What fluid should be used for resuscitation in a patient with Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN)?

Fluid Resuscitation in Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN)

Crystalloid solutions should be used for fluid resuscitation in patients with SJS-TEN, with balanced crystalloids preferred over normal saline when possible. 1, 2

Fluid Selection and Administration

Primary Fluid Choice

• Use crystalloid solutions (0.9% sodium chloride or balanced crystalloid solutions) as the primary fluid for resuscitation 1, 2
• Balanced crystalloid solutions are preferred when available due to lower risk of hyperchloremic acidosis compared to normal saline
• If using 0.9% sodium chloride, limit to 1-1.5L to avoid hyperchloremia and acidosis 1
• Avoid colloids due to their adverse effects on hemostasis 1

Special Considerations

• For patients with concomitant severe head trauma, avoid hypotonic solutions such as Ringer's lactate 1
• Administer fluids through non-lesional skin to minimize infection risk 2

Fluid Volume Management

Calculation of Requirements

• Fluid requirements in SJS-TEN are lower than predicted by burn formulas (Parkland formula) 1
• Replacement volumes can be determined using the formula: body weight/% BSA epidermal detachment 1
• Avoid overaggressive fluid resuscitation as it may lead to pulmonary, cutaneous, and intestinal edema 1

Monitoring Parameters

• Carefully monitor fluid balance with regular assessment of:
  • Vital signs (heart rate, blood pressure)
  • Urine output (target ≥0.5 mL/kg/hr)
  • Skin turgor and mucous membrane moisture
  • Daily weight
  • Electrolyte levels

Wound Care and Fluid Management Integration

• Regularly cleanse wounds using warmed sterile water, saline, or dilute chlorhexidine (1/5000) 1, 2
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the entire epidermis including denuded areas 1, 2
• Consider aerosolized formulations to minimize shearing forces during application 1
• Leave detached epidermis in situ as a biological dressing 1, 2
• Decompress blisters by piercing and expression or aspiration of fluid 1, 2
• Apply non-adherent dressings to denuded dermis (e.g., Mepitel or Telfa) 1, 2

Monitoring for Complications

• Monitor for signs of sepsis, which may be masked by disease-associated fever 2
• Watch for signs of systemic infection such as confusion, hypotension, reduced urine output, and reduced oxygen saturation 1
• Obtain bacterial swabs from lesional skin for culture 2
• Avoid prophylactic antibiotics without clinical signs of infection 2
• Monitor for fluid overload (pulmonary edema, peripheral edema)

Pitfalls and Caveats

• Avoid overhydration: Unlike burn patients, SJS-TEN patients require less aggressive fluid resuscitation
• Avoid colloids: Restrict use due to potential adverse effects on hemostasis 1
• Avoid hypotonic solutions in patients with concomitant severe head trauma 1
• Avoid prophylactic antibiotics without clinical signs of infection as they may increase skin colonization, particularly with Candida albicans 1
• Maintain ambient temperature between 25-28°C to prevent hypothermia and additional fluid losses 2

By following these guidelines for fluid resuscitation in SJS-TEN patients, you can help optimize outcomes while minimizing complications related to both inadequate and excessive fluid administration.