SCORTEN is a scoring system used to predict mortality in toxic epidermal necrolysis (TEN) patients. The accuracy of SCORTEN among TEN patients treated in burn centers has not been established. The purpose of this study was to assess the discriminative power and calibration of SCORTEN among TEN patients treated at an adult regional burn center. Retrospective analysis of a consecutive series of TEN patients was used to compare actual mortality with that predicted by SCORTEN. A standardized mortality ratio was obtained to compare the actual number of deaths to the predicted number based on SCORTEN. Discrimination was measured using the area under the receiver operator characteristic curve, and model fit (calibration) was measured using the Hosmer-Lemeshow goodness-of-fit statistic. A total of 61 adult patients were analyzed. The actual overall mortality rate of 29.5% was not significantly different than the mortality rate of 25.2% predicted by SCORTEN (standardized mortality ratio, 1.17; 95% confidence intervals, 0.695-1.853; P = .08). The area under the receiver operator characteristic curve was 0.82 and the Hosmer-Lemeshow statistic was 1.381 (P = .710). SCORTEN is an accurate scoring system for estimation of mortality among TEN patients treated in a burn center setting.
Lung protective ventilation strategies are recommended in acute respiratory distress syndrome to avoid ventilator associated lung injury, a recently characterized complication of mechanical ventilation. High-frequency oscillatory ventilation (HFOV) is an unconventional ventilation strategy which may achieve this goal. We reviewed our experience with HFOV in six severely burned patients with acute respiratory distress syndrome. The mean age (+/- SD) of the patients was 34 +/- 13 years, and the mean TBSA burn was 52 +/- 10%, with a mean full-thickness injury of 49 +/- 12%. HFOV was initiated as "rescue therapy" in three patients with oxygenation failure (mean PaO2/FIO2 ratio of 71 +/- 8 and mean oxygenation index [OI] of 42 +/- 3) that was unresponsive to conventional ventilation (mean FIO2, 1.0 +/- 0; mean positive end expiratory pressure, 14.8 +/- 2.8 cm H2O; and mean inhaled nitric oxide, 20 +/- 0 ppm). In the other three cases, HFOV was initiated "prophylactically" as a lung protective ventilation strategy in an attempt to prevent further respiratory deterioration. All six patients showed a rapid and substantial improvement in oxygenation after initiation of HFOV, with significant improvements in the PaO2/FIO2 and OI by 12 hours (P = 0.02). In four patients HFOV was also used during anesthesia and surgery, where a total of 10 procedures involving a mean excision and closure of 15 +/- 7% TBSA burns was performed. Five of the six patients died, but none died because of oxygenation failure. In three patients death resulted from sepsis and multiple organ dysfunction syndrome; their mean PaO2/FIO2 was 107 +/- 31 and their mean OI was 30 +/- 11 immediately before death. Two patients with multiple organ dysfunction syndrome died after withdrawal of life support; their mean PaO2/FIO2 and OI were 178 +/- 31 and 18 +/- 2 respectively, at the time of this decision. Although HFOV had no impact on mortality, it played a useful role in the supportive management of burn patients with severe oxygenation failure unresponsive to conventional ventilation. Importantly, HFOV allowed surgery to proceed in patients who may have otherwise been too unstable to go to the operating room. As far as we are aware, this is the first report of the use of intraoperative HFOV in burn patients.
Acute fluid requirements in toxic epidermal necrolysis (TEN) have neither been quantified nor reported. The purpose of this study was to examine acute fluid administration in TEN patients. A consecutive series of criteria and biopsy-confirmed cases of TEN admitted to our burn centre were selected for retrospective analysis. Charts were reviewed for demographic and resuscitation variables for the first (D0), second (D1), and third (D2) 24-hour periods after burn center admission. Twenty-one TEN cases were available for study, with a mean epidermal detachment of 53 +/- 24% TBSA. Mortality was 29%, with all deaths occurring after the study period. Average crystalloid volumes decreased from D0 (2.2 +/- 1.5 ml/kg/%TBSA) through D1 (1.6 +/- 1.1 ml/kg/%TBSA) and D2 (1.4 +/- 1.0 ml/kg/%TBSA), whereas urine output increased from D0 (1.3 +/- 0.9 ml/kg/hr) through D1 (1.4 +/- 0.9 ml/kg/hr) and D2 (1.8 +/- 1.1 ml/kg/hr). Worst base deficit (BD) corrected significantly from D0 to D1 (P = .01) and from D1 to D2 (P = .002). There was no correlation between daily crystalloid volumes and %TBSA detachment. Nonsurvivors had significantly higher severity-of-illness score for TEN and 24-hour mean and worst BDs than survivors, but did not require significantly more crystalloid or display lower urine outputs. Initial provision of approximately 2 ml/kg/%TBSA epidermal detachment to patients with TEN resulted in more than adequate urine output and significant correction of the BD. We emphasize that these data do not represent a resuscitation formula but rather a guideline for initial fluid administration, which should then be titrated to the patient's response.
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