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• W2145332183 abstract "Vascular leg ulcers are a very common disease with a complicated management, a significant sanitary expense, as well as a significant repercussion in patient's quality of life. An appropriate analgesic control is essential for the management of this condition. The most commonly used therapeutic options to treat the pain are oral analgesics (Non-Steroidal Anti-Inflammatory Drugs (NSAID), acetaminophen, metamizole, tramadol, pregabalin and gabapentin), opiates and topical anaesthetic creams, such as lidocaíne or prilocaine. These therapies may lead to several adverse effects and complications, depending on the drug used and the characteristics of the patient 1, 2. Sevoflurane is an inhalable, halogenated anaesthetic agent with an adequate safety profile, used for induction and maintenance of general anaesthesia in hospital and ambulatory surgery, and its efficacy as a topical anaesthetic in vascular leg ulcers has already been reported 1-5. We present the case of a 73-year-old woman with a personal history of arterial hypertension, morbid obesity, type 2 mellitus diabetes, apnoea-hypoventilation syndrome, chronic renal failure and ischaemic cardiopathy. She suffered from a deep venous thrombosis on her right lower limb. The patient complained of disabling and highly painful vascular ulcers on her lower limbs. Daily cures and topical and multiple oral antibiotics were prescribed with an improvement and recovery of the ulcers on her left lower limb. Nevertheless, the ulcers on her right lower limb increased in number with severe pain and discomfort. A dermatological examination showed several deep ulcers with erythematous edges, seropurulent exudate and whitish and haemorrhagic scabs over the anterolateral surface of her right leg (Figure 1). X-ray image of her right leg did not show any significant alterations. The ankle-brachial index was normal. An ultrasound for deep venous thrombosis detection was normal. Histological study showed a chronic inflammatory infiltrate, with granulation tissue and skin calcification (Figure 2). The culture was positive for methicillin-resistant and clindamycin-mupirocin-sensitive Staphylococcus aureus. The patient was admitted to the Internal Medicine Service. Treatment was initiated with clindamycin, right leg immobilisation and strict control of glycaemia and arterial blood pressure. Written consent from the patient and permission from the Pharmacy Department were obtained for the off-label use of topical sevoflurane for her painful right leg ulcers. Daily treatment was initiated with a saline solution, followed by direct irrigation of 10 ml of liquid sevoflurane daily over the ulcers. An intense analgesic effect was reported in 10 minutes, lasting 8 hours without using other systemic analgesics, and it allowed cleaning with chlorhexidine gluconate solution, surgical debridement of the necrotic tissue, and occlusive dressings with topical mupirocin. As the only adverse effects, she developed erythema and itching over the ulcer edges, which were resolved with emollients. The satisfaction level of the patient was high. After 21 days of treatment, most of the right leg ulcers were healed (Figure 3). The patient was followed up with no evidence of recurrence or new lesions. Inhalable sevoflurane has been clinically demonstrated to have an analgesic central effect without peripheral effect. Topical or subcutaneous sevoflurane has a reversible local and peripheral analgesic effect that has been clinically tested and is concentration-dependent, which is probably caused due to a sufficient partial pressure in the peripheral nociceptors that block the transmission of pain stimulus 6-9. Topical sevoflurane has been reported in the literature as an analgesic treatment for vascular leg ulcers that are refractory to usual analgesics 1-5. Geronimo-Pardo et al. 2 reported the first case of a 76-year-old female with several risk factors of cardiovascular disease and bilateral painful venous ulcers that were treated with 5 ml of topical sevoflurane daily. An intense analgesic effect was reported in 2 minutes that lasted 12 hours. The treatment was applied for 16 days with a progressive and significant improvement until complete healing. At the 17ª Annual Meeting of The European Society of Regional Anaesthesia and Pain Therapy, held in Barcelona, in October 2011, a study on nine ambulatory patients (six women and three diabetic men) was reported. These patients had painful venous ulcers in the lower limbs that were refractory to usual analgesics and were treated with topical sevoflurane, with 76 applications in total. In all the cases, the pain reduction was quick/fast (<2 minutes), intense (from 7·4 ± to 2·1 ± 0·6 points for the first time and from 7·2 ± 1·3 to 1·1 ± 0·6 points in the combination of the 67 remaining applications) and long-lasting (from 7 to 16 hours). In four patients, complete ulcer healing was achieved. Martinez Monsalve and Gerónimo Pardo 3 reported a case of a 73-year-old male with respiratory failure secondary to morphine and tibial ischaemic ulcer superinfected by multidrug-resistant Pseudomonas aeruginosa. The ulcer was treated with 10 ml of topical sevoflurane daily, resulting in complete analgesic effect in about 2 minutes that allowed cleaning and surgical debridement without using any other analgesic strategy. Rueda Martinez 4 reported the case of an immunocompromised 43-year-old male who had received a liver transplant because of cirrhosis caused by hepatitis C. The surgical site was initially infected by multidrug-resistant P. aeruginosa and sensitive Staphylococcus aureus and it healed after several topical sevoflurane applications. Sevoflurane presents two beneficial properties compared with the topical anaesthetics lidocaine and prilocaine: a more intensive, faster and longer analgesic effect and the application of liquid sevoflurane involves a larger extension 1-5. An epithelial regeneration action has been suggested because of a direct vasodilator effect that promotes cicatrisation 1-5. A bactericidal effect in vitro against sensitive and multidrug-resistant S. aureus, P. aeruginosa and Escherichia coli has been tested by an unknown action mechanism 10. Treatment consists of cleaning with a saline solution and irrigating the ulcer with 5–10 ml of liquid sevoflurane without exceeding the edges of healthy skin. The latency time goes from 2 to 10 minutes. An intense effect is achieved that facilitates ulcer cleaning and debridement. Topial sevoflurane presents a favourable benefit/risk balance, with an appropriate safety and efficacy profile. The only adverse effects are itching and irritation of healthy skin. Sensitisation capacity of sevoflurane has not been reported. It has been suggested that systemic absorption of direct topical sevoflurane over an ischaemic ulcer occurs only in a slow and incomplete way, without haemodynamic alterations 1-5. In conclusion, topical sevoflurane is an innovative and attractive therapeutic alternative for refractory, chronic vascular ulcers, with a quick, intense and lasting analgesic effect; a possible epithelial regeneration and antimicrobial action and an adequate tolerance and safety profile among elderly and pluripathological patients. Adrián Imbernón-Moya1, Cristina Blázquez1, Ana Puebla2, Micaela Churruca1, Alejandro Lobato1, Marcela Martínez1, Antonio Aguilar1, Miguel A Gallego1 1Department of Dermatology Hospital Universitario Severo Ochoa Madrid, Spain 2Department of Pharmacy Hospital Universitario Severo Ochoa Madrid, Spain adrian_imber88@hotmail.com" @default.
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• W2145332183 date "2015-07-21" @default.
• W2145332183 modified "2023-10-03" @default.
• W2145332183 title "Chronic venous ulcer treatment with topical sevoflurane" @default.
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• W2145332183 doi "https://doi.org/10.1111/iwj.12474" @default.
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