Name: a standardized procedure of dressing management for toxic epidermal necrolysis
Uploaded: 2025-03-14T13:40:00.000+00:00
Duration: 7 min 22 s
Description: Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with high mortality rates, demanding specialized wound care to address ...

All procedures performed in this study comply with the ethical standards of the First Affiliated Hospital of Chongqing Medical University and the Declaration of Helsinki and its later amendments or similar moral standards. This study was approved by the ethics committee of Chongqing Medical University (Number: 2024-155-01), Participants were informed of the process, content, and possible medical phenomena before the start of the trial to ensure their right to know. Patients and their families were consulted to determine their willingness to participate in the trial activities. Before the enrollment of this patient, their informed consent for the use of photographs and participation in this research was obtained. This dressing management protocol was primarily designed for patients diagnosed with TEN. However, this protocol is also applicable for patients with extensive body areas of epidermolysis, such as pemphigus, bullous pemphigoid, and epidermolysis bullous.
1. Preparations
<ol>
	<li>Environmental preparation
	<ol>
		<li>House the patient in a single room with protective isolation, maintaining it at 25-28 &#176;C and 40-50% humidity, with daily UV irradiation and ventilation. Place a far-infrared grill 30-50 cm from the patient for 30-60 min sessions to treat trauma; allow them to adjust their position for optimal exposure.</li>
		<li>Disinfect the room, including the floor and bed, using a 500 mg/L chlorine solution twice daily.</li>
		<li>Ensure that the bed is an antibedsore inflatable mattress with sterile sheets, sterile cotton pads, and disposable nursing pads. Use whole-body exposure therapy with disinfected quilt frames during dressing changes to minimize epidermal stripping. 
		NOTE: Disposable nursing pads were used to prevent fluid seepage.</li>
	</ol>
	</li>
	<li>Patient preparation
	<ol>
		<li>For bedridden patients, carefully rinse and dress localized skin breaks without moving them from the bed.</li>
		<li>For ambulatory patients who can stand by the bedside, place a medical waste bag beneath their feet to ensure that garbage and liquids are collected and flushed. 
		NOTE: This precaution prevents the ward floor from getting wet due to rinsing fluid.</li>
	</ol>
	</li>
	<li>Material preparation
	<ol>
		<li>Keep essential items ready, including a treatment trolley, sterile gauze rolls, gloves (both sterile and film), empty needles, a dressing change box with sterile scissors, and medical swabs.
		<ol>
			<li>Ensure the dressing change box contains large and small gauze blocks, Bactroban ointment, fu fang comfrey oil, povidone-iodine, 0.9% sodium chloride in 500 mL bottles, silver sulfadiazine lipid hydrocolloid dressings, rb-bFGF, sterile cotton pads, duvet covers, pillowcases, and petroleum jelly oil gauze.</li>
		</ol>
		</li>
		<li>Keep personal protective equipment ready-disposable sterile surgical gowns, caps, shoe covers, masks, and household and medical garbage bags.</li>
	</ol>
	</li>
</ol>
2. Skin cleansing and disinfection
<ol>
	<li>Prepare the cleaning solution by mixing povidone-iodine with bottled saline in a 1:9 ratio. Warm the mixture in hot water to achieve a temperature of approximately 35 &#176;C. 
	NOTE: The mixture&#39;s temperature should be based on the patient&#39;s comfort. Iodophor primarily functions as a disinfectant and sterilizing agent. If a patient is allergic to iodophor, its use can be selectively considered depending on the severity of the allergy. Nevertheless, chlorhexidine can serve as an alternative.</li>
	<li>Assess the patient&#39;s condition to ensure the cleaning technique is suitable.</li>
	<li>Remove the previous dressing by moistening it with ozone water to facilitate detachment from the skin.</li>
	<li>Clean the patient&#39;s entire body using the prepared povidone-iodine saline solution and gently dry the patient&#39;s skin using a large sterile gauze.
	<ol>
		<li>For the first dressing change, rinse the lesion area with the povidone-iodine saline solution. 
		NOTE: There is no need to remove all the necrotic epidermis entirely. Just wait for them to fall off naturally. When removing previous dressings, if the dressing adheres to the skin tightly, avoid forceful separation to prevent damage to the delicate neonatal epithelium.</li>
	</ol>
	</li>
	<li>Use far-infrared thermal retention devices throughout the process to warm the patient and protect against chill19.</li>
</ol>
3. Dressing change procedures
<ol>
	<li>Dressing change at the erythema and bullae stage 
	NOTE: Preserve the skin&#39;s integrity to improve the protective barrier and prevent secondary skin infections. Avoid forcibly removing extensive bullae and loosened epidermis; leave them in place to serve as biological dressings.
	<ol>
		<li>In cases in which the epidermis has been shed and there is debris, gently remove necrotic tissue and debris that can be easily detached without force. 
		NOTE: In step 2.3, when the previous dressing is moistened with ozone water, the necrotic, detached epidermis would come off with the removal of gauze or can be gently removed by hand.</li>
		<li>Preserve the unpeeled skin tissue (the ruptured epidermis that is not removable along with gauze). Use sterilized scissors to remove any loose or peeling skin tissue.</li>
		<li>Leave small bullae and those with minimal exudate untreated, keeping the bullae wall intact for natural absorption.</li>
		<li>For large bullae &#62;2 cm in diameter filled with fluid, apply iodophor for sterilization. Then, use a 2 mL sterile syringe to aspirate the fluid from the bullae through a low puncture, and send the fluid for bacterial and fungal cultures. Alternatively, use a surgical blade to make a small incision at the lowest point of the bullae for natural drainage.</li>
		<li>Overlay with sterile gauze.</li>
	</ol>
	</li>
	<li>Dressing change at the exfoliation stage
	<ol>
		<li>Confirm that the patient&#39;s epidermis is loose and exfoliated, with associated exudation and increased pain.</li>
		<li>Use the Numerical Rating Scale to assess the patient&#39;s pain level.</li>
		<li>To alleviate discomfort, administer 100 mg of Tramadol intramuscularly 30 min before dressing changes.</li>
		<li>Measure the dimensions and contour of the skin lesion to determine the appropriate dressing size.</li>
		<li>Apply Silver Sulfadiazine Lipid Hydrocolloid dressing, ensuring complete coverage and extending 0.5 to 1 cm beyond the wound margin.</li>
		<li>Saturate a substantial sterile gauze block with comfrey oil and Bactroban ointment and place it on the silver ion dressing.</li>
		<li>Overlay with sterile gauze and secure with sterile cotton pads. 
		NOTE: Avoid using tapes that adhere directly to the skin, which will tear the skin when changing dressing. Instead, sterile cotton pads, like clothes, should cover the whole body.</li>
	</ol>
	</li>
	<li>Dressing change at the reepithelization stage
	<ol>
		<li>Observe that the skin is in the reepithelization stage, showing a tendency to heal but remaining fragile.</li>
		<li>Discontinue using silver sulfadiazine lipid hydrocolloid dressings and switch to rb-bFGF to accelerate the healing process. 
		NOTE: Protect the newly formed skin tissues by avoiding any actions that could cause dragging, pulling, or tugging.</li>
		<li>Implement a bi-hourly axial turnover to reduce the risk of developing pressure ulcers due to prolonged contact pressure.</li>
	</ol>
	</li>
</ol>
4. Efficacy and number of dressing changes
<ol>
	<li>In cases of profuse exudates, replace the dressing 1-2x daily. Conversely, if the exudate is scant, change the dressing every 2-3 days.</li>
	<li>The three stages mentioned above could exist simultaneously. Monitor the patient&#39;s skin condition and adjust care procedures to support the healing process effectively.</li>
	<li>Closely monitor the exudate from cutaneous lesions, documenting its volume, color, and odor. Repeat the previous procedures if necessary. Adhere to the following standardized protocol during dressing changes: initial disinfection, subsequent cleansing, thorough drying, and applying a new dressing.</li>
</ol>
5. Dressing change at particular sites
<ol>
	<li>Mouth and lips
	<ol>
		<li>To alleviate oral discomfort, use a 5% sodium bicarbonate solution and lidocaine for gargling.</li>
		<li>Apply thick Bactrim or erythromycin ointment to the lips for local antiseptic and protective effects.</li>
		<li>Oral hygiene practices
		<ol>
			<li>Advise patients to avoid keeping their lips closed for long durations.</li>
			<li>Encourage patients to open their mouths frequently to reduce the risk of secondary chapping and promote healing.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Ocular area
	<ol>
		<li>In cases where a patient presents ocular symptoms, advise them to consult an ophthalmologist to assess the condition.</li>
		<li>Flush the conjunctival sac of the eyelid daily with 0.9% sodium chloride to maintain cleanliness.</li>
		<li>Cleanse the eye promptly of pseudo membranes and inflammatory secretions using sterile cotton swabs.</li>
		<li>Administer Tobramycin and levofloxacin eye drops 4x daily to treat ocular infections and inflammation.</li>
		<li>Cover both eyes with petroleum jelly gauze for a patient incapable of closing their eyes. 
		NOTE: Regularly covering both eyes with petroleum jelly gauze is also recommended for regular patients.</li>
	</ol>
	</li>
	<li>Perineum
	<ol>
		<li>Perform daily perineal irrigation with a saline solution to maintain hygiene.</li>
		<li>After irrigation, apply silver sulfadiazine lipid hydrocolloid dressings dressing to the affected skin lesions.</li>
		<li>Wrap the area with comfrey oil gauze.</li>
		<li>Advise male patients to use comfrey oil gauze to separate the penis from the scrotum to prevent adhesion and facilitate healing.</li>
	</ol>
	</li>
</ol>

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The authors declare that they have no competing interests.

TEN is a rare but devastating drug reaction characterized by extensive skin detachment affecting more than 30% of the body&#39;s surface area and the mucous membranes18. TEN is associated with severe complications, like sepsis with a mortality rate of 14%-30%. It has been reported that mortality is strongly linked with the areas of detached skin because the widespread skin bullae significantly increases the risk of infection due to the loss of the protective skin barrier20.
TEN poses a significant threat to patients&#39; physical and mental well-being, highlighting the importance of efficient dressing management in promoting skin healing, alleviating pain, decreasing hospital stays, and enhancing treatment efficiency21. Effective dressing management plays a crucial role in treatment, as it can promote skin healing, significantly reduce patient pain, shorten hospital days, and comprehensively improve treatment. Third-level centers usually have more advanced medical equipment and technology, which can provide more comprehensive treatment services, while local hospitals focus more on initial treatment and patient stability. Understanding the previous practice standards for all categories listed in the new plan helps medical institutions better develop and implement treatment plans, ensuring that patients receive the best treatment outcomes. This study aimed to evaluate. the effectiveness of a standardized dressing management protocol in the treatment of TEN.
Critical steps in the protocol 
The critical steps in managing skin conditions involve a systematic approach to environmental and patient preparation, including a single-occupancy room with controlled temperature and humidity, disinfection protocols, and using sterile materials to prevent infection. The process encompasses patient-specific care, such as maintaining oral and ocular hygiene and managing perineal health, with particular attention to non-ambulatory patients. Cleaning solutions, such as a warmed povidone-iodine saline mixture, are meticulously prepared for gentle and effective skin cleansing. The dressing change frequency must be adjusted according to the patient&#39;s exudate from the skin lesion. The silver sulfadiazine lipid hydrocolloid dressings dressing has the potential for antibacterial and anti-inflammatory properties and minimizes skin adhesion and discomfort. The benefits of comfrey oil include muscle regeneration, anti-inflammatory, antiviral, antioxidant, and vasodilatory effects. The comfrey oil and Bactroban combination form a protective lipid barrier on the skin, reducing the risk of wound infection and promoting rapid recovery of damaged areas22.
Iodine allergy patients should be cautious when using povidone-iodine (usually referred to as povidone-iodine). Due to the differences in chemical structure and bioavailability of different iodine preparations and iodine&#39;s slow and sustained release characteristics in povidone-iodine, its irritation to the skin is reduced, and its bactericidal effect is enhanced23. However, for iodine allergy patients, using povidone-iodine depends on the severity and mechanism of the allergic reaction. Individuals with mild allergies not caused by specific components of povidone-iodine may use it with caution under close medical supervision. Still, those with a history of severe allergies should be highly vigilant, as even small doses of iodine may cause severe reactions. Therefore, professional medical personnel must assess the patient&#39;s allergy history and health status before use. In case of uncertainty, it is advisable to avoid its use to prevent risks.
Infrared light, as a non-invasive physical therapy, has shown potential in TEN treatment. It is located between visible light and microwave, with solid penetration and the ability to penetrate deep into the skin. Near-infrared and far-infrared light have attracted medical attention due to their mild therapeutic effects. Infrared light can promote blood circulation, accelerate the delivery of nutrients and oxygen to wounds, facilitate healing, alleviate inflammatory response, decrease the release of inflammatory mediators, and relieve pain and discomfort24. It can also promote cell proliferation and collagen synthesis, accelerate skin regeneration and repair, and indirectly reduce the risk of infection by promoting blood circulation and reducing inflammation25. In TEN treatment, infrared light serves as an auxiliary treatment method. Doctors must develop personalized plans based on the patient&#39;s condition and wound status, use professional treatment equipment for irradiating the wound, and follow medical advice for treatment time and frequency. However, infrared therapy is not all-powerful, and various factors influence its effectiveness. It should be combined with other treatment methods to form a comprehensive treatment plan to achieve the best results.
Modifications and troubleshooting of the method 
The dressing management protocol utilized in this study represents an advancement over prior methodologies. A pivotal innovation is the selection of dressing materials. Historically, using Vaseline-impregnated gauze for dressing changes often posed difficulties, such as patient discomfort, wound bleeding, or secondary damage to newly formed tissue caused by gauze removal, thereby prolonging the wound healing process26. In contrast, silver sulfadiazine dressings offer a range of beneficial properties, including non-adherence to the wound bed, bacteriostatic effects, promotion of wound repair, absorption of exudates, and protection against skin injury27. Moreover, this protocol&#39;s approach of tailoring dressing frequency according to the condition of skin exudates exemplifies the principle of personalized care. This approach not only ensures the efficacy of the dressing but also minimizes the irritation caused by unnecessary dressing changes.
Consequently, it contributes to a reduction in the duration of hospital stays. Additionally, we proposed different methods for particular sites to tailor care for different patients. Since patients with TEN often have Nikolsky&#39;s Sign, protecting undetached but fragile skin from further damage during the dressing change process is crucial.
Limitations of the method 
This study has some limitations to address. First, the successful application of the protocol was confined to a single hospital setting, and multicenter studies have yet to demonstrate the findings. The generalizability of the results may be constrained, as different healthcare environments with diverse patient demographics and varying resource availability levels could produce divergent outcomes. Second, the performance of this protocol was concluded based on a retrospective analysis. The effectiveness and rigor of this method should be evaluated in prospective randomized controlled trials-besides, this method&#39;s core procedure involved applying silver ion dressings. While positive effects were observed with this dressing category, alternative dressing types&#39; potential efficacy and interchangeability remain unexplored. Furthermore, a comprehensive comparative analysis of different varieties was not undertaken within the silver ion dressing category. This could have yielded more granular and nuanced insights into the optimal dressing options.
Significance of the method 
Wound care is of great importance in TEN management; however, no consensus steps for dressing change for TEN have been proposed to date4,6. Some principles have been established, like anti-shear strategies, and careful drainage of large or painful bullae, but the application of these principles into clinical practice needs further investigation6. Here, we for the first time proposed practical wound care strategies and dressing change procedures in the management of patients with TEN. This dressing change strategy is especially applicable for patients with large areas of skin detachment. We believe that this protocol could provide nurses or doctors with limited wound care experience, with practical guidelines to operate, and easy to start. We also hope that this protocol can support the establishment of a consensus on intact and effective operating procedures for TEN patients in further studies.

Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction, distinguished by widespread epidermal detachment and bullae formation, which confers an increased susceptibility to complications such as infections and derangements in fluid and electrolyte balance1. This condition invariably precipitates a host of complications, notably infection and fluid and electrolyte imbalances, with the severity of TEN being inextricably linked to the manifestation and progression of such complications. The literature has documented that TEN mortality rates span from 12% to 30%2. Areas of diffuse erythema are seen in TEN, with individual macular lesions at the periphery. Large, flaccid blisters are formed from the detachment of the epidermis from the underlying dermis. The roofs of the blisters turn necrotic and large 5 cm sheets show denudation of the epidermis3. The efficacious management of TEN is predicated upon the prompt discontinuation of the inciting drug regimen and meticulous wound care4. Of particular note, wound care assumes a central position in the treatment paradigm for TEN patients. Its principal objectives are to stanch occult fluid loss, forestall the onset of sepsis, and foster epithelial regeneration5. The overarching principles governing wound care encompass safeguarding the underlying exposed dermis, attenuating the potential for infection, mitigating the risks of pigmentary alterations and scarring, and optimizing the process of epithelial reformation. More specifically, wound care resides within the purview of surgical debridement, and its operational modalities entail selecting either debridement procedures or supportive dressings. This translates into either the excision of detached and necrotic epidermal tissues or the retention of viable epidermis as a biological dressing, followed by the application of supportive dressings to facilitate epithelial reformation4.
The extensive skin lesions associated with TEN are particularly susceptible to being invaded by microbes such as bacteria, fungi, and other pathogens6. Conventional dressings, such as gauze and cotton pads, exhibit limited water absorption capabilities and have a propensity to adhere to wound surfaces, leading to iatrogenic trauma, exacerbated pain levels, and bleeding during dressing changes7. These materials provide inadequate air permeability, which impedes wound healing8. Furthermore, traditional dressings are ineffective at preventing and managing infections, increasing the risk of wound sepsis9. Their inability to facilitate wound healing results in prolonged convalescence, increased patient discomfort, and higher healthcare costs10.
Novel dressings, such as zinc oxide talcum powder wraps and silver ionic dressings, have been investigated for TEN management11. Notably, silver sulfadiazine lipid hydrocolloid dressings dressing, a typical silver ionic dressing that sustains the release of silver sulfadiazine, has shown promise in maintaining adequate antibacterial levels, promoting a moist healing environment, and decreasing irritation and pain during dressing changes12,13,14,15. Recent studies suggest that silver sulfadiazine lipid hydrocolloid dressings can reduce healing time, infection rates, and patient discomfort compared to traditional dressing16,17. However, standardized dressing change protocols still need to be developed for TEN patients.
At present, there is a lack of standardized protocols for the wound care of patients with toxic epidermal necrolysis (TEN). Moreover, wound management practices differ among various medical units. Consequently, the establishment of standardized wound management for TEN patients constitutes a crucial yet unfulfilled clinical priority18. The primary aim of this research is to standardize the wound dressing change procedures for TEN patients. Specifically, it endeavors to compare the wound healing time between two different dressing change regimens: one centered around silver sulfadiazine liposome hydrocolloid dressing, and the other being the conventional dressing change approach. The secondary objective is to investigate the efficacy of silver sulfadiazine liposome hydrocolloid dressing in facilitating wound healing in these patients.

<table><tbody><tr><td>0.9% sodium chloride</td><td>SOUTHWEST PHARMACEUTICAL Co.,Ltd.</td><td></td><td></td></tr><tr><td>Bactroban ointment</td><td>Tianjin Shike Pharmaceutial Co.,Ltd.</td><td></td><td></td></tr><tr><td>Disposable Medical Kit (a dressing change box with sterile scissors)</td><td>Zhende Medical Co.,Ltd.</td><td>GB/T HYA-15</td><td></td></tr><tr><td>Fu fang Comfrey oil</td><td>Jian Min Ji Tuan Ye KaiTaiGuoYao Co.,Ltd.</td><td>GBZ20044385</td><td></td></tr><tr><td>Medical&amp;nbsp; Swab</td><td>Zhende Medical Co.,Ltd.</td><td>6926515436841</td><td></td></tr><tr><td>petroleum jelly oil gauze</td><td>Henan PiaoAn Group Co.,Ltd.</td><td>GB20153140848</td><td></td></tr><tr><td>Povidone-iodine</td><td>SHANDOING LIERKANG TECHOLOGY Co.,Ltd.</td><td></td><td></td></tr><tr><td>rb-bFGF</td><td>ZHU HAi Yi SHENG&amp;nbsp; BIOLOGICAL MEDICAL Co.,Ltd.</td><td>GBS1098077</td><td></td></tr><tr><td>silver sulfadiazine lipid hydrocolloid dressings</td><td>LABORATOIRES URO</td><td>3546895089623</td><td></td></tr><tr><td>Single-Use Sterile Rubber Surgical Gloves (both sterile and film)</td><td>SHANDOING YU YUAN RBBER GLOVES Co.,LTD</td><td>GB/T 7543-2020</td><td></td></tr><tr><td>Sterile Dispensing Syringe for Single Use (empty needles)</td><td>SHANDON WEIGAO GROUP MEDICAL POLYER Co.,LTD</td><td>GB/T 20142140076</td><td></td></tr><tr><td>sterile gauze rolls</td><td>Zhende Medical Co.,Ltd.</td><td>6959385745812</td><td></td></tr></tbody></table>

a standardized procedure of dressing management for toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with high mortality rates, demanding specialized wound care to address epidermal detachment and bullae formation. This study summarizes a standardized dressing management protocol to enhance the healing process, reduce complications, and improve patient comfort during dressing changes for TEN patients. The protocol emphasizes a systematic approach to patient preparation, environmental control, and the utilization of silver-ion-based dressing materials. Specifically, it integrates gentle cleansing techniques with a warmed povidone-iodine saline solution, precise necrotic tissue removal, and silver sulfadiazine lipid hydrocolloid dressings to maintain an optimal healing environment. The effectiveness of this protocol was further validated through a retrospective analysis, which showed a significant reduction in the onset of re-epithelization, wound healing time, and hospital stays, resulting in diminished pain during dressing changes. Furthermore, this protocol also provides tailored strategies for dressing changes in sensitive areas, ensuring comprehensive care. The standardized protocol streamlines the dressing process and contributes to more efficient allocation of healthcare resources, establishing a robust foundation for TEN treatment that can be adopted in clinical practice and inform future research.

We retrospectively compared the outcomes of this new method (based on silver sulfadiazine lipid hydrocolloid dressings dressing) with the conventional method (which did not involve silver sulfadiazine lipid hydrocolloid dressings dressing or sterile cotton pads) throughout the years 2023-2024. Sixty patients with toxic epidermal necrolysis (TEN) from the Dermatology Department of the First Affiliated Hospital of Chongqing Medical University were enrolled for statistical analysis. Mean values, standard deviations (SD), and the Wilcoxon rank-sum test were applied to contrast the demographic details, rash control duration, wound desiccation time, skin healing period, and average hospitalization stay of patients in the experimental group treated with silver sulfadiazine liposome hydrocolloid dressing and those in the control group using common petrolatum gauze. P &#60; 0.05 was regarded as indicative of a statistically significant difference.
Figure 1&#160;shows the critical dressing change steps and outcomes in a patient with TEN. On admission, the patient&#39;s epidermis becomes loose and exfoliated (Figure 1A). The detached epidermis and the necrotic tissue or debris adhering to the wound are removed gently using sterile scissors (Figure 1B). Then, silver sulfadiazine lipid hydrocolloid dressings dressing is used based on the size of the skin lesion. An appropriate-sized silver sulfadiazine lipid hydrocolloid dressings dressing was gently applied to ensure complete coverage, extending 0.5-1 cm beyond the wound margin (Figure 1C). A large gauze block soaked in comfrey oil and Bactroban mixture was used to cover the silver sulfadiazine lipid hydrocolloid dressings. Finally, sterile gauze and cotton pads were fixed on top (Figure 1D). Figure 1E,F show the outcomes for this patient on day 7 (after two dressing changes) and day 11 (after three dressing changes). The skin was re-epithelized.
Table 1 compares patients&#39; demographic characteristics and outcomes between this new and conventional method. There was no significant difference in age, sex, and exfoliation area between the two groups (P &#62; 0.05). However, the re-epithelization start time, wound healing time, and length of stay were significantly shorter using our new method than the conventional method (P &#60; 0.001). Besides, when changing dress, patients feel less pain using our new method (P &#60; 0.001).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/67566/67566fig01.jpg" /> 
Figure 1: Key dressing change steps and outcomes in a patient with toxic epidermal necrolysis. (A) The exfoliated and necrotized epidermis on admission. (B) The back of the patient after removing the detached epidermis and necrotic tissue. (C) The use of silver sulfadiazine lipid hydrocolloid dressings dressing. (D) Final cover with sterile gauze and fixation with a sterile cotton pad. (E) Outcome at day 7. (F) Outcome at day 11. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/67566/67566fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Conventional method (N=25)</td>
			<td>Our new method (N=14)</td>
			<td>P</td>
		</tr>
		<tr>
			<td>Age, years</td>
			<td>48.55&#177;15.53</td>
			<td>49.27&#177;20.77</td>
			<td>0.335</td>
		</tr>
		<tr>
			<td>Sex, male</td>
			<td>14/16</td>
			<td>15/15</td>
			<td>0.394</td>
		</tr>
		<tr>
			<td>BSA detached, %</td>
			<td>46.36&#177;19.63</td>
			<td>47.49&#177;17.47</td>
			<td>0.834</td>
		</tr>
		<tr>
			<td>Wound drying time, days</td>
			<td>7.75&#177;1.06</td>
			<td>6.15&#177;1.21</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Re-epithelization start time, days</td>
			<td>6.08&#177;1.16</td>
			<td>3.85&#177;0.90</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Wound healing time, days</td>
			<td>17.78&#177;1.67</td>
			<td>13.54&#177;1.92</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Length of stay, days</td>
			<td>19.58&#177;2.50</td>
			<td>16.15&#177;1.99</td>
			<td>&#60;0.001</td>
		</tr>
		<tr>
			<td>Pain score during dressing change</td>
			<td>6.42&#177;1.33</td>
			<td>3.71&#177;1.12</td>
			<td>&#60;0.001</td>
		</tr>
	</tbody>
</table>
Table 1: Comparison of demographic and outcome results. Abbreviation: BSA = body surface area.

This is a standardized dressing protocol for patients with toxic epidermal necrolysis. This robust protocol utilizes silver ion dressings designed to accelerate healing and alleviate pain, minimizing hospital stays.

A Standardized Procedure of Dressing Management for Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a severe cutaneous adverse drug reaction with high mortality rates, demanding specialized wound care to address ...

a-standardized-procedure-dressing-management-for-toxic-epidermal

Nanyang Technological University

Research

JoVE Journal

Medicine

182 Views.  The First Affiliated Hospital of Chongqing Medical University. Dit is een gestandaardiseerd verbandprotocol voor patiënten met toxische epidermale necrolyse. Dit robuuste protocol maakt gebruik van zilverionenverbanden die zijn ontworpen om de genezing te versnellen en pijn te verlichten, waardoor het verblijf in het ziekenhuis tot een minimum wordt beperkt.

Video: Een gestandaardiseerde procedure voor verbandbeheer voor toxische epidermale necrolyse

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Surgical Technique for Spinal Cord Delivery of Therapies: Demonstration of Procedure in Gottingen Minipigs

This is a compact visual description of a combination of surgical technique and device for the delivery of (gene and cell) therapies into the spinal cord. While the technique is demonstrated in the animal, the procedure is FDA-approved and currently being used for stem cell transplantation into the spinal cords of patients with ALS. While the FDA has recognized proof-of-principle data on therapeutic efficacy in highly characterized rodent models, the use of large animals is considered critical for validating the combination of a surgical procedure, a device, and the safety of a final therapy for human use. The size, anatomy, and general vulnerability of the spine and spinal cord of the swine are recognized to better model the human. Moreover, the surgical process of exposing and manipulating the spinal cord as well as closing the wound in the pig is virtually indistinguishable from the human. We believe that the healthy pig model represents a critical first step in the study of procedural safety.

Short visual description of the surgical technique and device used for the delivery of (gene and cell) therapies into the spinal cord. The technique is demonstrated in the animal but is entirely translatable and currently being used for human application.

This is a  compact visual description of a combination of surgical technique and device  for the  delivery of (gene and cell) therapies into the spinal ...

Tibial Nerve Transection - A Standardized Model for Denervation-induced Skeletal Muscle Atrophy in Mice

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. Although originally developed and used extensively in the rat due to its larger size, the tibial nerve in mice is big enough that it can be easily manipulated with either crush or transection, leaving the peroneal and sural nerve branches of the sciatic nerve intact and thereby preserving their target muscles. Thus, this model offers the advantages of inducing less morbidity and impediment of ambulation than the sciatic nerve transection model and also allows investigators to study the physiologic, cellular and molecular biologic mechanisms regulating the process of muscle atrophy in genetically engineered mice. The tibial nerve supplies the gastrocnemius, soleus and plantaris muscles, so its transection permits the study of denervated skeletal muscle composed of fast twitch type II fibers and/or slow twitch type I fibers. Here we demonstrate the tibial nerve transection model in the C57Black6 mouse. We assess the atrophy of the gastrocnemius muscle, as a representative muscle, at 1, 2, and 4 weeks post-denervation by measuring muscle weights and fiber type specific cross-sectional area on paraffin-embedded histologic sections immunostained for fast twitch myosin.

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of skeletal muscle atrophy. The model surgical protocol is described and demonstrated in C57Black6 mice. &#160;

The tibial nerve transection model is a well-tolerated, validated, and reproducible model of denervation-induced skeletal muscle atrophy in rodents. ...

Pharmacologic Induction of Epidermal Melanin and Protection Against Sunburn in a Humanized Mouse Model

Fairness of skin, UV sensitivity and skin cancer risk all correlate with the physiologic function of the melanocortin 1 receptor, a Gs-coupled signaling protein found on the surface of melanocytes. Mc1r stimulates adenylyl cyclase and cAMP production which, in turn, up-regulates melanocytic production of melanin in the skin. In order to study the mechanisms by which Mc1r signaling protects the skin against UV injury, this study relies on a mouse model with "humanized skin" based on epidermal expression of stem cell factor (Scf). K14-Scf transgenic mice retain melanocytes in the epidermis and therefore have the ability to deposit melanin in the epidermis. In this animal model, wild type Mc1r status results in robust deposition of black eumelanin pigment and a UV-protected phenotype. In contrast, K14-Scf animals with defective Mc1r signaling ability exhibit a red/blonde pigmentation, very little eumelanin in the skin and a UV-sensitive phenotype. Reasoning that eumelanin deposition might be enhanced by topical agents that mimic Mc1r signaling, we found that direct application of forskolin extract to the skin of Mc1r-defective fair-skinned mice resulted in robust eumelanin induction and UV protection 1. Here we describe the method for preparing and applying a forskolin-containing natural root extract to K14-Scf fair-skinned mice and report a method for measuring UV sensitivity by determining minimal erythematous dose (MED). Using this animal model, it is possible to study how epidermal cAMP induction and melanization of the skin affect physiologic responses to UV exposure.

Epidermal melanin is induced by topical application of forskolin in a murine model of the fair-skinned UV-sensitive human. Pharmacologic manipulation of cAMP levels in the skin and epidermal darkening strongly protect against UV-mediated inflammation (sunburn) as measured by the minimum erythematous dose (MED) assay.

Fairness of skin, UV sensitivity and skin cancer  risk all correlate with the physiologic function of the melanocortin 1  receptor, a Gs-coupled signaling ...

A Standardized Obstacle Course for Assessment of Visual Function in Ultra Low Vision and Artificial Vision

We describe an indoor, portable, standardized course that can be used to evaluate obstacle avoidance in persons who have ultralow vision. Six sighted controls and 36 completely blind but otherwise healthy adult male (n=29) and female (n=13) subjects (age range 19-85 years), were enrolled in one of three studies involving testing of the BrainPort sensory substitution device. Subjects were asked to navigate the course prior to, and after, BrainPort training. They completed a total of 837 course runs in two different locations. Means and standard deviations were calculated across control types, courses, lights, and visits. We used a linear mixed effects model to compare different categories in the PPWS (percent preferred walking speed) and error percent data to show that the course iterations were properly designed. The course is relatively inexpensive, simple to administer, and has been shown to be a feasible way to test mobility function. Data analysis demonstrates that for the outcome of percent error as well as for percentage preferred walking speed, that each of the three courses is different, and that within each level, each of the three iterations are equal. This allows for randomization of the courses during administration.
Abbreviations: 
preferred walking speed (PWS) 
course speed (CS) 
percentage preferred walking speed (PPWS)

We describe an indoor, portable, standardized course that can be used to evaluate obstacle avoidance in persons who have ultralow vision. The course is relatively inexpensive, simple to administer, and has been shown to be reliable and reproducible.

We describe an indoor, portable, standardized course that can be used to evaluate obstacle avoidance in persons who have ultralow vision. Six sighted ...

Therapeutic Effectiveness of a Dietary Supplement for Management of Halitosis in Dogs

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized placebo-controlled crossover clinical evaluation, we assessed&#160;the effectiveness of a dedicated dietary supplement to improve chronic halitosis in 32 dogs of different breeds and ages. This protocol describes how to evalute the presence of oral volatile suphur compunds, e.g. methyl mercaptan, hydrogen sulfide and dimethyl sulfide, by means of a portable gas chromatograph device coupled with a syringe, which was used to collect the breath, and a dedicated software, which allows the operator to monitor each compound concentration during each measurement, in a relatively short time (8 min).
A significant modification of halitosis parameters was observed after 30 days since the beginning of treatment (p &#60;0.05), while a long-lasting effect was still observed even 20 days after the suspension of the treatment. Portable gas chromatograph, which is also widely used in clinical practice, can be therefore used to confirm&#160;and control halitosis in humans and animals. Even though human and animal species present some differences,&#160;this innovative and alternative therapy for halitosis management might be extended to human clinical practice as an adjuvant dietary approach.

We describe a simple approach for diagnosis of halitosis in dogs as well as a dietary approach for its management. This protocol may be extended to the management of halitosis in humans in the near future.

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized ...

Standardized Measurement of Nasal Membrane Transepithelial Potential Difference (NPD)

We describe a standardized measurement of nasal potential difference (NPD). In this technique, cystic fibrosis transmembrane conductance regulator (CFTR) and the epithelial sodium channel (ENaC) function are monitored by the change in voltage across the nasal epithelium after the superfusion of solutions that modify ion channel activity. This is enabled by the measurement of the potential difference between the subcutaneous compartment and the airway epithelium in the nostril, utilizing a catheter in contact with the inferior nasal turbinate.
The test allows the measurement of the stable baseline voltage and the successive net voltage changes after perfusion of 100 &#181;M amiloride, an inhibitor of Na+ reabsorption in Ringer&#39;s solution; a chloride-free solution containing amiloride to drive chloride secretion and 10 &#181;M isoproterenol in a chloride-free solution with amiloride to stimulate the cyclic adenosine monophosphate (cAMP)-dependent chloride conductance related to CFTR.
This technique has the advantage of demonstrating the electrophysiological properties of two key components establishing the hydration of the airway surface liquid of the respiratory epithelium, ENaC, and CFTR. Therefore, it is a useful research tool for phase 2 and proof of concept trials of agents that target CFTR and ENaC activity for the treatment of cystic fibrosis (CF) lung disease. It is also a key follow-up procedure to establish CFTR dysfunction when genetic testing and sweat testing are equivocal. Unlike sweat chloride, the test is relatively more time consuming and costly. It also requires operator training and expertise to conduct the test effectively. Inter- and intra-subject variability has been reported in this technique especially in young or uncooperative subjects. To assist with this concern, interpretation has been improved through a recently validated algorithm.

Standardized Measurement of Nasal Membrane Transepithelial Potential Difference NPD

Here, we present a standardized protocol to measure the nasal potential difference (NPD). Cystic fibrosis transmembrane conductance regulator (CFTR) and epithelial sodium channel (ENaC) function are evaluated by the change in the voltage across the nasal epithelium after superfusion of solutions that modify ion channel activity, providing an outcome measure.

We describe a standardized measurement of nasal potential difference (NPD). In this technique, cystic fibrosis transmembrane conductance regulator (CFTR) ...

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

Severe Burn Injury in a Swine Model for Clinical Dressing Assessment

Wound healing is a dynamic repair process and is the most complex biological process in human life. In response to burn injury, alterations in biological pathways impair the inflammation response, resulting in delayed wound healing. Impaired wound healing frequently occurs in patients with diabetes leading to unfavorable outcomes such as amputation. Hence, dressings having beneficial effect in promoting burn wound repair are needed. However, studies on burn wound treatment are limited due to lack of proper animal models. Our previous study demonstrated wound-healing performance in rat and swine models using a minimally invasive surgical technique. This study aimed to demonstrate a swine model of severe burn injury that eliminates wound contraction and more closely approximates the human processes of re-epithelialization and new tissue formation. This protocol provides a detailed procedure for creating consistent burn wounds and examining the wound-healing performance under the treatment of an experimental dressing in a swine model. Six burn wounds were created symmetrically on the dorsum, which were covered with a clinical dressing composed of four layers: an inner contact layer of experimental materials, an inner intermediate layer of waterproof film, an outer intermediate layer of gauze, and an outer layer of adhesive plaster. Upon the completion of experiments, wound closure, wound area, and Vancouver Scar Scale score were examined. The samples of skin resected from each animal post-sacrifice were histologically prepared and stained using hematoxylin and eosin staining. Antibacterial activity of each dressing in the context of wound healing was also examined. The application of the clinical dressing to the wounds in swine model mimics the biological processes of human wound healing with respect to the processes of epithelialization, cellular proliferation, and angiogenesis. Therefore, this swine model provides an easy-to-learn, cost-effective, and robust method to assess the effect of clinical dressings in severe burn injury.

To closely mimic the mode of burn injuries requires the interplay between clinical observation and studies in animal models. In this study, a swine model of severe burn injury was established to assess an experimental dressing in physiological and pathophysiological settings.

Wound healing is a dynamic repair process and is the most complex biological process in human life. In response to burn injury, alterations in biological ...

Remote Laboratory Management: Respiratory Virus Diagnostics

An uptick in recent pandemics (Ebola, Zika, MERS, influenza, etc.) underlines the need for a more 'nimble,' coordinated response that addresses a multitude of issues ranging from transportation, access, facilities, equipment, and communication to provider training. To address this need, we have developed an innovative, scalable, logistics-enhanced, mobile, laboratory facility for emergencies and epidemics in resource-constrained global settings. Utilizing a background in clinical operations as an academic medical center, we designed a rapidly-deployable, modular BSL-2 and BSL-3 facility with user-friendly software for tracking and management of drugs and supplies in remote regions during epidemics and outbreaks. Here, we present our intermodal, mobile, expandable shipping-container laboratory units. The design of the laboratory facilitates off-grid usage by minimizing power consumption and allowing alternate water sources. The unit's information communication technology (ICT) platform provides (i) user-friendly tablet-based documentation, (ii) enhanced tracking of patients and supplies, and (iii) integrated communication onsite with built-in telehealth capabilities. To ensure quality in remote environments, we have developed a checklist for a basic laboratory workflow and a protocol for respiratory viral diagnosis using reverse-transcription polymerase chain reaction (RT-PCR). As described, this innovative and comprehensive approach allows for the provision of laboratory capability in resource-limited global environments.

A rapidly-deployable, off-grid laboratory has been designed and built for remote, resource-constrained global settings. The features and critical aspects of the logistically-enhanced, expandable, multifunctional laboratory modules are explored. A checklist for a basic laboratory workflow and a protocol for a respiratory viral diagnostic test are developed and presented.

A Standardized Procedure of Dressing Management for Toxic Epidermal Necrolysis

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