Year: 2006
Type: letter
Abstract: Dear editor, Windle recently published an interesting article focused on nutrition problems posed by patients with toxic epidermal necrolysis (TEN) (Windle 2005). He described the case of a patient in which immune modulating artificial nutrition support was given initially via the parenteral route and then the nasogastric route. He also suggested that this type of intervention, based on this experience, could be of benefit for patients with TEN. Toxic epidermal necrolysis (also called Lyell syndrome) is a rare and severe adverse drug-induced skin disease. Its rarity poses difficult problems of prospective randomized trials and unfortunately management is still based on case series or case reports from different burn departments (Rzany et al. 1999). In our centre, we treated 32 patients affected by TEN from 1995. We noticed, along with other authors, that these patients are not completely similar to burn patients (Khoo & Foo 1996). Their liquids requirements, for example, cannot be predicted by standardized formulas as usually done for burns, because the exfoliated areas in TEN do not exude as much fluid and do not occur all at once like thermal burns, because transcutaneous fluid loss occurs in a staggered fashion and no third space phenomenon is observed. Additionally, the absence in TEN of vascular permeability alterations makes possible to administer solutions containing colloids, such as fresh frozen plasma, performing both a resuscitative function and a specific treatment for the disease since immunoglobulins block apoptotic cell receptors. With specific regard to nutrition, we believe that two arguments are worth to be discussed. First, are nutrition requirements the same of burn patients or similar considerations of for fluids requirements should be posed? Although Coff-Bu would suggest this, two patients are still not enough to reach definitive conclusions (Coss-Bu et al. 1997). Secondly, what is the best route of nourishment administration for TEN patients? In 1997, two patients of ours suffered important gastrointestinal haemorrhages, developed during nasogastric tube insertion, that required transfusions for stabilization. Additionally, in 1999 one patient, even if on heparin prophylaxis, died of fatal pulmonary embolism initiated around the femoral venous access used for total parenteral nutrition. For these reasons, we developed a protocol in which no nasogastric tubes or central venous lines are used and nourishment is administered in two phases. Initially, low osmolarity total parenteral nutrition is administered through peripheral veins. Later, oral supplements are introduced as soon as the patient's clinical conditions allow it. Considering the risks posed by the easy detachment of skin and mucosae and their catastrophic consequences, we agree with Windle that percutaneous endoscopic gastrostomy tube is too dangerous to be applied to these patients. Finally, the idea of immune–modulating–nutrition is interesting and could open the way to new additional therapeutic possibilities. However, the use of high dose steroids in many burn centres and emergency departments would alter the patient's immune response and could mask any positive effect developed by nutrition.
Institutions: St. Eugenio Hospital, University of Rome Tor Vergata
Language: English
Subfield: Nutrition and Dietetics
Field: Nursing
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2153644456