Ecthyma gangrenosum following toxic epidermal necrolysis syndrome in a 3-year-old boy-a survivable series of events.

Toxic epidermal necrolysis syndrome (TENS) is a severe but rare skin reaction leading to epidermal desquamation of greater than 30% of the TBSA. It is most commonly precipitated by the administration of medication. Frequent complications of this syndrome include local wound infections, respiratory, mucocutaneous, and ocular complications. Ecthyma gangrenosum (EG) is a rare disease characterized by a milliary seeding of the cutaneous tissue with Gram-negative bacteria; it is most commonly seen in immunocompromised individuals. Here we report a 3-year-old boy who developed EG subsequent to TENS. Although he had a complicated and prolonged hospital course, he survived these series of events. To our knowledge, this is the first reported case of TENS/EG in the pediatric population, and the first report of survivability following these illnesses.

A silver-coated antimicrobial barrier dressing used postoperatively on meshed autografts: a dressing comparison study.

In an effort to optimize the management of freshly grafted burn wounds, a silver-coated, low-adherence dressing, Acticoat (Smith & Nephew Inc., Largo, FL), was compared with 5% sulfamylon-soaked Exu-Dry burn wound dressings. Twenty subjects admitted to the Loyola University Medical Center were randomized to either Acticoat dressings or 5% sulfamylon-soaked burn wound dressings. Dressings were applied immediately after grafting in the operating room. Acticoat dressings were left in place for 3 days and then changed every 3 days thereafter. Sulfamylon-soaked dressings were changed at 48 hours and then every day. Subjects continued to have dressing changes on a twice-daily basis to wounds that were not grafted managed. Subjects were assessed for graft take, time to wound healing, and the number of dressings required until healing. Hospital charges and labor costs were retrospectively tabulated, yielding an expense estimate for each group. There were no significant differences between the two groups with respect to age, %TBSA, %TBSA of the grafted test sites, graft take, time to graft healing, or infectious complications. The median number of dressing changes to the test site was significantly less in the Acticoat group (P < .05). The average expense per dressing change was not significantly different between the two groups; however, the average total expense per patient was significantly lower for the Acticoat group because of the reduced number of dressing changes. Acticoat and 5% sulfamylon-soaked burn wound dressings were equivalent with respect to wound healing and infectious complications. The use of Acticoat was found to be a safe alternative to the use of 5% sulfamylon as a postsurgical dressing in this group of subjects. Because of the reduced number of dressing changes, the use of Acticoat was a less expensive alternative to 5% sulfamylon dressing changes in this study.

Long-term follow-up of patients treated for toxic epidermal necrolysis.

Patient outcomes concerning toxic epidermal necrolysis (TEN) have improved over the years as a better understanding of the pathophysiology of the illness has been gained and enhancements have been made in the care of the acutely ill. With increase in survival, long-term complications these patients experience are beginning to be recognized. In this study, we analyzed the outcomes of a cohort of TEN survivors treated at our burn unit and sought to determine the impact of clinical variables from the initial hospitalization on mortality after discharge. We performed a retrospective review of data from patients with TEN treated at our burn unit from March 1993 to September 2002. Follow-up data on new health problems were collected on patients who were alive at discharge via questionnaire. Survival was estimated using the Kaplan-Meier method with Cox regression model. During the study period, of the 64 patients treated for TEN, 46 survived. After discharge, 15 patients died, whereas the remaining 31 patients continued to suffer from ocular (54%), skin (81%), and renal (23%) problems. Median survival for the whole cohort has not been reached, with an estimated 5-year survival of 65%. No patient in either group had a TEN recurrence. Seventy-nine percent of the patients with ocular involvement in the acute phase of TEN had long-term ocular complications, and 73% of patients with mucosal involvement had persistent mucosal lesions. Five individual factors were found to be predictors of postdischarge mortality on univariate analysis: age at diagnosis of TEN>or=60 years, SCORTEN 3 to 6, % maximal TBSA slough>or=50%, days from onset of symptoms to admission to a burn unit>or=5 days, and presence of multiple comorbidities at diagnosis of TEN. In multivariate analysis, only SCORTEN of 3 to 6 (P=.003) and days to admission>or=5 (P=.027) maintained significance as predictors of mortality and may be used to heighten surveillance during postdischarge care of patients with TEN.

The evolving characteristics and care of necrotizing soft-tissue infections.

BACKGROUND: Necrotizing soft-tissue infections such as necrotizing fasciitis and Fournier's gangrene are a source of high morbidity and mortality. These difficult cases are increasingly being referred to burn centers for specialized wound and critical care issues. In this study, we examine our institution's recent experience with a large series of necrotizing soft-tissue infections. STUDY DESIGN: A retrospective chart review was performed of 65 consecutive patients over a 5-year period with necrotizing soft-tissue infections that required radical surgical debridement. RESULTS: Overall survival was 83%, with an average length of stay of 32.4+/-3.32 days for survivors and for the entire group of 29.5+/-3 days. Time from onset of symptoms to initial presentation to our institution averaged 6.9+/-1.19 days. Patients averaged 2.9+/-0.22 surgical procedures, and 46% of patients required skin grafting with an average graft area of 1554+/-248 cm(2). Of the survivors, only 54% were able to return home, with 46% needing further hospitalization or transfer to an inpatient rehabilitation facility. CONCLUSIONS: There were frequent delays in diagnosis and referrals to and from within our institution, and progress can be made in educating the medical community to identify these patients. Advancements in wound care and critical care have made inroads into the treatment of patients with necrotizing soft-tissue infections. However, these infections continue to be a source of high morbidity and mortality and significant healthcare resource consumption. These challenging patients are best served with prompt diagnosis, immediate radical surgical debridement, and aggressive critical care management. Referral to a major burn center may help provide optimal surgical intervention, wound care, and critical care management.

A survey of airway and ventilator management strategies in North American pediatric burn units.

A survey was used to gather information regarding airway management patterns in thermally injured children. North American pediatric burn centers listed by the American Burn Association were sent a survey designed to examine patterns of pediatric airway management in children with acute respiratory failure. The sample population means for the number of patients ventilated more than 48 hours and the number of patients ventilated more than 48 hours with inhalation injury were used to separate centers into large and small pediatric burn centers. Small pediatric burn centers had less than 50 patients who were intubated during a 5-year period. A five-point nominal scale was used to facilitate statistical analysis. Twenty-five pediatric burn centers included in the analysis estimated that 11,494 children were admitted during the 5-year period. There was no statistically dominant ventilator mode being used in the setting of acute respiratory failure identified by this survey. Large pediatric burn centers reported more frequent use of cuffed endotracheal tubes and more frequent change from an uncuffed to a cuffed endotracheal tube in patients who were difficult to ventilate because of an excess leak. Large pediatric burn centers reported a higher prevalence of tracheomalacia then small pediatric burn centers. Steroids were used by most centers before extubation in patients with persistent airway edema. No centers reported complications from steroid use. There is lack of clear consensus regarding the application of various ventilator modes in the setting of acute respiratory failure irrespective of center volume. There were divergent of practice patterns between large and small pediatric burn centers regarding the use of cuffed endotracheal tubes and the timing of tracheostomy. There was agreement between large and small pediatric burn centers in tracheostomy use in children older the age of 7 and the use of steroids as an adjunct to extubation in patients with lingering airway edema. Pediatric burn patients may benefit from clinical trials that clarify the advantages and disadvantages of various ventilator modes, the use of cuffed tubes, and the timing of tracheostomy.

Physiologic response to burn injury.

The physiologic response to bum injury is complex. Understanding the various components is important for the care and treatment of the critically injured bum patient. Because these injuries are nondiscriminatory and occur across the lifespan, patient characteristics and responses are highly variable. This diversity allows the critical care nurse to use a wide array of clinical skills. Care of the bum patient is rewarding because the critical care nurse plays an important role from the acute phase through the rehabilitative phase of injury.