Indications for intubation and early tracheostomy in patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Sedation and Analgesia for Toxic Epidermal Necrolysis in the Intensive Care Unit: Few Certainties, Many Questions Ahead

Toxic epidermal necrolysis (TEN) is a rare, acute mucocutaneous life-threatening disease. Although research has focused on the pathophysiological and therapeutic aspects of the disease, there is a paucity of data in the literature regarding pain management and sedation in the intensive care unit (ICU). Most therapies have been extrapolated from other situations and/or the general ICU population. These patients present unique challenges during the progression of the disease and could end up requiring invasive mechanical ventilation due to inadequate pain management, which is potentially avoidable through a comprehensive treatment approach. In this review, we will present clinical and pathophysiological aspects of TEN, analyze pain pathways and relevant pharmacology, and propose therapeutic alternatives based on a rational and multimodal approach.

Steven Johnson Syndrome in a 102-Year-Old Woman in Saudi Arabia: A Case Report

Medicines often cause serious immune-mediated mucocutaneous reactions including Steven-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN). In the acute phase of SJS and TEN, a febrile illness is followed by cutaneous erythema with blister formation, skin and mucous membrane necrosis, and separation of the skin and mucous membranes. The patient swiftly becomes in danger of dying, necessitating immediate medical attention. In this case report, we described a case of Steven-Johnson Syndrome in a 102-year-old female who was receiving palliative care and had stage 5 chronic renal disease. Although the agent that caused SJS in this patient is unknown, the patient was managed with topical medication, bandages for the lesions, and oral antihistamines. Skin biopsy, abdomen ultrasound, and sezary cell test were advised for the patient. Such presentations at that age have not, to our knowledge, been documented before.

Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

In the recently published guidelines by the Society of Dermatology Hospitalists on the management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), a brief section was included on airway management. These recommendations provide an easy reference on how to manage respiratory complications of the disease. Understanding the evidence that underlies these recommendations would offer physicians greater clarity on the considerations behind every decision and treatment offered. We present a review of the literature on respiratory manifestations associated with SJS and TEN. In addition, we aim to address specific concerns regarding the respiratory management of these patients. These include issues such as the indications and optimal timing of intubation, tracheostomy, role of flexible nasoendoscopy, bronchoscopy, ventilation strategies, and management of chronic respiratory complications.

Antishear therapy for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: a follow-up study

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN) are life-threatening conditions best approached with multidisciplinary burn-equivalent care. There is a lack of consensus on wound management, in particular whether to debride detached epidermis. Our center instituted "antishear" wound therapy thirty-five years ago, where detached skin is left in situ as a biologic dressing and a standardized protocol avoids shear forces to prevent further desquamation. Our center's initial results showed outcomes comparable to SCORTEN predictions, but advancements in burn critical care necessitate a re-evaluation of the antishear approach. A retrospective chart review was conducted for all patients admitted between 06/2004 to 05/2020 with a dermatologist-confirmed diagnosis of SJS/TEN (N=51). All patients were treated with burn-equivalent critical care and antishear wound therapy. Standardized mortality ratios were calculated using the established SCORTEN, and newly developed ABCD-10, prediction models. Mean SCORTEN, ABCD-10, and %TBSA were 2.6, 2.0, and 28%. Overall mortality was 22%; SCORTEN score (p<0.001), ABCD-10 score (p<0.01), %TBSA involved (p=0.02), and development of multi-system organ failure (p<0.001) correlated with increased mortality. Cohort-wide standardized mortality based on ABCD-10 was 1.18 (p=0.79). Standardized mortality based on SCORTEN was 0.62 (p=0.20) and 0.77 (p=0.15) for patients with scores ≤3 and >3; across the cohort it was 0.71 (p=0.11), representing a 29% mortality reduction. Incorporating the antishear approach as part of burn-equivalent care for SJS/TENS led to outcomes comparable to those predicted for surgical debridement via SCORTEN. However, the antishear approach has the advantage of avoiding painful dressing changes, sedation, and general anesthesia required for surgical debridement.

Toxic Epidermal Necrolysis and Steven-Johnson Syndrome: A Comprehensive Review

Significance: Toxic epidermal necrolysis (TEN) and Steven-Johnson syndrome (SJS) are potentially fatal acute mucocutaneous vesiculobullous disorders. Evidence to date suggests that outcomes for patients with both TEN and SJS are largely dependent on stopping the causative agent, followed by supportive care and appropriate wound management in a specialized burns unit. These are life-threatening conditions characterized by widespread full-thickness cutaneous and mucosal necrosis. This article outlines the approach to holistic management of such patients, in a specialized unit, highlighting various practical aspects of wound care to prevent complications such as infection, mucosal and adhesions, and ocular scaring. Recent Advances: There is improved understanding of pain and morbidity with regard to the type and frequency of dressing changes. More modern dressings, such as nanocrystalline, are currently favored as they may be kept in situ for longer periods. The most recent evidence on systemic agents, such as corticosteroids and cyclosporine, and novel treatments, are also discussed. Critical Issues: Following cessation of the culprit trigger, management in a specialized burns unit is the most important management step. It is now understood that a multidisciplinary team is essential in the care of these patients. Following admission of such patients, dermatology, ear, nose, and throat surgery, ophthalmology, urology, colorectal surgery, and gynecology should all be consulted to prevent disease sequelae. Future Directions: Looking forward, research is aimed at achieving prospective data on the efficacy of systemic immunomodulating agents and dressing types. Tertiary centers with burns units should develop policies for such patients to ensure that the relevant teams are consulted promptly to avoid mucocutaneous complications.

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.

Upper airway involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare life-threatening hypersensitivity conditions associated with epidermal detachment and mucositis. The indication for flexible nasoendoscopy (FNE) and overall predictive factors for early intubation are unclear.

OBJECTIVES

To describe the incidence of airway involvement and the key indicators for intubation in our SJS or TEN patient cohort. To determine the association between FNE findings and early intubation.

METHODS

A retrospective review of 45 patients with biopsy proven SJS or TEN admitted to an Australian tertiary burns centre from 2010 to 2017.

RESULTS

Thirty-five patients were diagnosed with TEN (77.8%), followed by overlap syndrome (SJS-TEN) (n = 6, 13.3%) and SJS (n = 4, 8.9%). Twenty (44.4%) patients were intubated; and all 20 had a diagnosis of TEN (100.0%) (p < 0.05). Intubated patients had a higher increase in total body surface area percentage(%) from day 1-3 [10.0% (IQR 0.0-23.8%)] and a longer length of stay [26.0 days (IQR 12.5-34.0)], compared to non-intubated patients [0.0% (IQR 0.0-4.0%)], [10.0 days (IQR 6.0-14.0)] (p < 0.05) respectively. The main indications for intubation were to facilitate operative and dressing management (47.4%) followed by airway involvement (26.3%). FNE was performed on 32 patients (71.1%), however FNE findings did not significantly influence intubation rates.

CONCLUSION

More than half (n = 20, 57.1%) of the 35 patients diagnosed with TEN underwent intubation, mainly to facilitate operative and dressing management. FNE was performed on most patients, however there was no clear association between FNE findings and early intubation.

Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immunologic reactions to several stimuli, mostly medications, which present as a spectrum of primarily widespread mucocutaneous lesions, but also with other organ involvement. Pathology is characterized by full thickness necrosis of the epithelial layer of the involved organ due to immune-mediated apoptosis of the resident keratinocytes. High suspicion for early detection and quick withdrawal of the culprit medication are the most important steps in stopping this reaction. Aggressive supportive care is often necessary as the patient recovers. Steroids, other immunosuppressants, and plasmapheresis have all been studied as treatments, but high-quality evidence supporting their contributions, either together or separately, in decreasing length of hospital stay or prolonging survival have not been consistently demonstrated. Further studies of the mechanism of action and novel treatment modalities are still needed to improve outcomes in patients with this rare but often fatal condition.

Stevens-Johnson syndrome and toxic epidermal necrolysis: epidemiological and clinical outcomes analysis in public hospitals

Background

Adverse drug reactions are harmful and involuntary responses to drugs that occur at doses normally used for a given condition. Among them are Stevens-Johnson syndrome and toxic epidermal necrolysis, both rare and potentially fatal conditions.

Objectives

To analyze the epidemiological and clinical characteristics related to patients diagnosed with Stevens-Johnson syndrome and toxic epidermal necrolysis in public hospitals in the Federal District - Brazil.

Methods

Retrospective, cross-sectional and descriptive study, in which data were collected referring to patients hospitalized in the public healthcare system of the Federal District from 1999 to 2014. Results: Between 1999 and 2014, 86 cases of hospitalized patients with diagnosis of Stevens-Johnson syndrome and toxic epidermal necrolysis in the Federal District were reported. The majority of patients were women; the most affected age group was 0 to 10 years. Patients older than 60 years (elderly) represent 6.98% of the cases. Most patients admitted to the referral hospital were discharged. However, occurrence of deaths exceeded that of discharge in elderly patients.

Limitations of the study

There is fragility in the registry of hospitalization of patients, both in the hospital information system and in the medical records of the reference hospital.

Conclusion

There is a need for greater production and better dissemination of information on the incidence of adverse drug reactions.