Impacto del shock durante la fase de resucitación en la mortalidad de enfermos con necrosis epidérmica tóxica (net)

Abstract

ABSTRACT BACKGROUND. The relationship between resuscitation and the development of organ dysfunction with certain outcomes is well established in the critical patient in general and in the critically ill patient in particular. Patients with toxic epidermal necrolysis (NET) resemble patients burned in their pathophysiology (related to extensive skin loss) and are treated optimally in large burn units. However, the pattern of organ dysfunction and resuscitation, and its relationship with mortality, have not been previously studied. OBJECTIVES. (1) Define mortality patterns in patients with NET. (2) Describe the pattern of resuscitation of patients with NET and study their relationship with mortality. (3) To identify the variables related to resuscitation that best discriminate mortality. (4) To compare the discriminative behavior of variables related to resuscitation with that of other prognostic variables in common use. (5) To study the relationship between noradrenaline administration during the resuscitation phase and unfavorable outcomes such as subsequent organ dysfunction and mortality. (6) To propose criteria that define an inadequate resuscitation in patients with NET. MATERIAL AND METHODS. We reviewed retrospectively the medical records of patients with the diagnosis of NET. The relevant demographic and clinical variables were collected to assess organ dysfunction during days 0-3 and resuscitation (fluid, acid-base balance). The qualitative and continuous variables were compared, respectively, with the Chi square test and the Mann-Whitnney U test. A multivariate logistic regression analysis was performed to estimate the association of the variables of interest. The strength of the association was measured by the odds ratio (OR) and its 95% confidence interval. The variables are presented as percentage (qualitative variables) or as median and interquartile range (continuous variables). The data were treated reversibly dissociated, according to the Ethical Committee of Clinical Research. RESULTS. We studied 84 patients (age 50 [34-67] years, skin surface affected 75 [50- 90]%), APACHE II 13 [11-16], mortality 16 cases [19%]). Two patients died ≤72 h after admission, and 14 died later. Among the patients who did not survive early (n = 2), the SOFA (days 0-3) was markedly superior to the SOFA of the rest of the patients (n = 82), and dysfunction of all organs (cardiovascular, respiratory , Renal, hepatic and hematological). The time of transfer to the specialized center was higher in the nonsurvivors early than in the rest of the patients. Among non-survivors late (n = 14), SOFA (days 0-3) was greater than the survivors' SOFA (n = 68), but the difference between groups was lower than in the case of Not early survivors. Among late non-survivors, cardiovascular and respiratory dysfunctions (always 0-3) were a risk factor for mortality, whereas renal, hepatic and hematologic dysfunctions were not associated with mortality. The administration of more fluid (income, balance [income-diuresis], and ratio [income / diuresis]) was associated with mortality. However, after normalizing these variables (income, balance, ratio) according to the affected skin surface, this relationship was lost. Among the variables related to resuscitation, the income / diuresis ratio (day 2) and arterial pH (day 1) were more related to mortality, with a discrimination capacity comparable to that of APACHE II. Patients receiving noradrenaline during the resuscitation phase (i.e., those with cardiovascular SOFA> 2) subsequently exhibit increased organ dysfunction and increased mortality. CONCLUSIONS. (1) Patients with OSD who die are obeyed by two well-differentiated clinical and pathophysiological characteristics. (2) Increased fluid administration during the resuscitation phase is not related to increased mortality if the affected skin surface is considered. (3) The income / diuresis ratio (day 2) and arterial pH (day 1) are, among all variables related to resuscitation, those with the best discriminative properties of mortality. (4) The income / diuresis ratio (day 2) and the arterial pH (day 1) discriminate mortality with the same characteristics as other variables accepted as forecasts (such as APACHE II, SAPS II, and SOFA). (5) Patients receiving noradrenaline during the resuscitation phase subsequently exhibit increased organ dysfunction and increased mortality. (6) Inadequate resuscitation criteria are proposed as a high income / diuresis ratio, a decreased arterial pH, and the need to administer