Retrospective Analysis of Toxic Epidermal Necrolysis Over a Period of 20 Years from a Single Institution

二十年回顧分析毒性表皮壞死鬆解症患者的治療

周杰(Chieh Chou) ； 郭耀仁(Yur-Ren Kuo) ； 張智豪(Chih-Hau Chang) ； 李書欣(Su-Shin Lee) ； 歐素妃(Su-Fei Ou) ； 林采蓉(Tsai-Rung Lin) ； 黃書鴻(Shu-Hung Huang)

《臺灣整形外科醫學會雜誌》 26卷2期 (2017/06) Pp. 139-148

摘要

Background: Toxic epidermal necrolysis (TEN) refers to severe mucocutaneous reactions, which are most commonly triggered by drugs and characterized by blistering, extensive necrosis and detachment of the epidermis. Several treatment protocols for TEN management have been reported; however, none has been standardized, especially in children and severe cases. This study compares our current management in TEN cases combined with bundle care versus supportive care methods in the last twenty years. Methods: A retrospective study of all patients admitted to intensive care unit (ICU) because of TEN was reviewed. The patients were histologically confirmed (＞30% total body surface area, TBSA). KMUH started implementing bundle care after the year 2006, thus we divided our data into 2 groups: patients from January 1996 to January 2006 who received supportive care are the same as for major burns as Group I and patients from January 2006 to October 2016 who received bundle care management as the group II. Charts were reviewed for patient characteristics, age, causative agent, TBSA, average delay to ICU, average duration to achieve 95% healing of the wound, mean hospital stay, and overall mortality rate. Results: The outcomes for the patients with TEN admitted to our hospital during 1996-2006 and 2006-2016 were compared. Group I had 21 patients and group II had 19 patients, respectively. The average age was 61.3 years (7-87 years) and 56.6 years (6-81 years). The SCORTEN score is 2.9±1.2 and 3.0±1.1, respectively (P= 0.7858). The mean TBSA affected by epidermal slough was 49% and 52%, respectively (P=0.3385). The average delay in presentation to the ICU was 7.8±2.4 days (3-12 days) and 5.1±2.1 days (0-10 days), respectively (P= 0.0006). The average duration to achieve 95% wound healing was 13.5±2.8 and 11.2±2.7 days, respectively (P=0.012). The mean hospital stay was 23.5±4.0 and 21.6 ±3.6 days, respectively (P=0.124). Overall mortality was 33% and 21%, respectively (P=0.0399). Conclusion: In addition to appropriate intensive care facilities, standardized wound care, specialist expertise and rapid admission to ICU contribute to the improvement of TEN patients management. We believe a standardized care bundle with proper protocol can provide high quality care with improved clinical outcomes.

關鍵字

toxic epidermal necrolysis ； bundle care ； intensive care unit ； mortality

並列摘要

背景：中毒性表皮壞死鬆解（TEN）是嚴重的粘膜皮膚反應，最常見的是由藥物觸發，其特徵是起泡，廣泛的壞死和表皮脫離。目的及目標：目前在不同醫院中對TEN有著不同且歧異度大的治療方式，但卻沒有一套標準化流程，且並無針對兒童以及較嚴重的案例。本文介紹了我們過去二十年來治療TEN的經驗，比較前十年與後十年的臨床成效。材料及方法：KMUH從2006開始組合式措施來照護病人，因此我們將這二十年來共40位病人並分為從1996年1月至2006年1月為第一組，以及從2006年1月至2016年10月為第二組。從組織學證實（＞ 30％總體表面積，TBSA）的所有患者進入重症加護病房（ICU）的TEN所有患者的回顧。回顧此族群特徵，年齡，致病因素，總燒傷體表面積（TBSA），到達ICU的平均延遲天數，達到95％傷口癒合的平均持續時間，平均住院時間，總死亡率等。結果：第一組21名患者和第二組19名患者來做比較。平均年齡為61.3歲和56.6歲。SCORTEN的得分分別是2.9±1.2和3.0±1.1（P=0.7858）。平均TBSA分別是49％和52％（P=0.3385）。至ICU的平均延遲為7.8±2.4天（範圍：3-12天）和5.1±2.1天（範圍：0-10天）（P=0.0006）。達到傷口的95％癒合的平均持續時間為13.5±2.8和11.2±2.7天（P=0.012）。平均住院時間為23.5±4.0和21.6±3.6天。總死亡率分別為33％和21％（P=0.0399）。結論：我們認為適當的重症監護設施，妥善換藥，儘早進入ICU改善TEN患者的結果外。標準化的組合式照護，跨團隊運作與適當的流程可以提供更高質量的治療，改善臨床結果。