Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe, life-threatening skin disorders characterized by extensive epidermal necrosis and detachment. These conditions are often treated in burn centers due to the similarity in clinical presentation and management requirements with burn patients, particularly concerning nutritional needs. This article aims to provide an overview of dietary recommendations and nutritional support strategies for patients with SJS/TEN, drawing from available research and clinical practices.
Understanding SJS/TEN and Their Metabolic Impact
SJS and TEN are severe adverse reactions, most commonly triggered by medications. The conditions involve widespread blistering and peeling of the skin and mucous membranes, leading to significant fluid and electrolyte imbalances, increased risk of infection, and hypermetabolism. The severity is often quantified by the percentage of total body surface area (TBSA) affected. Studies show that the median TBSA involvement in SJS/TEN patients is around 35%.
Similar to burn patients, individuals with TEN exhibit elevated resting energy expenditure early in their hospital course, sometimes reaching twice the predicted values. This hypermetabolic state necessitates careful nutritional management to support healing and prevent complications.
Nutritional Assessment and Goals
Given the increased metabolic demands and potential for inadequate oral intake, nutrition support is crucial in managing SJS/TEN patients. The primary goals of nutritional intervention include:
- Meeting increased energy and protein needs to support wound healing and prevent muscle wasting.
- Maintaining fluid and electrolyte balance.
- Supporting immune function.
- Minimizing the risk of infection.
Indirect calorimetry is a valuable tool for accurately measuring energy needs in these patients. Studies using indirect calorimetry have reported measured energy needs around 24.2 kcal/kg of admit weight.
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Routes of Nutritional Support
Enteral Nutrition (EN)
Enteral nutrition (EN), which involves delivering nutrients directly into the gastrointestinal tract via a feeding tube, is generally preferred over parenteral nutrition (PN) whenever feasible. EN helps maintain gut integrity, supports immune function, and reduces the risk of infectious complications compared to PN.
In patients with SJS/TEN, a significant proportion require EN support due to inadequate oral intake. Research indicates that about 81% of patients may need EN, often remaining on it until around day 16 of hospitalization. High-protein enteral formulas are commonly used to meet the elevated protein requirements associated with these conditions.
Parenteral Nutrition (PN)
Parenteral nutrition (PN), which involves providing nutrients intravenously, is typically reserved for patients who cannot tolerate or absorb nutrients through the gastrointestinal tract. While earlier literature on SJS/TEN suggested PN as the preferred route, more recent data indicates that PN is used less frequently when EN is possible.
Oral Intake
Some patients with SJS/TEN may be able to start oral intake relatively early in their hospital stay. Studies have shown that about 31 patients started oral intake on hospital day 1. However, oral intake should be carefully monitored to ensure it meets the patient's nutritional needs.
Dietary Recommendations
While specific dietary recommendations for SJS/TEN may vary based on individual patient needs and clinical status, some general guidelines can be considered:
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- High Protein Intake: Protein is crucial for wound healing and preventing muscle loss. High-protein enteral formulas are often recommended.
- Adequate Caloric Intake: Meeting the increased energy needs is essential to fuel the healing process. Indirect calorimetry can help determine the appropriate caloric intake.
- Micronutrient Supplementation: Patients with SJS/TEN may have increased requirements for certain micronutrients, such as vitamin C, zinc, and selenium, which play a role in wound healing and immune function.
- Fluid and Electrolyte Management: Careful monitoring and management of fluid and electrolyte balance are critical due to the extensive skin losses and potential for dehydration.
- Soft and Bland Diet: For patients able to tolerate oral intake, a soft and bland diet may be better tolerated, especially if there is oral or esophageal involvement.
- Avoidance of Irritants: Spicy, acidic, or very hot foods should be avoided as they can further irritate the mucous membranes.
Nursing Care and Environmental Considerations
Suitable nursing care is paramount in managing SJS/TEN, especially when a large area of skin/mucosa is affected, often necessitating intensive care. Expert nursing care should start upon the patient's arrival at the hospital and continue until discharge. The environment in which the patient is cared for also plays a crucial role. The SJS/TEN patient should be managed in a single room to minimize the risk of infection. Daily bathing should be limited to 15 minutes, and bacteria mapping should be performed twice a week before bathing, focusing on areas more prone to infection.
Prognosis and Risk Assessment
The prognosis of SJS/TEN should be determined within the first 24 hours of admission. The SCORTEN (Score of Toxic Epidermal Necrolysis) is an illness severity score developed to predict mortality in SJS/TEN. It assigns one point for each of seven criteria present at admission, with the risk of mortality increasing with the score.
Infection Control
Given the extensive skin damage, patients with SJS/TEN are at high risk of infection. Strict infection control measures are essential, including:
- Maintaining a sterile environment.
- Using sterile gloves and equipment.
- Regular monitoring for signs of infection.
- Prophylactic antibiotics may be considered in some cases.
Analgesia
Pain management is a critical aspect of care for SJS/TEN patients. Analgesics, including paracetamol and opioids, should be prescribed based on the intensity of pain.
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