Sevoflurane/silver-sulfadiazine

Abstract

Lack of efficacy and off-label use: case report An 88-year-old woman exhibited lack of efficacy during treatment with silver sulfadiazine for a right ischial pressure ulcer. Subsequently, she received off-label treatment with sevoflurane [not all dosages stated]. The woman had a main history of severe stenosis of the medullary canal from C3 to C7, which produced cervical compressive myelopathy and spastic tetraparesis, so she needed a wheelchair. Following 4 years of evolution, this picture was complicated by the appearance of an ischial pressure ulcer. It was initially treated with daily wound cleanings with diluted oxygenated water, application of a silver sulfadiazine cream on the bed, covering the entire wound with a fatty dressing and a silicone secondary dressing. This treatment was performed at home by health personnel; however, this pressure ulcer was refractory to the above treatment, with an increase in the surface area and lesion volume. Therefore, the plastic surgery service was consulted. At the review, she had a grade II–III right ischial ulcer, 6cm in diameter larger, which emitted a haemorrhagic, purulent and smelly exudate. A sample was taken for microbiological culture, and it was indicated to continue the same treatment. The culture isolated mixed polymicrobial flora, including Gram-negative bacilli and Pseudomonas aeruginosa, and it was decided to schedule systemic antibiotic therapy guided by antibiogram with ciprofloxacin. In a subsequent review by plastic surgery, it was found that the situation of the ulcer had worsened, since it was grade IV and had a path of 5cm to reach the ischial bone. At this point, it was considered that healing options with topical treatment were scarce, largely because of the absence of neural factors owing to lack of nerve feedback, and surgery consisting of debridement, ischiectomy and coverage by myocutaneous gluteal flap plus vacuum-assisted therapy was recommended. In the preanaesthetic consultation, a high risk of difficult orotracheal intubation was found, conditioned both by a very reduced mouth opening and by the difficulties of cervical manipulation because of its basic pathology, and for the proposed intervention, she had to be placed in prone position in a scissor position. Considering the high anaesthetic risk, she and family members were offered the possibility of treating the wound with off-label topical sevoflurane. After being informed, they accepted this option. On the day of initiation of sevoflurane irrigation, she had been treated for 48 days with the previous treatment described. She had a right ischial painless ulcer near the anal orifice, about 6cm in diameter and 5cm in the path, with exposure of the ischial bone. It emitted little smelly exudate, so it was sampled with swab in which was subsequently isolated mixed flora among which Gram-negative bacilli predominated, but without P. aeruginosa. This result was considered as contamination, not as infection, and she was not given antibiotic treatment. The final diagnosis was right ischial pressure ulcer. The novel action consisted simply in the irrigation of the wound with 5mL of sevoflurane (off-label) taking advantage of the daily cure. Specifically, the wound was cleaned with oxygenated water, and after waiting for it to dry, it was irrigated with sevoflurane and covered with gauze for about 5 minutes in order to minimise volatilisation to the environment. After waiting, silver sulfadiazine cream was applied to the woman’s wound and covered with the silicone dressing. As an added advantage, this treatment was performed at home, since the medical relative was instructed on how to apply sevoflurane. Apart from the introduction of sevoflurane, throughout the process, she remained in bed with postural changes to avoid prolonged sitting, and the treatment described above was maintained as a basis. The evolution of the wound was favourable, as it started to close by second intention, reducing its depth and re-spying from the edges, being considered completely closed at 10 weeks following the introduction of sevoflurane. She never experienced systemic or local adverse effects, nor did the family member applying sevoflurane. Following 2 years of evolution, the fibrous scar persisted with similar appearance, but for the moment, she had not developed more ulcers and enjoyed an acceptable state of health.