Pain management & opioid dose reduction with topical sevoflurane instillations in intractable venous ulcers: a case report

Abstract Vascular ulcers (VU) constitute a major cause of pain and disability, and significantly compromise quality of life. VU have a natural tendency to become chronic and in many cases exhibit anunsatisfactoryresponse to many of the standard therapeutic options.The case of a 73 year-old Caucasian female with severe pain and poorly-controlled pain (Visual Analogic Scale-VAS- of 8-9) due to three lower leg long-standing VUs is reported and discussed herein. The patient was treated with topical instillations of undiluted sevoflurane as per institutional off-label protocol (starting doses of 1mL/cm2 twice a day, and up-titrated according to response to a maximum of 7 mL twice daily). The VAS score dropped to 0-1 shortly after initiation of therapy and remained stable throughout treatment up until the closure of the observations. Subsequently, opioid therapy was gradually tapered down and ultimately abandoned.Sevoflurane application resulted on adequate and sustained pain management of refractory VU, with no significant side effects. On account of its beneficial effectivity and safety profiles, topical sevoflurane emerges as an add-on alternative for the long-term management of VU, and potentially other painful conditions.

Epilepsia na gravidez / Epilepsy in pregnancy

As epilepsias constituem uma das mais frequentes condições neurológicas encontradas na gravidez, ocorrendo entre 0,5% e 1% das gestações. O risco de morte materna está aumentado em 10 vezes nas grávidas epilépticas. Na gestante, o diagnóstico adequado é fundamental, já que deve ser afastada a possibilidade de se tratar de crise de eclâmpsia, doença exclusiva do período gravídico-puerperal. A preocupação materna quanto aos efeitos adversos (malformações) das drogas antiepilépticas no bebê pode levar à descontinuação ou redução da dose do medicamento, aumentando o risco de convulsão ou de morte súbita e inesperada na epilepsia (SUDEP). Nesta revisão foi dada atenção única e exclusiva às recomendações do Royal College of Obstetricians and Gynaecologists.(AU)

Epilepsiy is one of the most frequent neurological conditions found in pregnancy, occurring in 0.5 to 1% of pregnancies. The maternal death risk is increased 10-fold in epileptic pregnancies. In pregnant women, its adequate diagnosis is essential, since eclampsia is a differential diagnosis, which is disease exclusive to the pregnancy-puerperal period. Maternal concerns about the adverse effects (malformations) of antiepileptic drugs in the infant may lead to the discontinuation or reduction of the drug dose, increasing the risk of seizure or sudden and unexpected death in epilepsy (SUDEP). In this review exclusive attention was given to the recommendations of the Royal College of Obstetricians and Gynecologists.(AU)