Palliative analgesia with topical sevoflurane in cancer-related skin ulcers: a case report

Abstract

A Caucasian 39-year-old male patient with a poorly-differentiated infiltrating epidermoid penile carcinoma with urethral invasion was diagnosed. The patient received concomitant adjuvant chemotherapy with radiotherapy in the palliative setting, which produced painful ulceration of tumour lesions at loco-regional level (Numerical Rate Scale, NRS=9). The patient consented for treatment with direct topical sevoflurane instillations, at initial doses of 1 mL/cm2 of ulcerated area, as per unit protocol. The local use of undiluted sevoflurane achieved a marked reduction of the pain score in both nociceptive and irruptive pains (average NRS=3 immediately post-application). This improvement was corroborated by a decline in total morphine needs, any adverse events associated with major opiates. PGI-I and CGI-I scales were used before and after treatment with topical sevoflurane to assess patient and clinician perceptions of improvement in the quality of life. The pharmacy of our hospital had the responsibility to elaborate pre-loaded syringes with sevoflurane so that the patient was instilled simply and comfortably.

Analgesic effectiveness of topical sevoflurane to perform sharp debridement of painful wounds

“…Sevoflurane application was followed by a remarkably fast analgesic effect, with 50% of patients allowing initiation of debridement after only 1 or 2 minutes. This quick analgesic effect is in line with previous reports with sevoflurane 9,13,[15][16][17][18][19][20][21][23][24][25][26][27][28] or even ether 29 and contrasts compellingly with the delay of 30-40 minutes needed for EMLA cream. 10 Therefore, sevoflurane seems a more convenient alternative than EMLA.…”

“…It has been reported that sevoflurane produces a quick, intense, and long-lasting analgesic effect when it is irrigated on vascular chronic wounds of both venous 9,14-24 and ischemic 13 etiology, both for pain at rest 9,[13][14][15][16][17][18][19][20][21][22][23][24] and pain elicited by debridement. 13 Irruptive pain of neuropathic origin in chronic oncologic 15,25 and diabetic foot 26 wounds has been successfully controlled with sevoflurane, and the analgesic effect has also been described when treating infected postsurgical wounds. 27,28 The results of the present work confirm these analgesic properties for the specific case of acute wound pain caused by sharp debridement of vascular wounds as well as wounds of other etiologies.…”

“…In previous reports, some patients experienced pruritus each time sevoflurane was applied, but it was not an obstacle to continue with the treatment. 9,[14][15][16][18][19][20][21]24,25 Pruritus (itching) has been described when treating ulcers with EMLA 6,33,34 or even placebo, 6,34 indicating that these adverse events may be more related to manipulation of the wound than to the application of any specified drug. The occurrence of any neurologic disturbance by patients or surgeons was not recorded in the charts.…”

“…In addition, these results were consistent with previous reports. 9,[13][14][15][16][17][18][19][20][21][23][24][25][26][27] In any case, it is necessary to conduct clinical trials comparing topical sevoflurane with other analgesics, especially EMLA cream, for the debridement of ulcers. In addition to the analgesic effect, other important topics such as economic evaluation, 28 quality of life, 21 and sevoflurane pollution 41 require further investigation, not forgetting the development of a lessconcentrated and easier-to-handle new nonliquid formulations of sevoflurane.…”

Pain reduction of topical sevoflurane vs intravenous opioids in pressure ulcers

“…In recent years, a number of studies on the successful use of topical sevoflurane on vascular ischaemic ulcers has been published . In the same line, but conducted in a somewhat different setting, other authors have reported an improvement in pain scores after topical sevoflurane administration in patients with oncological ulcers, which was also associated with a decrease of opioid requirements . In all these studies, sevoflurane achieved rapid, intense, and durable pain relief.…”