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Title of Guideline Contact Name and Job Title (author) Directorate & Speciality Date of submission Date on which guideline must be reviewed Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words The management of patients with Toxic Epidermal Necrolysis or Stevens Johnson Syndrome within Adult Critical Care Dr Martin Levitt, Consultant in Intensive Care, Critical Care, NUH Dr Martin Beed Consultant in Intensive Care, Critical Care, NUH Specialist Support Adult Critical Care 1/12/2013 1/12/2018 Applies to all adult patients requiring Critical Care admission for management of Toxic Epidermal Necrolysis or Stevens Johnson Syndrome Excludes: All paediatric cases This guideline describes the procedures and management plan associated with the Critical Care Management of the above patients. Management and care are shared between Burns Team ICU Team, Dermatology Team Toxic Epidermal Necrolysis, Stevens Johnson Syndrome, Adult critical care Evidence base of the guideline: Peer reviewed by: NUH critical care consultants; Critical care cross-town guidelines group Evidence base: (1-5) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practice based on the clinical experience of the guideline developer Consultation Process Cross-town guidelines group Target audience Burns and dermatology consultants Medical and nursing staff all adult critical care areas This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Management of TEN within Adult Critical Care Review date 2018 Dr M Levitt 2013 Page 1 of 9 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST CRITICAL CARE GUIDELINES Guidance for the management of patients with Toxic Epidermal Necrolysis (or Stevens Johnson Syndrome) within Adult Critical Care Introduction: Toxic epidermal necrolysis (TEN) is a rare, potentially life threatening dermatological condition. It is characterised by widespread detachment of the epidermis from the underlying dermis as a result of immune mediated keratinocyte death. TEN is regarded as part of a spectrum of conditions that include Stevens-Johnson syndrome (SJS), the differentiation being the percentage skin involvement. The condition is usually precipitated by an adverse reaction to a drug (see table 1) but may also be associated with infections such as mycoplasma and HSV, and following bone marrow transplantation. The overall mortality for TEN is around 30% with the more severe cases having greater than 90% risk of death. For this reason TEN is managed on Critical Care in a similar manner to a thermal burn injury. Table 1. Common drug causes of TEN Sulfonamides Beta lactam antibiotics Macrolides NSAIDS Allopurinol Methotrexate Antiretroviral drugs Phenobarbitone Carbamazepine Sodium valproate Corticosteroids Management of TEN within Adult Critical Care Review date 2018 Dr M Levitt 2013 Page 2 of 9 Diagnosis Diagnosis may be suspected from the clinical appearance and temporal association with drug administration. It is usual for the diagnosis to be made or confirmed by the dermatologists. Referral is then made to the burns team at Nottingham University Hospital, City Campus for further management. Skin biopsy is not considered essential, but may be helpful in cases where there is diagnostic uncertainty and in those uncommon cases that fail to reepithelialize. Assessment of severity Although thought of as a cutaneous disease, TEN can affect all mucous membranes. Typically the eyes and mouth are involved, but involvement of the genitalia, gastro-intestinal tract and the respiratory epithelium can occur. On admission to Critical Care, the patient should be examined thoroughly and the extent and location of the skin involvement documented. Note that the disease may progress following admission. It is customary to assess the patient using the SCORTEN scoring system (table 2). This was developed in the 1990’s and gives an approximate mortality prediction based upon the presence or absence of 7 predictive factors at admission . It should be noted that the confidence intervals are extremely wide and overlapping. Table 2. SCORTEN Severity of illness score for TEN Age >40 years Malignancy Heart rate >120 Initial percentage of epidermal detachment >10% Serum Urea >10 mmol/L Serum glucose level >14 mmol/L Bicarbonate level <20 mmol/L SCORTEN Score 0-1 2 3 4 5+ Management of TEN within Adult Critical Care Review date 2018 Mortality % 3 12 35 58 90+ Dr M Levitt 2013 Page 3 of 9 Critical Care Management. With the obvious exception of stopping all potential causative agents, there is no definitive treatment for TEN. Management is therefore resuscitative and supportive in the anticipation that the epidermis will regenerate allowing re-epithelialisation. The management of TEN patients is complex and requires a multidisciplinary team approach involving Critical Care, burns team, dermatology and the ophthalmology / corneal team. 1. Ensure that all possible causative agents have been stopped. 2. If possible, the patient should be admitted to a single room to facilitate infection control and control of the thermal environment. 3. Perform an initial ABC assessment of the patient. Immediate intubation is seldom required, but the majority of patients require ventilation at some stage of their admission. 4. Unless resuscitation has been commenced, the patient should be assumed to be hypovolaemic. Obvious gross volume depletion should be corrected using a colloid of choice. Following this, initial volume requirements can be calculated using a modification of the Baxter-Parklands formula. Because skin involvement can be patchy, it is difficult to accurately assess the area of skin loss. Volume requirements are given by: Skin area affected x body weight x 3 ml. This is approximately 2/3 of the thermal burn requirement and is given over the first 24 hour period. There is no evidence of benefit for colloids over crystalloids and it is usual to use Hartmann’s solution. Fluid requirements beyond the first 24 hours should be managed according to the patient’s condition. 5. Patients with TEN are likely to have protracted ICU stay. The loss of skin precludes non-invasive BP monitoring. Patients should have arterial and central venous access achieved through unaffected skin. It is usual to utilise non-invasive cardiac output monitoring to guide volume requirements and the need for inotropic or vasopressor agents. 6. Measures to promote skin healing may be used: keeping the patient in a warmed environment; warming peripheral skin to avoid a core-peripheral gradient of >2ºC; Management of TEN within Adult Critical Care Review date 2018 Dr M Levitt 2013 Page 4 of 9 avoidance of vasopressors unless severe hypotension occurs which is intractable to fluids (or there is evidence that the patient’s fluid balance is too positive / tissue oedema is problematic) 7. Nasogastric or naso-jejunal feeding should be established as soon as practical according to the ICU protocol. 8. TEN is painful. Non-intubated patients will require opiate analgesics. Ventilated patients will require sedation with morphine and midazolam. Dressing changes will require additional analgesia e.g. ketamine, propofol, remifentanil. 9. The Burns team will be aware of the patient’s admission and will attend to carry out dressings. The routine de-roofing of blisters is not recommended. Patients with TEN are at risk of wound infection. There is no evidence for the use of one type of dressing over another, but current opinion favours the use of nano-crystaline silver dressings on the basis of stronger antimicrobial action and decreased frequency of dressing changes. Dressing changes are at the discretion of the Burns Consultants, but should always form part of the screening in patients who develop sepsis. 10. Ophthalmology assessment. Ophthalmic involvement in TEN can lead to blindness and the development of adhesions. The corneal team, based at QMC, should be notified of the admission and should assess the patient within 24 hours of admission. The current recommendations are: a. Topical eye lubricants 1-2 hourly b. Topical antibiotics (preservative free) c. The application of amniotic membrane to the corneas to prevent the development of symblepharon formation guided by corneal team. 11. Therapeutics. Patients with TEN should receive routine thromboprophylaxis and stress ulcer prophylaxis. Intubated patients should receive oral decontamination. There is no indication for prophylactic antibiotic administration. There is no evidence for benefit in the use of plasmapheresis, corticosteroids, cyclophosphamide, cyclosporin, or TNF-alpha inhibitors. Thalidomide was associated with an increase in mortality. Management of TEN within Adult Critical Care Review date 2018 Dr M Levitt 2013 Page 5 of 9 12. Intravenous Immunoglobulin: The role of IVIG remains controversial, with little evidence for benefit and some for potential harm. There is no consensus, so the use of IVIG remains at the discretion of the dermatology or the burns teams. TEN is listed in the DOH guidelines for use of IVIG. 13. Infection issues: TEN patients are at high risk of developing infection. Wound colonization is usual and wound infection common. The use of nano-crystaline silver dressings may reduce this. Regular surveillance cultures should be performed at each dressings change. Other sources of infection include lines and VAP. Persistent fever is common in patients with TEN, and does not always indicate the presence of infection. The following indices may be used to aid the decision-making process: New fever (>38ºC, when the patient was previously apyrexial) Fever >39ºC Hypothermia (<36.5ºC) Especially where any of the above occurs in combination with any of: New tachycardia (>110 beats per minute) New tachypnoea (>25 breaths per minute); or increasing O2 requirement New thrombocytopaenia (<100x109) New hyperglycaemia New diarrhoea New failure to absorb enteral feed Antimicrobials should be prescribed in the presence of suspected or proven infection and on the advice of microbiology. In case of suspected sepsis, a full dressing change must be performed. Blood and sputum cultures should be taken and consideration given to requirement for resiting invasive lines. Empirical antimicrobial cover should include vancomycin, an antipseudomal such as piperacillin-tazobactam and an aminoglycoside. Discuss the addition of an antifungal with the duty microbiologist 14. Pyrexia: the presence of a core body temperature >39ºC should prompt measures to cool the patient (cooled IV fluids, peripheral cooling, paracetamol). Management of TEN within Adult Critical Care Review date 2018 Dr M Levitt 2013 Page 6 of 9 NSAIDs as antipyretics may only be prescribed at the direction a consultant and must not be used if there is the possibility that they may have been the initial trigger 15. Patients who recover from TEN must be aware of the potential for re-exposure to the causative drug and of the risks of cross reactivity, especially with anticonvulsants and NSAIDS. The potential for a genetic basis for TEN suggests that blood relatives should avoid exposure to trigger agents. References: Toxic epidermal necrolysis: current evidence, practical management and future directions Chave TA, et al British Journal of Dermatology 2005;153:241–253 Toxic Epidermal Necrolysis and Stevens Johnson Syndrome: Our Current Understanding. French LE Allergology International. 2006;55:9-16 SCORTEN: A Severity-of-Illness Score for Toxic Epidermal Necrolysis Bastuji-Garin S, et al Journal of Investigative Dermatology 2000;115:149-153 Toxic Epidermal Necrolysis: Does Immunoglobulin Make a Difference? Brown KM, et al Journal of Burn Care & Rehabilitation 2004;25(1):81-88 Treatment of Toxic Epidermal Necrolysis With High-Dose Intravenous Immunoglobulins Multicenter Retrospective Analysis of 48 Consecutive Cases Prins C, et al; for the TEN-IVIG Study Group Arch Dermatol 2003;139:26-32. Management of TEN within Adult Critical Care Review date 2018 2013 Dr M Levitt Page 7 of 9 Equality Impact Assessment Report 1. Name of Policy or Service Response to external best practice policy 2. Responsible Manager Owen Bennett (Clinical Quality, Risk and Safety Manager) 3. Name of person Completing EIA Dr Martin Beed (Consultant in Intensive Care and Anaesthesia) 4. Date EIA Completed 1/4/2011 5. Description and Aims of Policy/Service This clinical guideline has been written to inform adult critical care staff of how to safely manage critically ill patients requiring a tracheostomy. 6. Brief Summary of Research and Relevant Data There is no research or relevant data at the present time. 7. Methods and Outcome of Consultation Consultations have been carried out with the following: Adult critical care consultants and senior nurses Comments from the above consultations have been received and incorporated where appropriate. 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Assessment of Impact Age No Impact Identified Gender No Impact Identified 8 Race No Impact Identified Sexual Orientation No Impact Identified Religion or belief No Impact Identified Disability No Impact Identified Dignity and Human Rights No Impact Identified Working Patterns No Impact Identified Social Deprivation No Impact Identified 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the procedure, and following the initial screening, it is my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements 1/12/2018 9