Toxic epidermal necrolysis syndrome: mortality rate reduced with early referral to regional burn center.

Toxic epidermal necrolysis syndrome is an uncommon, acute, life-threatening disorder that involves sloughing of skin at the dermal-epidermal junction with associated mucositis. Between 1985 and 1995, 36 patients were treated for toxic epidermal necrolysis syndrome, at the Baltimore Regional Burn Center. A retrospective chart analysis was performed to discover significant determinants of mortality. Ninety-seven percent of the patients (35 of 36) were referred from outside institutions after an average of 6.3 +/- 0.8 days. Analysis of the data shows that patients who survived had been referred 7.5 days earlier than nonsurvivors (4.0 +/- 0.5 days versus 11.5 +/- 1.4 days, p < 0.001). When the patients were separated into two groups on the basis of time of referral, those referred "early" (< or = 7 days) had a mortality rate of 4 percent (1 of 24) versus 83 percent (10 of 12) for those referred "late" (> 7 days) (p < 0.001). Data were available from transferring institutions for 21 of the 36 patients. Analysis of the microbiologic data from these 21 patients revealed bacteremia, and subsequent death occurred in 100 percent (6 of 6) of the patients referred with positive cultures, whereas bacteremia developed in only 33 percent (5 of 15) of the patients referred with negative cultures, for a mortality rate of 7 percent (1 of 15). In addition, 86 percent (6 of 7) of the patients who were referred late (> 7 days) had positive cultures on referral. The current trend toward prolonged treatment in outside facilities before referral to a burn center is detrimental to the care of patients with toxic epidermal necrolysis syndrome. The overall rate of bacteremia, septicemia, and mortality is significantly reduced with early (< or = 7 days) referral to a regional burn center.