Resumen El sevoflurano es un líquido volátil de la familia de los hidrocarburos halogenados derivados del éter que está aprobado para realizar la inducción y el mantenimiento de la anestesia general inhalatoria en ambiente exclusivamente hospitalario. En esta revisión se expone la experiencia pionera de nuestra Unidad del Dolor en el tratamiento domiciliario de heridas dolorosas complejas mediante irrigaciones de sevoflurano tópico según un protocolo aprobado para su uso fuera de ficha técnica. Se abordan aspectos de seguridad y eficacia, tanto analgésica como antimicrobiana y procicatrizante, y se comentan algunas líneas de futuro en cuanto a nuevas formulaciones para uso tópico. Tras más de 7 años de vigencia del referido protocolo, contamos con una experiencia acumulada de más de 70.000 aplicaciones de sevoflurano tópico. En líneas generales, el efecto analgésico aparece rápidamente en cuestión de minutos, es de gran intensidad, y de duración prolongada por espacio de varias horas; gracias a ello los pacientes pueden reducir el consumo de analgésicos sistémicos y, en general, su calidad de vida mejora. Además, existen indicios que sugieren que también ejerce acción antimicrobiana y procicatrizante. En cuanto a seguridad, el prurito a nivel de la piel periulcerosa es el efecto adverso más frecuentemente comunicado, aunque suele ser transitorio y bien tolerado, y no hay signos sugerentes de toxicidad sistémica. Globalmente, el balance beneficio-riesgo es muy favorable para los pacientes hasta el momento. Para evitar la manipulación de la presentación líquida y volátil hemos desarrollado una nueva formulación de sevoflurano en tipo gel, lo cual ha permitido tratar satisfactoriamente patologías dolorosas que cursan con piel íntegra; además, este tipo de nuevas formulaciones, incluyendo las microesferas de sevoflurano que también desarrollamos, podrían mejorar la eficacia y la seguridad del fármaco tópico a la vez que se reduce la exposición ocupacional del personal sanitario, por lo que el desarrollo de nuevas formulaciones es un campo con un futuro muy prometedor.

Abstract Sevoflurane is a volatile liquid from the family of ether-derived halogenated hydrocarbons that is approved for the induction and maintenance of inhalational general anesthesia in the hospital setting. This review describes the pioneering experience of a Spanish Pain Unit in the home treatment of complicated painful wounds using topical sevoflurane instillations according to a protocol approved for off-label use. Aspects of safety and efficacy, both analgesic, antimicrobial and pro-healing are addressed, and some future lines of research are discussed in terms of new formulations for topical use. After more than seven years of use of the protocol, an experience of over 70,000 applications of topical sevoflurane has been gained. In general terms, the analgesic effect appears quickly, is highly intense and persists for several hours. As a result, patients can reduce their consumption of systemic analgesics and benefit from an improvement in their quality of life. In addition, there are signs that suggest sevoflurane also possesses antimicrobial and pro-healing properties. Regarding safety, pruritus at the level of the periulcerous skin is the most frequently reported adverse effect, although it is usually transient and well-tolerated, and no systemic toxicity has been reported. Overall, the risk-benefit balance of the drug has so far been very favorable. To avoid manipulation of this volatile liquid, we have developed a new formulation of sevoflurane in gel form, which has made it possible to successfully apply sevoflurane in the context of painful pathologies where the skin remains intact. Furthermore, these types of new formulations, including sevoflurane microspheres, which we have also developed, could improve the efficacy and safety of topical sevoflurane while reducing the occupational exposure of healthcare staff. This means that the development of new formulations is a field with a very promising future.

Resumo Introdução: Recentes pesquisas utilizando animais demonstraram efeitos imunossupressores depois da suspensão de opiáceos, associados a um maior risco de infecção nosocomial. O objetivo desta investigação foi determinar o impacto da interrupção do opioide remifentanilo em uma Unidade de Reanimação Pós-cirúrgica (URP) nas infecções associadas aos cuidados da saúde depois de uma pauta de sedoanalgesia de ao menos 6 dias. Método: Foram relacionados de forma consecutiva todos os pacientes maiores de 18 anos com internação na unidade superior a 4 dias. A população investigada foi aquela afetada por patologia cirúrgica de qualquer origem, na qual a sedação esteve baseada em qualquer hipnótico e como analgésico, foi utilizado o opioide remifentanilo durante pelo menos 96 horas em perfusão contínua. Foram excluídos os pacientes que faleceram durante a internação na unidade e aqueles com analgesia combinada (bloqueios periféricos ou neuroaxiais). Foi realizada uma análise bivariante para determinar fatores de risco para a infecção adquirida na unidade. Foi realizada uma investigação comparativa entre períodos dos 6 dias anteriores e posteriores à interrupção de remifentanilo. Utilizamos o teste de amostras pareadas e a prova de McNemar para as variáveis quantitativas e categóricas, respectivamente. Resultados: O número de pacientes internados na URP durante o período de investigação foi de 1.789. Depois de aplicar os critérios de inclusão e exclusão, a população elegível ficou constituída por 102 pacientes. A densidade de incidência de infecção de forma global foi de 38 por cada 1.000 dias de internamento. A pneumonia associada à ventilação mecânica foi a infecção adquirida mais frequente e Pseudomona aeruginosa, o micro-organismo mais frequentemente isolado. A mortalidade hospitalar foi de 36,27%. Não foram observadas diferenças estatisticamente significativas na incidência de IACS em pacientes oncológicos em relação à descontinuação de remifentanilo (p=0,068). Conclusão: O estado basal de imunossupressão dos pacientes oncológicos não implica uma maior incidência de IACS em relação à interrupção do remifentanilo. Seria interessante a realização de uma investigação multicêntrica de URP que incluísse padrões imunológicos.

Summary Introduction: Recent animal studies demonstrated immunosuppressive effects of opioid withdrawal resulting in a higher risk of infection. The aim of this study was to determine the impact of remifentanil discontinuation on Post-Anesthesia Care Unit (PACU)-acquired infection after a schedule of sedoanalgesia of at least 6 days. Method: All patients over 18 years of age with a unit admission of more than 4 days were consecutively selected. The study population was the one affected by surgical pathology of any origin where sedation was based on any hypnotic and the opioid remifentanil was used as analgesic for at least 96 hours in continuous perfusion. Patients who died during admission to the unit and those with combined analgesia (peripheral or neuroaxial blocks) were excluded. Bivariate analysis was performed to determine risk factors for infection acquired in the unit. A comparative study between periods of 6 days before and after the cessation of remifentanil was performed. Paired samples test and McNemar test was used for quantitative and categorical variables, respectively. Results: There were 1,789 patients admitted to the PACU during the study and the population eligible was constituted for 102 patients. The incidence rate of PACU-acquired infection was 38 per 1,000 PACU days. Ventilator-associated pneumonia was the most frequently diagnosed PACU-acquired infection. Pseudomona aeruginosa was the most frequently isolated microorganism. Hospital mortality was 36.27%. No statistically significant differences were seen in the incidence of HAI in cancer patients in relation to discontinuation of remifentanil (p=0.068). Conclusion: The baseline state of immunosuppression of cancer patients does not imply a higher incidence of HAI in relation to the interruption of remifentanil. It would be of interest to carry out a multicenter PACU study that included immunological patterns.

Objectives: When talking about day surgery we have to differentiate between minor and major ambulatory surgery. Ambulatory surgery enables the patient to stay in the hospital not more than a few hours, showing similar safety and efficacy than conventional surgery. The objective of this paper is to evaluate the results of an ambulatory surgery program. Methods: Descriptive retrospective study of the results of the Ambulatory Surgery in a Urology Department, including 4185 patients in a four-year period, from January 1 st 2003 to December 31 st 2006. Results: In the study period the global substitution rate was 83.6%. The hospital admission rate was 2.5%, most of which were early admissions. Major complications appeared in 26 patients (0.6%), being major bleeding the predominant one. Most complications were minor or mild, and pain at the site of the surgical wound was the most frequent problem found. Conclusions: The increase and continuous promotion of ambulatory surgery are more than justified. The high satisfaction among patients undergoing this type of surgery, with a very low number of complications registered, provides us with a valuable tool for health-care expenditure control.

Objetivo: En la cirugía sin ingreso deberemos distinguir entre el concepto de cirugía menor ambulatoria y cirugía mayor ambulatoria. La cirugía ambulatoria, permite que el paciente no esté en el hospital más allá de unas horas, mostrando una seguridad y efectividad similar a la cirugía convencional. Evaluar los resultados de un programa de cirugía ambulatoria. Métodos: Estudio descriptivo retrospectivo de los resultados de funcionamiento de la Cirugía Ambulatoria (C.A) en un Servicio de Urología, incluyendo 4185 pacientes en un periodo de estudio de cuatro años, que comprende desde el 1 de enero del 2003 hasta el 31 de diciembre del 2006. Resultados: En el periodo de estudio el índice de sustitución global fue del 83,6%. El índice de ingresos fue del 2,5%, de los cuales la mayoría fueron ingresos precoces. Las complicaciones mayores se presentaron en 26 pacientes (0,6%), siendo la hemorragia mayor la predominante. La mayoría de las complicaciones son menores o leves, y el dolor en la zona de la herida quirúrgica es el problema encontrado con mayor frecuencia. Conclusiones: El auge y la promoción continua de la cirugía ambulatoria están más que justificadas. La alta satisfacción de los pacientes sometidos a este tipo de cirugía, con el escaso número de complicaciones registradas, nos proporcionan una valiosa herramienta de control del gasto sanitario.