the recommendations apply, Intervention: the thera- in an ICU setting, 2) There had to be a defined EMR in-
peutic or diagnostic intervention of interest, Comparator: The tervention, 3) There had to be a comparator (eg, no early
alternative approach to the intervention (used in the control rehabilitation/mobilization, “standard” or “traditional” reha-
group), Outcome: The outcome(s) of interest for the clinical bilitation/mobilization, or late rehabilitation/mobilization),
problem). The authors developed the following four clinically and 4) At least one of the predefined PICO outcomes had to
important questions surrounding the topic of EMR in the have been measured and reported. Following an independent
burn ICU: review, the three reviewers (R.C., L.J., and J.R.) met virtually
and reached a consensus on June 10, 2020, on which articles
1. Among critically ill burn patients in an intensive care set-
to finally include.
ting, does EMR, compared with nonstandardized or late
Three articles31–33 met these criteria and have been included
mobilization and rehabilitation, (a) shorten the duration
in this clinical practice guideline (Table 1). Two articles34, 35
of MV and (b) reduce the development of ICUAW?
were dropped because although a clear early rehabilitation in-
tervention, comparator, and outcome were described, their
study populations contained burn and trauma patients with

mobilization and rehabilitation, result in fewer pressure
less than 9%34 and less than 7.5%35 of the study populations
injuries?
being burn patients, with no subgroup analyses of the burn
3. Among critically ill burn patients in an intensive care
patients alone. The remaining 10 articles were dropped as
setting, does EMR, compared with nonstandardized or
they did not meet the criteria to address any of our PICO
late mobilization and rehabilitation, result in loss of skin
questions.
grafts or skin substitutes?
The three included articles31–33 were systematically and in-
dependently evaluated by three committee members (R.C.,
D.L., and B.N.) using the critical appraisal form described
mobilization and rehabilitation, reduce the prevalence
by Law et al.36 These members then met virtually on July 5,
of delirium?
2021, to compare each other’s results and scores. Differences
in the total score were resolved by consensus. The consensus
Search Strategy scores for the quality of evidence in each of these studies are
A comprehensive literature search based on these four PICO presented in Table 2. Subcommittees were then formed to
questions was conducted by a professional medical librarian address each PICO question and write a review using the
(H.T.L.). The three main concepts and the Boolean Logic selected articles, and where there was insufficient burn litera-
involved in the search included: (Burn/Burn Patients) AND ture, RCTs and/or systematic reviews and meta-analyses from
(critically ill/ICU/mechanical ventilation) AND (early mo- the non-burn ICU literature were reviewed. The committee
bilization or early rehabilitation or early occupational therapy met virtually on December 8, 2021, to form recommendations
or early physical therapy). All outcomes identified in the four by consensus, based on the available scientific evidence.
clinically relevant PICO questions were considered. The
Question 1: Among critically ill burn patients in
search involved the following databases: Ovid MEDLINE,
an intensive care setting, does EMR, compared with
Embase, the Cumulative Index of Nursing and Allied Health
nonstandardized or late mobilization and rehabilitation,
Literature (CINAHL), and the Cochrane Central Register
(a) shorten the duration of MV and (b) reduce the devel-
of Controlled Trials (Central). For MEDLINE, we used the
opment of ICUAW?
complete file that included published articles, Epub Ahead
of Print, In-Process, In-Data-Review & Other Non-Indexed For this question, we defined EMR as any physical or oc-
Citations. We restricted results to English only and searched cupational therapy that involves muscle activation or mo-
from the inception of the database to April 29, 2021. bilization from recumbent or semi-recumbent position to
The search yielded a total of 286 articles and three clin- sitting, standing, or walking within 7 days of burn injury
ical trials registered on ClinicalTrials.gov that are currently in even if receiving MV. This would be performed according
process (Figure 1). Rayyan™ reference management software to a clearly defined protocol or criteria. “Early mobilization
(Rayyan Systems Inc., Cambridge, MA, USA) was used to up- and rehabilitation” for this question does not include passive
load and organize the articles. Following the removal of 56 mobilization and stretching to prevent joint contractures.
duplicate articles, two committee members (R.C. and B.N) The comparator for this question could include no mobili-
independently evaluated the titles and abstracts of the re- zation, any undefined or nonstandardized mobilization pro-
maining 230 citations to identify articles suitable for full-text gram or “standard” mobilization, or mobilizing after 7 days.
review. Further duplicates, articles published only as abstracts, We identified two main outcomes for this intervention: 1)
surveys, case reports, and unrelated articles were excluded. The duration of invasive MV in days and 2) Development of
Consensus between the two reviewers (R.C. and B.N.) was ICUAW documented through objective evaluation, including
reached on May 14, 2021, to include 15 articles for an initial but not limited to measures such as the Medical Research
full-text review. Council Sum Score (MRC-SS), Physical Function in the ICU
Articles selected for initial full-text review were then inde- Test (PFIT, Barthel Index [BI], Timed up-and-go, 6-minute
pendently screened for inclusion by three committee members walk test, SF36-physical function(SF-36PF), or time to walk
(R.C., J.R., and L.J.) to determine if they addressed any of independently. We selected 7 days as opposed to 14 days
the PICO questions, based on the following mandatory set of as the cutoff to initiate EMR because we believe that com-
inclusion criteria: 1) The study had to involve burn patients mencement of EMR after 7 days, while still relatively “early,”

Figure 1. Flow diagram describing search and extraction process for included articles.
would not be early enough to affect the selected outcome Deng et al31 retrospectively assessed the effects of enhanced
measures. early mobilization among adult patients with burns ≥50%
We identified only three low to very low quality37 interven- TBSA admitted to a burn ICU within 7 days of injury and
tional studies that evaluated the effects of EMR in critically ill who survived. The “mobilization training” regimen included
burn patients31–33 on our outcomes of interest for this ques- a staged program starting with active range of motion (ROM)
tion (Tables 1 and 2). The study by Baytieh and Li32 retrospec- progressing to transfer to sitting training, then tilt table training,
tively compared burn-ICU patients mobilized early, before the then standing, and ultimately assisted in progressing to in-
start of any surgical interventions to patients mobilized later, dependent ambulation. This was compared with a historical
and after the start of surgery. The group mobilized early had “passive training” cohort who only received anti-contracture
a significantly shorter time from the burn to the day of unas- positioning and passive ROM exercises. The enhanced mobility
sisted walking (“independent mobilization”) compared with the training did not result in any difference in the days of MV, or
patients mobilized later (19.5 vs 42.1 days). While this differ- the Functional Independence Measure (FIM) and BI measured
ence in outcome suggests a positive benefit to early mobiliza- within one week of burn ICU discharge compared with passive
tion and possibly less ICUAW, there were several limitations that training. However, patients in the mobility training group spent
lower our confidence in this finding. Patients mobilized earlier significantly fewer days confined to strict bed rest, fewer days in
had significantly smaller total burn size than those mobilized the burn ICU, and fewer days in hospital compared with the
later. The extent of lower extremity burns was not described patients who received only passive training. While there was a
which is important since that center’s approach was to not mo- statistically insignificant trend toward a shorter duration of MV
bilize until 5 days post grafting of legs. Similarly, the number of in the mobility training group, we do not know if ventilator
patients on ventilators in each group was not disclosed. These weaning protocols were equally applied to either group or the
variables may have affected the time to walk. Details of the in- number of patients with tracheostomies in each group; both
tervention (“assisted walking”) were missing and included no variables could affect the duration of MV. While the shorter
description of the administering personnel, or the duration, dis- duration of ICU and hospital length of stay (LOS) suggest less
tance, or frequency of walking. Finally, in the early mobilization impairment of overall function, these are at best surrogate meas-
group, the length of ICU stay was only 4.1 days. Thus, patients ures of the overall functional capability, strength, and cognitive
may have been able to walk sooner simply by virtue of being out function. Furthermore, while the groups appeared reasonably
of the ICU and not encumbered by monitors, invasive devices, well-matched at baseline, the number of deaths, number of
or affected by the greater anxiolysis and analgesia that is pro- patients requiring MV, and measures of organ dysfunction at
vided to patients in an ICU compared with a ward. The out- admission were not disclosed for each group, possibly masking
come of independent mobilization was not quantified beyond differences in illness severity which might have affected ICU
the day it started. There was no description of the “dose” (dis- and hospital LOS. Also, the measurement of the FIM and BI
tance, speed or duration, or frequency per day). This study also just prior to ICU discharge may not reflect later functional
looked at a variety of nutritional factors. One interesting finding status post hospital discharge, and the FIM and BI were not
was that there was a significant correlation between diarrhea and measured in all subjects. Thus, we cannot confidently make any
the time to independently ambulate, suggesting that diarrhea is conclusions as to the effects (if any) of early mobilization on the
potentially a barrier to mobilizing burn-ICU patients, especially duration of mechanical rehabilitation or ICUAW and later the
those where a fecal diversion device is in use to manage diarrhea. overall physical functioning, from this study.
Table 1. Descriptions of included studies
PICO-Relevant Outcome
Authors Design Total Size Sample Measure Intervention Results
Baytieh et Case–con- 35 Adults • Days to independent •Early mobilization (inter- • Days from burn to independent
al32 trol • Early mobiliza- mobilization (“walking vention) was assisted walking mobilization were less in the early
tion (N = 18, age without assistance”). prior to the start of burn sur- mobilization group (19.5 +/− 18.4)
Volume 44, Number 1
42.8 +/− 19 yrs., • Other outcomes: diarrhea gery (mobilized at 2.3 +/− 1 than in the late mobilization group
% TBSA burn episodes, ICU LOS, an- days postburn). (42.1 +/− 36, P = .033).
24.8 +/− 11.5). tibiotic administration, •Late mobilization (compar- • The ICU length of stay was shorter
• Late mobilization time to enteral feeding, ator) was assisted walking in the early mobilization group than
(N = 17, age 40.2 first surgery, serum al- after the start of burn surgery in the late mobilization group (4.1
+/− 14.7 yrs, % bumin, white cell count. (mobilized at 13 +/− 8.3 days +/− 3.9 days vs 10.8 +/− 7.3 days;
TBSA burn 39.5 postburn). P = .002).
+/− 20.8. [P = • Significant correlations were
.028 vs early]). identified between longer time to
independent mobilization and diar-
rhea and between shorter time to in-
dependent mobilization and higher
serum albumin.
Deng et al31 Case–con- 73 Adults • Barthel Index (BI) •Mobility training (interven- • Ventilator-dependent days were 2.7
trol • Mobility training • Functional independence tion) included daily active +/− 6.7 for mobility training and
cohort (early mo- measure (FIM) (both ROM, progressive HOB 5.5 +/− 7.6 for passive training (dif-
bilization group) assessed by blinded rehab elevation, transfer to sit- ference ns).
N = 24, age 38.9 therapist 7 days prior to ting training b.i.d., tilt table • Total BI was 51.3 +/− 31.5 (N =
+/− 9.4 yrs., % BICU discharge). training b.i.d., standing to 19) for mobility training vs 55.9 +/−
TBSA burn 65.3 • Ventilator-dependent progressive ambulation. 28.8 (N = 17) for passive training
+/− 10.1, 58% days. •Passive training (com- (difference ns)
with INHI. • Other outcomes: PROM, parator) included anti- • Total FIM was 81.3 +/− 29.5 (N =
• Passive training LOS (BICU, hospital), contracture positioning and 19) for mobility training vs 83 +/−
cohort (control) days of strict bed rest, b.i.d. passive ROM. 24.8 (N = 14) for passive training
N = 49, age 40.8 days of rehab. (difference ns).
+/− 10.8 yrs, % • Cognitive FIM was 30.5 +/− 3.9 (N
TBSA burn 70.9 = 19) for mobility training vs 33.5
+/− 12.4, 47% +/− 3.7 (N = 14) for passive training
with INHI. (P < .001).
• The mobility training group also ex-
perienced significantly shorter BICU
LOS and hospital LOS.
Cartotto et al 5

6 Cartotto et al
Table 1. Continued
PICO-Relevant Outcome
Authors Design Total Size Sample Measure Intervention Results
33
Gille et al Case–con- 80 Adults • Continued ventilation •
Protocol for early sponta- •
Median continued ventilation hours
trol • Protocol group hours after admission. neous breathing included after admission was 4.8 (4–22.5)
(group A) N = • Total ventilator days. 1) extubation < 6 h post hr in the protocol group vs 378
38, median age • Other outcomes: admission when possible, (8.5–681.5) hr in the controls (P =
58.5 (45–67.8), perioperative ventilation, 2) avoiding “routine in- .0003).
median % TBSA pneumonia, sepsis, fluid tubation,” 3) early post- •
Median total ventilator days was 3
burn 31 (18.9– input volume first 24 hr, operative extubation, (1–5.8) days in the protocol group
46), 18.4% with urine output first 24 hr, 4) “intensive” chest vs 18.5 (0.5–30.5) in the controls (P
INHI. fluid balance over 1–3 physiotherapy including = .001).
• Historical control days, fluid balance 1–7 expectorants, and 5)
group (group B) days, SOFA score. early active mobilization
N = 42, median (mobilized to chair or
age 56 (46.3– walking if possible).
70.8), median % •
Historical control (com-
TBSA burn 30 parator) protocol not
(25–44.8), 35.7% described.
with INHI.
BICU, Burn ICU; b.i.d, twice a day; HOB, head of bed;ICU, intensive care unit; INHI, Inhalation Injury; LOS, length of stay; PICO, Population, Intervention, Comparator, Outcomes; PROM, passive range of motion;
ROM, range of motion; SOFA, sequential organ failure assessment.
January/February 2023

The study by Gille et al33 was mainly aimed at facilitating
Score
Total
5
13
8
early spontaneous breathing in adults with burns and an ab-
breviated burn severity index ≥7 who were admitted to the
Conclusions
Appropriate
ICU. However, one element of their intervention included
“early active mobilization,” which appears to have been mo-
1
1
1
bilization starting on postburn day 1 to a chair or walking.
The protocol also included early extubation after burn center
Dropouts
admission, avoidance of “routine intubation,” early postop-
Reported
erative extubation, and aggressive chest physiotherapy in-
1
1
1
cluding the use of expectorants. Compared with historical
controls, patients in the protocol group experienced signifi-
Importance
cant reductions in the continued hours of ventilation after ad-

Clinical
mission, and the total ventilator days compared with patients

0
1
1
in the historical control group. In the protocol group, 73% of

patients had been extubated within 24 hours compared with
Appropriate
only 36% in the controls. Thus, early aggressive extubation

Analysis
alone may have accounted for the significant reduction in con-

0
1
1
tinued hours of ventilation and ventilator days observed in

Results
the protocol group rather than any specific effect of “early

mobilization”. Also, the early mobilization protocol was not
tical Sig-
nificance
Statis-
described in detail (frequency, duration, distance of walking,

1
1
1
or use of assistance), and no data were provided to show how

much mobilization was administered. Therefore, it is impos-
Intervention
sible to determine with any confidence the effects of the early

Co-
Intervention
mobilization component of this protocol on the duration of

0
1
0
ventilation.
Two studies have evaluated EMR among mixed trauma and
tamina-
burn populations in an ICU setting. Neither study was for-

Con-
tion
1
1
0
mally included for critical review because burn patients formed

a distinct minority in each study and were not separately
Detailed
Descrip-
evaluated. Clark et al34 conducted a retrospective case–con-

tion
0
1
0
trol study of 2176 patients of which 10% were burns (% TBSA

burn and inhalation injury not reported), and 75% were blunt
trauma. Patients who received a progressive early mobiliza-
Valid
0
0
1
tion protocol did not have a significant reduction in days of

MV compared with a historical cohort of patients prior to the
Reliable
Outcomes
institution of the early mobility protocol (7.8 ± 13.4 days vs

0
1
1
8.9 ± 17.4 days, P = .08). The development of ICUAW was

not evaluated. Coles et al35 reported a case–control study of
Justified
526 adults admitted to a trauma ICU, where 5% of the study

Table 2. Evidentiary table: quality of interventional studies
0
1
1
population was categorized as “burn/drowning/asphyxia”

(with no description or % TBSA burn or inhalation injury).
Details
A protocolized early mobilization program (EMP), compared

0
1
1
Sample
with a historical cohort not receiving this intervention, had

no significant effect on ventilator-free days (OR 0.98, 95%
Size
CI: 0.79 to 1.21), and ICUAW was not specifically measured.

35
73
80
Although both studies utilized detailed and carefully planned

Design
early mobilization interventions, we cannot make conclusions

CC
CC
CC
on any effects of early mobilization on the outcome of the

duration of MV in burn patients, because of the small and
Literature
undescribed burn populations included in these two studies.

Review
1
1
0
Given the lack of high-quality studies involving critically

ill burn patients on the effects of early rehabilitation and mo-
bilization on our outcomes of interest, we reviewed litera-
CC, case controlled study.
Purpose
Study
ture from the general ICU population. With respect to the

0
1
1
outcome of time spent on the ventilator, numerous RCTs in

non-burn ICU patients have assessed the effect of early re-
Baytieh et al32
Deng et al31
habilitation and mobilization on the duration of MV and/

Gille et al33
Authors
or ventilator-free days.38–53 One systematic review and

meta-analysis14 of three of these trials,38, 41, 52 using pooled
data and a fixed-effects model, found a small but significant
effect of early rehabilitation and mobilization on improving duration of MV or ventilator-free days. Heterogeneity in the
(increasing) ventilator-free days. However, it should be noted intervention and control approaches as well as in the study
that the physical therapy interventions differed considerably population are important factors to consider and are likely re-
between these three studies; one used lower extremity elec- sponsible for the disparity in findings for this outcome.
trical muscle stimulation (EMS),52 one added cycling exercises The outcome of ICUAW has also been evaluated in many
with a bedside cycling ergometer,41 and one used a variety RCTs involving non-burn patients in the ICU, using nu-
of early passive and active ROM exercises, with progressive merous outcome measures including the Medical Research
mobilization to ambulation.38 Also, the comparators used in Council Sum Score (MRC-SS),38, 39, 42, 45, 46, 52 proportion
the control groups were heterogeneous; one approach was to developing ICUAW,38, 40, 45, 50 time needed to walk,38, 45,
“not use EMS” but with no other detail provided,52 one used 46
Six-Minute Walk Test (6MWT),40, 41, 46, 55 SF-36 phys-
early “standardized” physiotherapy and mobilization without ical function (SF-36 PF) score,40, 42, 46, 48, 54 BI,38, 56 Physical
cycling exercises,41 and one used “standard care” provided Function in the ICU Test (PFIT),40, 42, 45 Timed Up and Go
later in the hospital stay.38 Another systematic review12 that in- (TUG) test,40, 49 distance walked without assistance,38 and the
cluded many of these studies38–40, 42, 43, 45, 48, 49, 54 was unable to ability to walk independently.38, 41 Several systematic reviews

perform a meta-analysis on the outcome of MV duration be- and meta-analyses of these RCTs have been conducted1, 9–14 to
cause much of the data were significantly skewed. In addition, examine the effects of EMR on many of these outcome meas-
there was considerable heterogeneity between these studies ures. Some meta-analyses did not find any effect of the early
with respect to the comparisons made (eg, systematic early vs mobilization intervention on peripheral muscle strength (eg,
late mobilization, systematic early vs standard early mobiliza- measured by MRC-SS,1, 13 or incidence of ICUAW1) or phys-
tion, or systematic early vs no mobilization). ical function (eg, measured by PFIT)10, 13 but did show the
Individually, the vast majority of RCTs have not intervention improved walking without assistance at hospital
demonstrated that an early physical therapy intervention discharge.13 Conversely, other meta-analyses did find evidence
produced any significant reduction in the duration of MV39, 40, that an early mobilization and physiotherapy intervention led
42, 45, 46, 48, 49, 51, 53, 54
or improvement (increase) in ventilator- to better short-term peripheral muscle strength (eg, meas-
free days.41, 42, 45, 48–50 ured by MRC-SS score,11, 12, 14 or incidence of ICUAW11) and
However, a small number of RCTs have shown an effect of greater physical function (eg, measured by SF-36,1 time to
early rehabilitation and mobilization on time spent on a venti- walking,1 walking without assistance at hospital discharge,12
lator. Schweickert et al38 randomly assigned 104 ICU patients or BI).14
either to receive an early exercise and mobilization rehabilita- There are several reasons for these discrepancies.
tion program or to receive “standard” occupational and phys- Examination of a specific outcome such as the MRC-SS is il-
ical therapy that started on average almost 6 days later than the lustrative: Among six RCTs that measured the MRC-SS,38, 39,
intervention. The median duration of MV in all patients was 42, 45, 46, 52
two studies found that the early physiotherapy inter-
significantly shorter with the intervention (6.1 [IQR 4–9.6] vs vention produced significant improvement in MRC-SS,39, 52
3.4 [2.3–7.3] days; P = .02), but the reduction in ventilator while four studies found no effect of the intervention compared
time became statistically insignificant when only survivors were with control.38, 42, 45, 46 However, one study compared sys-
evaluated. Median ventilator-free days in the first 28 days were tematic early mobilization to late mobilization,38 four studies
improved (increased) from 21.1 (0–23.8) days in the control compared systematic early to standard early mobilization,39, 42,
group to 23.5 (7.4–25.6) days with the intervention (P = .05). 45, 46
and one study compared the early physiotherapy inter-
Two studies from the same medical center in China,43, 44 one vention to no intervention.52 The physiotherapy interventions
involving 60 general ICU patients and the other involving differed markedly between studies. One study used active and
106 post coronary artery bypass grafting (CABG) patients, passive ROM, activities of daily living (ADL), and transfers
compared randomly assigned early physiotherapy and mobiliza- to sitting and walking,38 while another included in-bed leg
tion with routine therapy started later. In both studies, patients cycle ergometry,39 while yet another included upper and
receiving the intervention experienced significant reductions in lower extremity cycle ergometry,42 and one study used only
duration of ventilation compared with the controls (5.6 ± 2.1 EMS.52 The “dose” of the intervention was not clear in all
vs 7.3 ± 2.8 days, respectively; P = .005,44 and 8.1 ± 3.3 vs instances. Similarly, the comparator used in the control group
13.9 ± 4.1 days, respectively; P < .01).43 Finally, Routsi et al52 was not always clearly described and varied between “conven-
randomly assigned 140 ICU patients to either a 55-minute tional” therapy, “standard care,” passive movement only, or
daily EMS to both lower extremities or to a control group that no therapy intervention. Finally, the MRC-SS was measured
did not get EMS. The intervention resulted in a significant re- at ICU discharge in five studies38, 39, 42, 45, 46 but during the
duction in the duration of ventilator weaning as well as an im- ICU stay in one.52 Certainty in the overall quality of the evi-
provement (increase) in ventilator-free days. As with exercises dence for this outcome is considered low to very low,1, 10 due
such as in-bed cycling,41 the targeted stimulation and exercise to lack of blinding of subjects and evaluators, heterogeneity
of skeletal muscle groups not directly involved in breathing of the intervention, and variability in the comparators. Thus,
may have provided systemic benefits that reduce critical illness with respect to this one measure of ICUAW, it is difficult to
polymyoneuropathy (CIPMN).52 reach any reliable conclusion on the effect of EMR. The afore-
In summary, there is uncertainty about the effect of an mentioned problems recur when other outcome measures of
early physiotherapy intervention on the duration of MV in ICUAW and physical function are examined.
non-burn ICU patients. A small number of studies have re- Therefore, at the present time, there is uncertainty about
ported benefits, but most studies have found no effect on the the effect of EMR on the development of ICUAW among
non-burn ICU patients. The timing of the intervention must non-protocolized mobilizing schedule or mobilizing after
be carefully considered; systematic early mobilization appears 7 days post-injury. The outcome of interest was the devel-
to be effective when compared with late mobilization in opment of a hospital-acquired pressure injury (HAPI) of any
improving physical function (measured by SF-36 PF, propor- stage (I–IV) in the first 3 weeks postburn injury. We selected
tion of patients reaching independence, and time needed to 7 days as opposed to 14 days as the cutoff to initiate EMR
walk), but not when compared with “standard” early mobi- because we believe that commencement of EMR after 7 days,
lization.1 The composition and “dose” of the intervention while still relatively “early,” would likely not be early enough
need to be considered as does the nature and timing of the to affect the development of a HAPI.
comparator. The difference in the timing of the intervention Pressure injuries, also referred to as “pressure sores,” “pres-
and comparator may be as important as when the intervention sure ulcers,” or “bedsores” occur when external pressure on
starts after ICU admission.1 the skin, and less frequently shear on the skin, causes ischemic
Recommendation: breakdown of the skin and underlying soft tissues to create a
wound or ulcer. When pressure injuries occur in hospitalized
(a) Duration of MV:
patients, they are referred to as HAPIs. HAPIs are reportable

No recommendation. At the present time, there is insufficient adverse events that increase healthcare costs and in some cases
evidence to make a recommendation to initiate EMR to re- result in financial penalties to hospitals.57 The estimated prev-
duce the duration of MV in critically ill adult burn patients in alence of pressure injuries among patients in the ICU is 16.9
an ICU setting. to 23.8%.58 A point prevalence study among ICU patients in
Rationale and Considerations: There is no available scientific France found a prevalence of pressure injuries of 18.7%, with
evidence in the burn literature, which directly examines the newly acquired HAPIs having a prevalence of 12.5%.58 While
effect of EMR on the duration of MV. There is uncertainty the incidence and prevalence of HAPIs have not been widely
about the effect of EMR on the duration of MV in the non- examined in patients with burns in an intensive care setting,
burn ICU literature. Taken together, we do not have confi- burn patients may be at even higher risk of HAPIs due to
dence in the strength of the scientific literature to recommend several unique risk factors: prolonged bedrest, LOS and MV,
EMR to shorten the duration of MV among critically ill burn significant edema formation during resuscitation, progressive
patients in the ICU. weight loss from hypercatabolism, loss of skin integrity and
excessive moisture contacting the skin, splinting, multiple
(b) ICU-acquired weakness
surgical procedures with postoperative immobilization or-
We conditionally recommend that EMR be initiated to reduce ders, and substantial analgesia and sedation requirements.59,
ICUAW among critically ill adult burn patients in an ICU 60
A retrospective study estimated the incidence of pressure
setting. injuries to be 6.9% among burn patients admitted to the
Rationale and considerations: Low- to very-low-quality ev- ICU.59
idence in a small number of studies in the burn literature The literature on mobilization and HAPI reduction in crit-
suggests a possible beneficial effect of EMR on reducing ically ill burn patients is sparse. None of the studies selected
ICUAW among critically ill burn patients. While there is some for formal review from our search identified pressure injuries
uncertainty in the non-burn ICU literature about the effect of as an outcome. However, the study by Clark et al34 (which we
EMR on the development of ICUAW, we have greater con- did not include because its study population consisted of 90%
fidence that this intervention may help to diminish ICUAW blunt or penetrating trauma cases and only 10% burn cases,
in that population. The earlier intervention appears to be without sub-analysis of the burns) did assess “pressure ulcers”
the most important consideration. There appears to be no before and after institution of an EMP. The incidence of pres-
signal of harm (see Safety and Barriers to Implementation sure ulcers did not change significantly from before the EMP
section), but we recommend that when early mobilization is (7%) to after the EMP (7.3%).34
undertaken that it is done with open dialogue between the In the non-burn ICU literature, a recent systematic review
medical, nursing, and rehabilitation staff to identify any spe- and meta-analysis found no effect of EMPs on the develop-
cific safety concerns or medical/surgical limitations. ment of pressure injuries in critically ill patients (OR 0.97;
95% CI: 0.49 to 1.91).61 Four of the five studies in that meta-
Question 2: Among critically ill burn patients in an inten-
analysis were considered to have moderate to serious risk of
sive care setting, does EMR, compared to nonstandardized
bias, and none were RCTs.61 An earlier meta-analysis of 15
or late mobilization and rehabilitation, result in fewer
RCTs involving “early mobilization and rehabilitation” of
hospital-acquired pressure injuries?
patients in the ICU assessed four trials for the outcome of
For this question, we specified a population of adults > “pressure sore” development. “Early rehabilitation” compared
18 years old with burns in an intensive care setting requiring with “standard physical care” or “daily nursing care” was as-
invasive or noninvasive ventilation. We defined “early mobili- sociated with a decreased risk of pressure sore reduction (RR
zation and rehabilitation” as any specified or protocolized ac- 0.14; 95% CI: 0.04, 0.44; P = .001)62 *.
tive mobilization to sitting at bedside or standing or walking, It is important to distinguish regular turning schedules
which starts within the first 7 days post-injury. “Early mobili- from an EMR program. The former would be considered
zation and rehabilitation” for the purpose of this question does standard care, while the latter is the main intervention of in-
not include routine turning schedules or passive mobilization terest in this CPG. Since it would be unethical to study “no
and stretching to prevent burn-related joint contractures. turning” compared with a protocolized turning regimen, most
The comparison could include an absent, undefined, or of the literature on patient turning and HAPI development in
critically ill patients concentrates on comparisons of different burn patients with skin grafts was reviewed. All of the studies
intervals of patient turning or alternative patient positioning described involved some form of early mobilization, but some
approaches. A Cochran systematic review found that the effect described mixed patient populations, some did not involve
on HAPI development of two-hourly vs three-hourly vs four- patients in the ICU setting, and some did not have a compar-
hourly turning schedules was uncertain, as was the effect of ator group. Still, these studies offer insight and direction for
30° vs 90° tilt positioning, again due to low confidence in the future studies and may be of value in understanding the effects
literature quality.63 In summary, there is uncertainty, mainly of early mobilization on skin grafts and skin substitutes in the
from a distinct lack of scientific studies, on the effect of EMR burn population.
on the development of HAPIs in critically ill burn patients.63 Clark et al34 conducted a retrospective case–control study
*The four studies used to conduct this meta-analysis on the of 2176 patients of which 10% were burns (% TBSA burn
outcome of HAPI development were not specifically identified and inhalation injury not reported), and 75% were blunt
in the text and no Forest plot was shown. Hence, details of the trauma, with no sub-analysis of the burn patients. The authors
individual RCTs cannot be provided and remain uncertain. identified no change in complication rate in the “musculo-
Recommendation: skeletal/integumentary” category with the initiation of a

No recommendation. At the present time, there is insuffi- progressive mobilization protocol (10.7% vs 10.8%; P = .93),
cient evidence to make a recommendation to initiate EMR to though the exact nature of the complications considered as
reduce the development of HAPIs among critically ill adult “integumentary” was not specified. Tan et al64 reviewed their
burn patients in an ICU setting. experience with 108 burn patients who sustained TBSA burns
Rationale and Considerations: We were unable to identify in excess of 50% who received early rehabilitation, looking for
any interventional studies specifically among critically ill burn an association with contracture formation. While the authors
patients on the effect of EMR on HAPI development. Among delineated their graduated rehabilitation plan in detail, no
non-burn ICU patients, we have low confidence in the avail- comparison group was available to assess the stated outcomes.
able literature to recommend EMR to reduce HAPIs. EMR The authors concluded that extended rehabilitation days
must be distinguished from the important process of reg- increased the number of moderate contractures relative to
ular passive turning and position changes of an ICU patient. severe contractures. Although severe contracture could have
The latter was not evaluated as part of this guideline, and been related to graft loss and poor healing, this study did not
institutions should continue to follow their existing guidelines provide enough detail to draw conclusions about the impact
on this intervention. on skin graft adherence from early rehabilitation.. Schmitt
et al65 reported their experience with mobilization in a set of
Question 3. Among critically ill burn patients in an in-
patients with burn injury who received a novel dermal substi-
tensive care setting, does early mobilization and rehabili-
tute. This case series included a range of patients from 2 to
tation (EMR), compared with nonstandardized or late
75% TBSA with an ICU LOS 0 to 68 days and acute hospital
mobilization and rehabilitation, result in loss of skin
LOS of 9 to 258 days. The analysis was not strictly limited to
grafts or skin substitutes?
our patient population of interest, and no comparison group
For this question, EMR is defined as any physical or oc- was available. The authors clearly delineated their graduated
cupational therapy that involves muscle activation or mo- rehabilitation plan in detail and reported that clearance for
bilization from recumbent or semi-recumbent position to mobility occurred at a mean of 10.4 and 4.9 days after dermal
sitting, standing, or walking within 14 days of burn injury. substitute and after skin graft application to lower limbs, re-
This would be performed according to a clearly defined pro- spectively. They found no reported incidents where physical
tocol or criteria. “Early mobilization and rehabilitation” therapy interfered with dermal substitute integration or split-
for this question does not include passive mobilization and thickness skin graft take and reported no adverse events re-
stretching to prevent joint contractures. The comparator for lated to physical therapy; however, no additional data were
this question could include no mobilization, any undefined or provided.
nonstandardized mobilization program, or “standard” mobi- ABA Practice Guidelines written by Nedelec et al in 2012
lization or mobilizing after 14 days. Two main outcomes were discussed early ambulation after lower extremity grafting.66
identified for this intervention: 1) loss or disruption of skin They reviewed literature from 16 studies spanning 1969 to
grafts or skin substitutes requiring reoperation or reapplica- 2009, with early mobilization defined as early as 24-h post-
tion and 2) loss or disruption of skin grafts or skin substitutes grafting, and concluding that there was no signal that graft
not requiring reoperation or reapplication. We selected loss occurred with early mobilization, regardless of whether
14 days as opposed to 7 days as the cutoff to initiate EMR to patients underwent grafting for burn or non-burn reasons.
capture more grafting operations. In a major critically ill burn One of the limitations of this practice guideline was noted to
patient, all grafting (with autologous skin, allograft, or skin be the lack of data for burn wound sizes greater than 300 cm2
substitutes) may not have been completed by day 7. which could include those more likely to be in the intensive
On review of the literature, none of the studies addressing care unit for large surface area cutaneous injury.
these outcomes of interest met all four criteria and, therefore, Lorello et al67 conducted an RCT to evaluate the risk of
did not undergo formal review for inclusion in the practice graft failure in patients with burn injury receiving early mo-
guideline. Given the lack of high-quality studies specifically bility (EAG) and standard therapy (ST) after lower extremity
involving critically ill burn patients and the effects of early skin grafting. Although this study specifically addresses the
rehabilitation and mobilization on the viability of skin grafts impact of early mobilization on skin grafts, it was not in-
and skin substitutes, available literature on the mobilization of cluded in the formal review because the patients were not all
treated in the ICU. Thirty-one adults with small TBSA burns Rationale and Considerations: There does not appear to be
(3.59% in EAG and 4.07% in ST) were randomized to ambu- any evidence that mobilization causes harm to skin grafts and
late within 24 hours of surgery (EAG) or remain on bedrest skin substitutes in burn patients outside of an ICU setting,
postoperatively for 5 days (ST). There was no difference in the but the effect of early mobilization on this outcome in crit-
number of patients with graft loss in either group. In those ically ill burn patients in the ICU has not been specifically
patients who had graft loss, however, the standard group had examined.
a higher percentage of loss of the graft (EAG 1.0%, STG 7.7%;
Question 4. Among critically ill burn patients in an inten-
P = .0376). Although this study looks at small burns in non-
sive care setting, does EMR, compared to nonstandardized
critically ill patients, it offers some support for early mobiliza-
or late mobilization and rehabilitation, reduce the preva-
tion without significant graft failure.
lence of delirium?
Franczyk et al68 retrospectively evaluated adherence of
skin grafts applied in conjunction with sub-atmospheric pres- For this question, we defined EMR as any physical or oc-
sure wound therapy (SAWT) for patients who received gait cupational therapy that involves muscle activation or mo-
training on post-operative day (POD) #2 as part of a standard bilization from recumbent or semi-recumbent position to

protocol. This study was not included in the formal review be- sitting, standing, or walking or within 7 days of burn injury
cause only 26% of the patients had burn injury and there was even if receiving MV. This would be performed according to
no comparator group. The mean surface area grafted for 154 a clearly defined protocol or criteria. The comparator for this
patients reviewed was 172 cm2. The authors reported that question could include no mobilization, any undefined or
none of the patients experienced graft loss or fluid collection nonstandardized mobilization program, or “standard” mobi-
with the removal of SAWT. In addition, none of the patients lization or mobilizing after 7 days. We identified three main
returned to the operating room for additional debridement outcomes for this intervention: 1) the presence or absence of
or grafting because of early mobilization, and most patients delirium as a binary variable, 2) the number of hospital days
were discharged by POD #5 (83%). Other small retrospective with delirium, and 3) the percentage of time experiencing de-
studies of patients with lower extremity grafts have also found lirium. We selected 7 days as opposed to 14 days as the cutoff
no adverse effects from early mobilization.69, 70 to initiate EMR because we believe that commencement of
Finally, Retrouvey et al71 conducted a systematic review and EMR after 7 days, while still relatively “early”, would not be
meta-analysis evaluating the impact of early vs late mobiliza- early enough to affect the selected outcome measures.
tion after split thickness skin graft (STSG) in adult patients No interventional studies were identified that evaluated the
with extremity wounds. Seven studies were included for re- effects of EMR in critically ill burn patients on our outcomes
view, two of the three that defined the patient population in- of interest related to delirium.
cluded burns. Early mobilization occurred within 3 days of Given the lack of studies involving critically ill burn patients
surgery, whereas late mobilization was defined as occurring on the effects of early rehabilitation and mobilization on de-
4 or more days after surgery. No statistically significant dif- lirium, we reviewed literature from the general medicine and
ference was found for the number of grafts lost or the per- medical ICU (MICU) populations.
centage of graft take between early and late mobilization. The Delirium is defined as a serious disturbance in mental
findings of this systematic review and meta-analysis support abilities that results in confused thinking and reduced
the postulation that early mobilization does not detrimen- awareness. Development of delirium may have one or more
tally impact wound healing. However, again, because the contributing factors, such as a severe or chronic illness, elec-
analysis was conducted with more than the burn population trolyte disturbances, medications, infections, operations, and
and it is uncertain if the burn patients were critically ill, fur- alcohol or drug intoxication or withdrawal.72 Multiple studies
ther burn ICU patient population-specific work is needed. have examined risk factors for delirium. A single factor rarely
Intriguingly, the same data analysis identified a trend toward causes delirium to occur, whereas the more risk factors a pa-
less deconditioning with early mobilization, a finding with tient has the higher the likelihood of developing delirium.73–76
significant implications for outcomes after critical illness. Immobility has been identified as a potentially modifiable risk
In summary, there is no clear consensus about the effect of factor for the development of delirium and became a target for
an early physiotherapy intervention on graft outcomes in crit- possible interventions to prevent delirium.38, 77–80
ically ill burn patients. No studies have been completed in the One of the first studies looking at the importance of mo-
ICU setting, though extrapolation of studies and guidelines bility on the development of delirium was completed by
from the general burn and wound populations would sug- Inouye et al.81 A multicomponent intervention was compared
gest that early mobilization is safe for skin grafts and skin with usual treatment in patients admitted to a general med-
substitutes. icine service. The intervention addressed six risk factors for
Recommendation: delirium: cognitive impairment, sleep deprivation, immo-
No recommendation. At the present time, there is insufficient bility, visual impairment, hearing impairment, and dehydra-
evidence to determine whether EMR leads to skin graft or tion. The primary outcome was the development of delirium
skin substitute loss among critically ill adult burn patients in as assessed daily using the Confusion Assessment Method
an ICU setting. We suggest that surgeons and rehabilitation (CAM). The intervention in this study for immobility was
therapists consider whether early mobilization is feasible and ambulation or active ROM exercises three times daily as well
warranted in a critically ill burn patient with recent grafting, as limiting immobilizing equipment such as bladder catheters
taking into consideration surgeon preference along with the and restraints. The intervention group had an incidence of
size and extent of the skin graft or substitute. delirium which was significantly lower than in the usual-care
group (9.9 vs 15.0%, P = .02). The intervention reduced the and the percent of ICU days spent delirious decreased by 17%
likelihood of developing delirium (OR 0.6; 95% CI: 0.39 to (50% [IQR 30–64.3] vs 33.3% [IQR 18.8–50]; P = .003).
0.92), and the total number of days of delirium was signif- Multivariable regression found that the ABCDE was associ-
icantly lower in the intervention group (105 vs 161 days; ated with significantly less delirium (OR 0.55; 95% CI: 0.33
P = .02) as was the total number of episodes of delirium (62 to 0.93; P = .03).
episodes vs 90 in the usual-care group; P = .03). The ABCDE bundle was revised to the ABCDEF bundle in
The effects of mobility on the development of delirium in 2014. The new bundle included: Assess, Prevent, and Manage
the ICU have been studied. Schweickert et al38 sought to ex- Pain; Both SATs and SBTs; Choice of Analgesia and Sedation;
amine the efficacy of combining daily interruption of sedation Delirium: Assess, Prevent, and Manage; Early Mobility and
with physical and occupational therapy on functional outcomes Exercise; and Family Engagement and Empowerment.89
in patients receiving MV to assess both functional outcomes A multicenter, cohort study90 enrolled 15,226 ICU patients
and ICU-associated delirium. Mechanically ventilated patients and looked at the results of the bundle with respect to “com-
were randomly assigned to either an enhanced exercise and plete performance,” which was defined as a patient-day in
mobilization intervention or standard of care. The inter- which every eligible element of the bundle was performed,

vention involved a stepwise therapy program starting with and with respect to “proportional performance,” which was
passive ROM exercises, then progressing to active ROM defined as the percentage of eligible elements a patient re-
exercises while supine then sitting, and finally working toward ceived on a given day. When the complete ABCDEF bundle
independence with ADLs and functional tasks. Patients were was performed, there was a lower likelihood of delirium
assessed daily using the Confusion Assessment Method for the (adjusted odds ratio of 0.60; 95% CI: 0.49 to 0.72; P <
ICU (CAM-ICU) for delirium and coma. Patients in the in- .00010). Additionally, when the proportional performance of
tervention group (N = 49) had fewer days with ICU delirium the bundle was investigated, they found that a higher propor-
(2 vs 4 days; P = .03), and shorter percent of time in ICU tion of eligible ABCDEF bundle elements performed on a
with delirium (33 vs 57%; P =·.02) than the standard of care given day was associated with a significantly decreased likeli-
patients. hood of delirium, (P < .0001).
Needham et al79 conducted a before/after quality im- In summary, while there are no studies that examine the
provement project in MICU patients. Prior to implementing effects of mobility on delirium in the burn ICU literature, in
changes, patients were placed on bed rest without any the critical care population, a small number of studies have
standardized physical or occupational therapy program. The shown the benefit of mobility in the ICU as a stand-alone
changes to their standard of care included increasing activity prevention for delirium. There is some heterogeneity in the
to “as tolerated,” decreasing the use of continuous infusions interventions that are provided in these studies, but they all
of benzodiazepines and opioids, establishing guidelines for increase the amount of activity that patients in the ICU are
physical and occupational providing full-time therapists, and receiving. In addition, there have been several studies that ex-
use of physiatry and neurology consultants when appropriate. amine the ability of mobility in combination with other risk
Post-intervention, there was a significant decrease in the per- factor mitigation protocols that have been shown to decrease
centage of patients who were classified as delirious by the the development of delirium in ICU patients. Thus, there is
CAM-ICU score (28 vs 36%; P = .003). reasonably consistent evidence that early mobility (both alone
The Society of Critical Care Medicine (SCCM) created an and in connection with other strategies) in ICU patients is a
“ABCDE bundle” which incorporates mobility as a prevention safe and effective prevention strategy for delirium.
for delirium.82, 83 The ABCDE bundle refers to: Awakening Recommendation:
and Breathing Coordination, Delirium monitoring/manage- We conditionally recommend that EMR be initiated to reduce
ment, and Early exercise/mobility. The bundle was developed delirium among critically ill adult burn patients in an ICU
to reduce exposure to MV and sedatives while encouraging setting.
mobility with the goal of preventing delirium.84–87 Balas et al88 Rationale and Considerations: Although we were unable to
performed a prospective before–after cohort safety and effec- identify any studies on the effect of EMR on the development
tiveness study utilizing the ABCDE bundle in multiple ICUs of delirium in critically ill burn patients, we have confidence in
at a single institution. They recruited a total of 296 patients the effect of this intervention, as part of an ABCDEF bundle,
(146 pre-implementation and 150 post-implementation) ir- on reducing delirium in the non-burn ICU population.
respective of MV status. The pre-implementation patients re- Again, good communication between the medical, rehabili-
ceived standard of care, whereas post-implementation patients tation, and nursing staff is mandatory to determine whether
underwent protocolized spontaneous awakening trials (SATs), early mobilization is safe and feasible in an individual critically
spontaneous breathing trials (SBTs), daily monitoring of seda- ill burn patient (see Safety and Barriers to Implementation
tion/agitation levels and delirium, and mobilization at least section).
once a day, including sitting on edge of bed, standing at the
bedside, sitting in a chair, and walking a short distance. SAFETY AND BARRIERS TO
Prior to implementation, only 48% of patients were IMPLEMENTATION
mobilized compared with 66% after implementation
(P = .002). Following implementation of the ABCDE bundle, Although we did not formally examine complications or ad-
the percentage of patients who experienced delirium was verse effects related to EMR as an outcome, it is important to
reduced (pre 62.3 vs post 48.7%; P = .02). Overall, the dura- consider the safety of and barriers to implementation of this
tion of delirium decreased by one day post-implementation, intervention. While the concept of EMR in an ICU setting is
not new, survey data suggest wide variation in the application may not want patients with fresh lower extremity skin grafts
of this intervention. Among critically ill burn patients, a survey to be mobilized for at least 3 to 5 days postoperatively.30 Burn
of six high-volume burn centers in the United States reported patients are frequently more heavily sedated due to pain from
substantial variability in the frequency, intensity, and duration extensive wounds, relative to non-burn patients in the ICU.
of various isometric, isotonic, aerobic, and resistive exercises.30 Thus, medical clearance to mobilize a burn patient in the
While mobilization out of bed was used as a type of exercise ICU is of utmost importance and must involve good dialog
in all six burn centers, only four centers reported ambulating between the medical/surgical, rehabilitation, and nursing
intubated patients.30 A 2021 survey of 63 burn rehabilitation staff. Most importantly, the success of implementing an EMR
therapists and nurses from multiple North American burn program in the burn ICU rests upon developing a realistic and
centers found that 54% mobilize ventilated patients out of bed, practical protocol, having adequate resources for education,
and 50% mobilize patients on vasopressor support. The pres- training, and implementation, advocates who support the in-
ence of vascular catheters, mode of ventilation, mental status, tervention, and a unit “milieu” or “culture,” which recognizes
and vital signs were the most important precautionary factors the importance and limitations of the intervention.94
to be reviewed with the medical team prior to mobilizing a

patient.91 Among non-burn ICU patients, a survey of 194
critical care physicians and 117 physiotherapists in Canada92 OPPORTUNITIES FOR FURTHER
revealed that 69% underestimated the incidence of ICUAW RESEARCH
and 60% felt they lacked the skill and knowledge to mobilize This guideline has uncovered a deficiency in studies of the
a patient on a ventilator. Interestingly, the physiotherapists effects of EMR among critically ill burn patients in an ICU
(PTs) were more likely than the physicians (MDs) to con- setting. The CPG ad hoc Committee identified the following
sider early mobilization crucial or very important. The most potential areas for scientific investigation:
common perceived barrier to early mobilization in the ICU
was patient medical instability (91% of PTs, 77% of MDs), • Metrics to define and measure ICUAW in critically ill
followed by excessive sedation (64% of PTs, 58% of MDs), risk burn patients have not been widely examined. There is a
of dislodgement of lines or devices (21% of PTs, 55% of MDs), need for a common set of measurements to identify and
obesity (26% of PTs, 37% of MDs), and cognitive impairment study ICUAW.
(22% of PTs vs 37% of MDs). Surprisingly, endotracheal intu- • Well-defined EMR protocols have not been studied in
bation was the sixth most common perceived barrier (15% of comparison to “standard therapy” or later mobilization
PTs, 37% of MDs). and rehabilitation with respect to the outcome of dura-
Adverse events during early mobilization in the ICU ap- tion of MV in critically ill burn patients.
pear to be uncommon. One systematic review and meta- • Observational studies to assess the safety and adverse
analysis of EMR in ICU patients12 involving 14 randomized effects (eg, graft loss) of early mobilization in critically
or controlled clinical trials (1753 patients) identified only one ill burn patients in the ICU are needed.
study that reported a serious adverse event (oxygen desatu- • The effect of a defined EMR protocol during the critical
ration < 80% in 1/498 [0.2%] of mobilization sessions).38 illness phase on the development of HAPIs during the
Six studies reported adverse events during the intervention, entire hospital stay has not been studied.
including cessation of the session due to patient medical in- • The effect of EMR, as part of an ABCDEF bundle in
stability (4% of sessions),38 orthostatic hypotension in 11% of critically ill burn patients, on the outcome of delirium
patients in one study50 and 3% of patients in another,44 syn- development needs to be examined.
cope in one patient (2%),54 dislodgement of an arterial line in
one patient (1%) in one study50 and in 1% of sessions in an-
other study,38 loss of a nasogastric tube in one patient (1%),50 QUALITY AND PERFORMANCE MEASURES
oxygen desaturation less than 90% in two patients (2%),50 and
This guideline has conditionally recommended that EMR be
one episode of asymptomatic bradycardia (one patient, 1%).54
considered in critically ill burn patients in the ICU to reduce
Several RCTs of early mobilization reported no episodes of
ICUAW and delirium. No recommendation could be formed
endotracheal tube dislodgement,.38, 44, 48, 50, 54 A Cochrane sys-
regarding the outcomes of HAPI development or skin graft
tematic review10 of four RCTs of early mobilization or active
loss. Despite the relatively “weak” recommendations and need
exercise in critically ill adults (690 patients)38, 42, 48, 93 had low
for further study, burn care facilities may wish to collect and
certainty in the evidence regarding adverse events due to the
compare data on certain benchmarks to measure the use of
low frequency of these events, which occurred in 2 to 5% of
EMR for burn-ICU patients. We stress that such benchmarks
patients in the intervention arms of the included studies.
should not be considered definitive standards of care to deter-
While it seems that adverse events are infrequent, there are
mine reimbursement but rather should be used as measures of
some unique considerations for burn patients in the ICU.
performance and to improve quality of care. While refinement
Inadvertent loss of the airway could be catastrophic in a pa-
of definitions for “critically ill” and “mobilization” is needed,
tient with significant burn-related facial and neck edema.
possible measures might include:
Thus, the threshold for mobilization might be higher in some
intubated burn patients compared with the average medical– • Proportion of critically ill burn patients in the ICU who
surgical ICU patient. The same rationale applies to the loss of are mobilized within the first 7 days following injury.
vascular catheters in burn patients who may have limited sites • Frequency and duration of mobilization sessions in each
for access due to wounds, grafts, and dressings. Burn surgeons critically ill burn patient in the first 7 days after injury.
• Time from injury to mobilization in each critically ill 24. Mlcak R, Desai MH, Robinson E, Nichols R, Herndon DN. Lung func-
tion following thermal injury in children—an 8-year follow up. Burns
burn patient. 1998;24:213–6.
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26. Esechie A, Bhardwaj A, Masel T, Raji M. Neurocognitive sequela of burn
injury in the elderly. J Clin Neurosci 2019;59:1–5.
27. Suman OE, Mlcak RP, Herndon DN. Effect of exercise training on pul-
monary function in children with thermal injury. J Burn Care Rehabil
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ABA GUIDELINES

Clinical Practice Guideline: Early Mobilization and

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The study by Gille et al33 was mainly aimed at facilitating

cant reductions in the continued hours of ventilation after ad-

mission, and the total ventilator days compared with patients

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only 36% in the controls. Thus, early aggressive extubation

alone may have accounted for the significant reduction in con-

tinued hours of ventilation and ventilator days observed in

the protocol group rather than any specific effect of “early

described in detail (frequency, duration, distance of walking,

or use of assistance), and no data were provided to show how

sible to determine with any confidence the effects of the early

mobilization component of this protocol on the duration of

burn populations in an ICU setting. Neither study was for-

mally included for critical review because burn patients formed

evaluated. Clark et al34 conducted a retrospective case–con-

trol study of 2176 patients of which 10% were burns (% TBSA

tion protocol did not have a significant reduction in days of

institution of the early mobility protocol (7.8 ± 13.4 days vs

8.9 ± 17.4 days, P = .08). The development of ICUAW was

526 adults admitted to a trauma ICU, where 5% of the study

population was categorized as “burn/drowning/asphyxia”

A protocolized early mobilization program (EMP), compared

with a historical cohort not receiving this intervention, had

CI: 0.79 to 1.21), and ICUAW was not specifically measured.

Although both studies utilized detailed and carefully planned

early mobilization interventions, we cannot make conclusions

on any effects of early mobilization on the outcome of the

undescribed burn populations included in these two studies.

Given the lack of high-quality studies involving critically

ture from the general ICU population. With respect to the

outcome of time spent on the ventilator, numerous RCTs in

habilitation and mobilization on the duration of MV and/

or ventilator-free days.38–53 One systematic review and

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