ABSTRACT
The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. This study was aimed to compare the analgesic effectiveness and safety of systemic analgesics alone or plus at-home topical sevoflurane for the management of patients with painful nonrevascularizable leg ulcers who were referred to a Pain Clinic by their attending vascular surgeons. We reviewed charts of patients treated in a single Pain Clinic with analgesic Standard of Care either alone (group SoC) or plus at-home topical sevoflurane (group SoC + Sevo), according to safety criteria. The area under the curve of pain over a year (AUC-Pain) was the primary outcome for analgesic effectiveness. Opioids were converted into Oral Morphine Milligram Equivalents. Groups SoC (n = 26) and SoC + Sevo (n = 38) were similar in baseline characteristics. Compared to SoC, median values [interquartile range] of area under the curve of pain for one-year follow-up were markedly lower for SoC + Sevo (54 [35-65] vs. 15 [11-23]; p < 0.000001, U Mann-Whitney test). Oral Morphine Milligram Equivalents were similar at baseline (SoC: 78.5 [22.5-135] vs. SoC + Sevo: 101.3 [30-160]; p = 0.753), but significantly lower for SoC + Sevo at three (120 [22.5-202.5] vs. 30 [0-80]; p = 0.005), six (120 [11.3-160] vs. 20 [0-67.5]; p = 0.004), nine (114.4 [0-154] vs. 0 [0-37]; p = 0.018), and 12 months (114.4 [0-154] vs. 0 [0-20]; p = 0.001). Multiple linear regression analysis revealed the addition of sevoflurane to be the most likely variable to explain this difference in outcome (ß:-33.408; p < 0.000001). Nine patients (24%) in SoC + Sevo had adverse effects attributed to sevoflurane, but only one patient needed to stop using sevoflurane due severe dermatitis. In conclusion, the addition of topical sevoflurane to the analgesic standard of care in patients with painful nonrevascularizable leg ulcers was a well-tolerated therapy that significantly improved pain control and allowed for a significant reduction in opioid consumption.
ABSTRACT
La presencia de úlceras cutáneas, con tendencia a la cronicidad y con mala respuesta al arsenal terapéutico-analgésico clásico, conllevan un alto grado de dolor, discapacidad y merma en la calidad de vida. Presentamos el caso de una paciente terminal con un cuadro álgico debido a la presencia de múltiples úlceras vasculares en miembros inferiores de 3 meses de evolución y de difícil manejo por mala tolerancia a anticomiciales y opioides mayores. Las instilaciones tópicas de forma periódica del anestésico halogenado sevoflurano sobre el lecho ulceroso lograron un excelente control del dolor basal e irruptivo a los pocos minutos de su administración, y una progresiva mejoría en la cicatrización de las úlceras sin evidenciar efectos secundarios asociados
The presence of cutaneous ulcers, with a tendency to become chronic and without a response to the therapeutic-analgesic arsenal available, carry a heightened degree of pain and disability and significantly compromise patient quality of life. A case is reported of a terminally ill woman with a painful condition due to the presence of multiple vascular ulcers of 3 months onset in lower right limb, and difficult to manage because of poor tolerance to anticonvulsants and major opioids. Periodically administered topical applications of halogenated anaesthetic sevoflurane on the ulcer bed achieved good results in baseline and breakthrough pain management within a few minutes after application and a progressive improvement in the healing of ulcers without associated adverse effects
Subject(s)
Humans , Female , Middle Aged , Skin Ulcer/drug therapy , Anesthetics/administration & dosage , Administration, Topical , Palliative Care/methodsABSTRACT
PURPOSE: Results of efficacy and safety assessments of topical sevoflurane use in patients with long-term treatment-refractory vascular ulcers are reported. METHODS: Patients were randomly assigned to receive sevoflurane instillations (1 mL per cm2 of ulcer area 1-4 times daily) plus standard wound care (ulcer cleaning, debridement, and dressing changes) or standard care only. Topical sevoflurane was initiated during hospitalization, with self- or nurse-administered instillations continued after discharge. Study participants were evaluated at least once weekly for 1 month and then every 2 weeks for up to 90 days. The primary efficacy measures were debridement-related and overall pain (assessed using a 10-point visual analog scale), daily opioid use, and ulcer size; secondary measures were patient and clinician impressions of improvement and ulcer-related admissions during treatment. The primary safety endpoint was intolerable sevoflurane-related adverse effects. RESULTS: Compared with the group receiving standard care alone (n = 5), the sevoflurane group (n = 10) had significant (p = 0.001) reductions in mean ± S.D. scores for debridement-related pain on day 1 of treatment and at subsequent time points; the sevoflurane group also had significant reductions in overall pain, daily opioid use, and ulcer size. Outcomes in terms of patient- and clinician-rated improvement and emergency admissions also favored the sevoflurane group. Mild localized reddening in the area surrounding ulcers occurred in 4 sevoflurane-treated patients. CONCLUSION: Direct application of sevoflurane onto vascular ulcers resulted in an intense and long-lasting analgesia and was associated with a progressive reduction of ulcer size.
