What Are the Fluid Requirements in Toxic Epidermal Necrolysis?

Abstract

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.

Mortality and Use of the Auxiliary Score in Extensive Toxic Epidermal Necrolysis Patients Admitted to an Adult Burns Referral Centre

“…Age has been previously reported as a factor associated with mortality for TEN patients, consistent with many other studies [12,14,15,18]. Interestingly, in our series, TBSA% was not significantly different between survivors and non-survivors, which is in keeping with some studies [14,15,18], but conversely at odds with others that have shown a strong association between TBSA% and mortality [4,13,15].…”

“…Whilst mortality rates for TEN patients has been reported widely, the percentage of patients that died of 37% was similar to current trends, which have suggested that 30-40% mortality was commonplace with advances in critical care management of patients afflicted with burn-like diseases, introduction of intravenous immunoglobulin and standardised TEN treatment protocols [4,12,13,14,15,16]. This notwithstanding, mortality rates >40% have been reported, even in the last decade [17].…”

The management of toxic epidermal necrolysis

“…The initial administration of 2 mL/kg/% affected body surface area of intravenous crystalloids is usually sufficient to ensure adequate urine output and correct hypotension. 4 Additional nutritional requirements result from the loss of nitrogen and energy from the wound exudate, the hypermetabolic response of TEN and sepsis and the promotion of wound healing. However, these requirements may be lower than in burns, with one paediatric study suggesting that patients with TEN require 22% fewer calories per day than patients with burns.…”

Severe Cutaneous Adverse Reactions

“…The unit has expertise in providing analgesia, maintaining fluid and electrolyte balance and preventing and treating superinfection. It has been recently noted that in contrast to burns, TEN affects the epidermis and hence fluid and electrolyte requirements are less than for burns of the same extent [121]; initial administration of 2 ml/kg/%TBSA is usually sufficient [122]. Additional nutritional requirements result from loss of nitrogen and energy from the wound exudate, the hypermetabolic response of TEN and sepsis and the promotion of wound healing.…”