How should glucose be measured in a patient with Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)?

Glucose Monitoring in Patients with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN)

In patients with SJS/TEN, blood glucose should be monitored using non-invasive or minimally invasive methods that avoid creating new skin wounds, with preference for venous sampling through existing IV lines rather than capillary finger sticks when possible. 1, 2

Rationale for Specialized Glucose Monitoring

SJS/TEN presents unique challenges for glucose monitoring due to:

• Extensive epidermal detachment and skin fragility
• High risk of infection through damaged skin barriers
• Risk of creating new wounds that may not heal properly
• Potential metabolic disturbances requiring close monitoring

Preferred Methods for Glucose Monitoring

Primary Approach

• Use existing intravenous (IV) access for blood glucose sampling whenever possible 1
  • Most patients with >10% BSA involvement will already have IV access for fluid resuscitation
  • Minimizes additional skin trauma
  • Provides more accurate readings than capillary samples in critically ill patients

Alternative Approaches (in order of preference)

1. Continuous glucose monitoring systems (CGMS) applied to intact skin areas

   • Place sensors on non-affected skin areas only
   • Change sites less frequently than manufacturer recommendations if necessary
   • Monitor insertion sites closely for signs of infection or skin reaction

2. Venous blood draws from existing central or peripheral lines

   • Coordinate with other blood tests to minimize frequency
   • Use the smallest gauge needle possible when new venipuncture is required

3. Capillary blood glucose monitoring (finger sticks) as a last resort

   • Only if no other options are available
   • Select sites carefully on non-affected fingers
   • Use single-use lancets with minimal depth settings
   • Apply strict aseptic technique
   • Avoid repeated sampling from the same site

Special Considerations

Metabolic Monitoring Requirements

• Monitor glucose regularly as SJS/TEN patients are in a hypermetabolic state 1
• Patients require 20-25 kcal/kg daily during the early catabolic phase 1, 2
• Be alert for development of hyperglycemia, which may indicate complications 3
• Consider more frequent monitoring in patients receiving corticosteroid therapy

Risk of Fulminant Type 1 Diabetes

• Recent case reports indicate SJS/TEN may rarely trigger fulminant type 1 diabetes mellitus 3
• Monitor for symptoms of hyperglycemia and diabetic ketoacidosis
• Consider more frequent glucose monitoring if patient shows signs of polyuria, polydipsia, or unexplained metabolic acidosis

Infection Control

• Use strict aseptic technique for all glucose monitoring procedures
• Cutaneous infection is a common complication and major cause of death in SJS/TEN 1
• Avoid creating new portals of entry for bacteria

Documentation

• Document glucose monitoring sites to avoid repeated trauma to the same areas
• Include glucose monitoring in the overall wound care plan
• Coordinate with the multidisciplinary team to optimize monitoring schedule

Implementation in Different Care Settings

Burn Center/ICU Setting

• Utilize arterial lines or central venous catheters for blood sampling when available
• Coordinate glucose monitoring with other laboratory tests
• Consider continuous glucose monitoring for unstable patients

General Ward Setting

• Prioritize venous sampling through existing IV lines
• Train staff on special considerations for skin fragility
• Implement strict infection control protocols

By following these guidelines, healthcare providers can effectively monitor glucose levels while minimizing additional trauma to the compromised skin of patients with SJS/TEN, reducing the risk of infection and promoting healing.