toxic epidermal necrolysis ( ten ) is a rare disease with an incidence of approximately 12 per million / year , . ten is clinically diagnosed by cutaneous erythema , progressive blistering , epidermolysis ( > 30% total body surface area ( tbsa ) ) , mucosal erosions , and/or ophthalmic affection . the cutaneous eruption is characterized by the nikolsky sign , which is defined as epidermolysis with mobility of the affected epidermis upon healthy skin and epidermal detachment on the slightest friction . skin biopsy is the only reliable method to confirm the diagnosis of ten ( separation of the epidermo - dermal junction ) in correlation with the macroscopic clinical presentation of the skin . burn center treatment is recommended in ten - patients , because of the extensive cutaneous defects . high mortality rates of ten have been reported ( 14 to 70% ) , , , . the independent predictors of mortality in ten are age ( > 40 years ) , heart rate ( > 120/min ) , presence of malignant tumors , initial epidermolysis ( > 10% affected surface area ) , serum urea ( > 10 mmol / l ) , serum bicarbonate ( < 20 mmol / l ) , and serum glucose ( > 14 mmol / l ) . these variables are described by bastuji - garin et al . after evaluating epidemiologic and diagnostic parameters . hypernatremia ( > 145 mmol/ ) is a common electrolyte disorder characterized by a deficit of total - body water relative to total - body sodium . it is almost never found in an alert patient with a normal thirst mechanism and access to water . hypernatremia can be classified according to the patient 's volume status ( hypovolemia , euvolemia , hypervolemia ) . in hypovolemic hypernatremia free water loss exceeds sodium loss , whereas patients with an euvolemic hypernatremic state have pure water loss without signs of hypovolemia . hypervolemic hypernatremia , caused by a pure sodium overload is rare and frequently caused iatrogenically , by excessive sodium administration , overcorrection of hyponatremia , hypertonic dialysate , and hypertonic enteral or parenteral hyperalimentation . noniatrogenic etiologies include various mineralocorticoid deficiencies , salt water neardrownings , ingestion of improperly prepared infant formula , and ingestion of salt tablets . free water loss can result from extrarenal ( i.e. sweating , burns , diarrhea , skin diseases ) or renal ( diuretics , severe osmotic diuresis , severe glucosuria in diabetics , or elevated urea in postobstructive diuresis ) causes . it is difficult to distinguish whether these high mortality rates are caused by the hypernatremia itself , the underlying disease process , or the sequelae of hypernatremia treatment . in non - ten critically ill patients an acquired hypernatremic state appears to be associated with increased mortality rates ( range from 31% to 66% ) , , , , , , . we present a retrospective study to elucidate the impact of in - hospital acquired hypernatremia on mortality . fifty - two patients with a severe cutaneous drug reaction were treated during the past 10 years . twenty - five patients with ten ( epidermolysis > 30% tbsa ) were identified retrospectively . patients with an epidermolysis < 30% tbsa were excluded from this study , because of the lower severity of illness and to provide a better comparability in with previous studies in the ten group . hemodynamic monitoring was realized by continuous invasive blood pressure measurement . to achieve a balanced fluid regimen , urinary output , mean amount and type of infusate ( ringer 's solution , glucose 5% ) and/or diuretics ( e.g. furosemid ) were adjusted to individual requirements . hypernatremia was treated immediately with an increased infusion rate of electrolyte free water ( glucose 5% ) . chicago , usa ) . to estimate significance mann - whitney - u- or chi - square - test were performed . survival was calculated using kaplan - meier method ; logrank ( mantel - cox ) analysis was used to calculate statistical significance . 25 ( 17 female ; 8 male ) patients with a mean age of 5918 years , a mean epidermolysis surface of 76.419% , and a mean scorten - score of 3.21 were included . mean urinary output was 1.20.4 ml / hour within the first 10 days after admission . patients were separated into two groups : group a ( without ) and group b ( with ) in - hospital acquired hypernatremia . in group a , 10 patients ( 5 female ; 5 male ) were summarized . mean age , affected tbsa , scorten , diuresis , serum sodium level ( on admission ) , amount of furorese and daily infusion - diuresis - ratio ( idr ) ( for day 1 to 4 and day 1 to 10 ) are given in table 1 ( tab . there was no elevated serum sodium level in group a within the first 10 days after admission . in group mean age , affected tbsa , scorten , diuresis , serum sodium level ( on admission ) , amount of furorese and daily idr ( for day 1 to 4 and day 1 to 10 ) are given in table 1 ( tab . no significant differences in age , sex , affected tbsa , mucosal involvement and daily amount of furorese applied ( over a 10-days - period ) and daily idr were found between group a and group b. statistical analysis showed a significantly higher mean creatinine within 10 days after admission ( p=0.025 ) , higher diuresis ( p=0.007 ) , higher mean serum sodium levels on admission ( p=0.004 ) , and a higher scorten - score ( p=0.04 ) in group b ( table 1 ( tab . one normonatremic and 8 hypernatremic patients died during icu - stay ( overall mortality 36% ) . a significantly higher mortality rate was found in group b ( odds ratio : 13,5 ; 95% confidence interval : 1.34135.98 ; p=0.01 ) during icu - stay ( figure 1 ( fig . 1 ) ) . 4 patients died in a septic state due to pneumonia , 2 patients died after myocardial infarction , and 1 patient died due to a pulmonary embolism . the remaining 2 patients died of multi - organ failure for which no pathologic mechanism could be identified . ten is a rare , but life - threatening , exfoliative dermatitis , affecting the skin and mucous membranes . the large open surface caused by epidermolysis , leads to an enormous transdermal fluid loss of up to 4 liters per day . in ten the type and the amount of infusate need to be adjusted to individual parameters such as the extent of epidermolysis , body weight , and co - morbidities such as renal insufficiency , chronic or acute pulmonary disease and cardiac dysfunction . a well balanced infusion - diuresis - ratio has to be achieved and monitored vigilantly . bastuji - garin et al . described a scoring system ( scorten ) that enables the physician to determine the severity of the illness and risk of death on admission of ten patients . age , tachycardia , presence of malignancy , initial epidermolysis , serum urea , serum bicarbonate , and serum glucose have been shown to predict mortality in ten . in - hospital hypernatremia ( > 146 mmol / l ) is a reliable marker for systemic dehydration . even a short period of hypernatremia may lead to an induction of apoptosis apart from its neurologic effects , . serum sodium is easy to evaluate in an icu setting by blood gas analysis and provides additional information about the patients systemic fluid status . patients admitted to an icu have a higher incidence of hypernatremia compared to general hospital population and there is a strong correlation in peak serum sodium level and mortality .   in the study of bastuji - garin et al . serum sodium imbalance ( hypo- and hypernatremia ) was shown to have a significant univariate association to patients survival . the aim of our study was to elucidate the impact of hypernatremia in the mortality of ten patients . there was a significantly higher mean serum sodium level at admission in group b ( with hypernatremia ) , but only 2 individuals showed abnormally high values ( > 146 mmol / l ) . the other group b patients showed normal serum sodium levels at admission . in - hospital the mean daily idr for the two analyzed periods ( day 1 to 4 and day 1 to 10 ) was higher in the hypernatremic subgroup , but statistical analysis did not show any significance . we registered a mortality rate of 36% in all analyzed ten - patients , which is at the lower range of prior reported studies , , , . we registered a significantly higher mortality in hypernatremic patients than in normonatremic patients ( figure 1 ( fig . the mortality rate of hypernatremic ten patients ( 60% ) was comparable to the results of other hypernatremic non - ten studies ( 31% to 66% ) , , , , , , . one explanation may be the amount of transdermal fluid loss ( epidermolysis > 30% tbsa ) and the painful limitation of oral feeding and fluid uptake due to erosive mucous membrane lesions . on the other hand , termination of the patient 's prior medication at admission  as an elementary step in ten treatment  can provoke alterations in urinary output . in our study a significantly higher diuresis was detected in patients with hypernatremia ( group b ) , but no larger amount of administered diuretics was registered . a hypernatremic state in ten patients is a symptom , which may provoke severe complications such as an increased mortality . the reason for increased mortality in hypernatremic patients could not be identified in our study . even previous studies , focused on hypernatremia and mortality , could not elaborate the specific mechanisms by which hypernatremia leads to increased mortality , , , , , , , . there was a significantly higher scorten at admission in group b , which indicates an increased severity of illness in these patients compared to normonatremic patients . we conclude that even in specialized burn units the incidence of hypernatremia in ten patients is unavoidable . in case of a hypernatremic state early intervention an arterial line offers easy electrolyte control besides continuous blood pressure monitoring as well as control of pulmonary gas exchange parameters . in a life - threatening disease like ten early transferral of ten patients to regional burn units for critical care management and optimized wound care has been shown to have a positive effect on survival . in this retrospective study the collected values and findings only have an empiric character and should be investigated by prospective randomized clinical trials . the collected values and findings only have an empiric character and should be investigated by prospective randomized clinical trials .
introduction : in - hospital hypernatremia is associated with increased mortality rates . 
 we want to elucidate the impact of in - hospital acquired hypernatremia in mortality of toxic epidermal necrolysis ( ten).purpose : is there an association between hypernatremia and mortality in patients with ten?method : retrospective study of 25 patients with ten . 
 laboratory electrolyte results , diuresis and survival were analyzed . 
 patients were separated in two groups without ( group a ) or with ( group b ) hypernatremia.results : in group a 10 patients with a tbsa of 7425% ( mean  standard deviation ) , and a scorten - score of 2.70.9 were summarized . 
 diuresis within the first 10 days after admission was 10.3 ml / kg / hour . in group 
 b 15 patients with a tbsa of 7619% , and a scorten - score of 3.51 were included . 
 diuresis within the first 10 days after admission was 1.40.4 
 ml / kg / hour . 
 hypernatremia occurred on day 3.32.4 after admission and persisted for 5.32.9 days . 
 statistical analysis showed a significantly higher diuresis ( p=0.007 ) and scorten - score ( p=0.04 ) in the hypernatremic patients . 
 one normonatremic and 8 hypernatremic patients died during icu - stay ( overall mortality rate 36% ) . 
 a significantly higher mortality rate was found in group b ( odds ratio : 13,5 ; 95% confidence interval : 1.34135.98 ; p=0.01 ) during icu-stay.conclusion : ten patients with an in - hospital acquired hypernatremia have an increased mortality risk . 
 close electrolyte monitoring is advisable in these patients .