HORSE-CHESTNUT SEED EXTRACT FOR CHRONIC VENOUS INSUFFICIENCY
Pittler MH, Ernst E.
Arch Dermatol 1998; 134;1356-60
ABSTRACT AND COMMENTARY BY:
Neil Sadick, MD
New York, New York
This paper assesses the role of horse-chestnut seed extract (HCSE) in treatment of
chronic venous insufficiency. It was a computerized literature search-based review
performed in Medline, Embase, Biosis, Ciscom, and the Cochrane Library. Double-blind
randomized controlled trials of oral HCSE for patients with chronic venous insufficiency
were included. Trial outcomes and methodologic quality of each trial were independently
assessed by two observers.
The superiority of HCSE was suggested by all placebo-controlled studies. The use
of HCSE was associated with a decrease in leg circumference at the calf and ankle.
Leg pain, pruritus, fatigue, and tenseness were also reduced. Five comparative
trials showed that HCSE and O-(þ-hydroxyethyl)-rutosides are equally effective. One trial
suggested equivalent results with compression therapy versus HCSE.
COMMENTARY
The role of herbal medicine in treating medical disease is increasing. It must at
least be analyzed and not dismissed by the medical profession. Several of the trials
showed some degree of bias and design flaw.
The mechanism of action is felt to be mediated through saponin. This inhibits the
activity of elastase and hyaluronidase which are structure-degrading components
of capillary endothelium and extravascular matrix or a decreased excretion of proteoglycan
hydrolases with vascular leakage. Further well-designed, standardized, double-blind,
controlled trials are necessary to determine the exact role of this therapy in the
therapeutic armamentarium of chronic venous insufficiency. vdsad100
THE SAFETY AND EFFICACY OF A PROTEOLYTIC OINTMENT IN THE TREATMENT OF CHRONIC ULCERS
OF THE LOWER EXTREMITY
Falabella AF, Carson P, Eaglstein WH, Falanga V.
J Am Acad Dermatol 1998; 39:737-40\
ABSTRACT AND COMMENTARY BY:
J. Leonel Villavicencio, MD
Professor of Surgery
Director, Venous & Lymphatic Surgical Clinics
Walter Reed Army Medical Center
National Naval Medical Center
Bethesda, Maryland
There are numerous techniques and dressing materials available today to cover a leg
ulcer. While most claim favorable clinical experience, there is little objective
data available to prove their effectiveness.
In this study, the authors investigated the effectiveness (or lack of) of a proteolytic
ointment in the treatment of chronic ulcers of the lower extremity. The objective
was to assess the efficacy and safety of Elase, a widely used ointment containing
a combination of two proteolytic enzymes: Fibrinolysin and desoxyribonuclease (DNAse).
This agent is said to promote debridement of necrotic purulent debris from skin
ulcers. The purpose of the study was to assess the safety and efficacy of the ointment and its components in the treatment of chronic ulcers of the lower extremity.
This was a double-blind, randomized, prospective study of 84 patients with leg ulcers
exhibiting necrotic and purulent debris, treated for 21 days with twice-daily application
of one of the following: 1) complete ointment containing fibrinolysin and DNAse, 2) fibrinolysin alone, 3) DNAse alone, or 4) ointment vehicle (placebo). Six efficacy
features were examined: ulcer size, purulent exudate, necrotic tissue, erythema,
pain, and overall condition of the lesion at 8, 15, and 21 days following initiation of treatment. The frequency of adverse effects was also evaluated.
There was some improvement in the efficacy parameters and overall clinical condition
of the ulcers by week 3 with all the treatments; however, no statistically significant
difference was found when compared with placebo. There were no serious adverse events. There was an uexplained statistically significant reduction of purulent exudate
only at treatment days 3 and 7 in the group treated with complete ointment but not
with the other agents. The authors conclude that use of a proteolytic ointment does
not provide a clinical benefit in reducing purulent exudate, pain, erythema, necrotic
tissue, or overall condition of leg ulcers when compared with placebo.
COMMENTARY
This study was performed on leg ulcers of the lower extremities and confirms that
topical medications in the treatment of leg ulcers fail to demonstrate a statistically
significant difference when compared to placebo. During extensive review of leg
ulcer dressings and topical agents performed by the Alexander group five years ago, it
was concluded by 20 experts that topical agents in the treatment of leg ulcers
offered no benefits when compared to placebo. Topical agents may produce sensitization
and local or generalized allergic reactions to the agents. Even though in the present
case, inflammation of the wound edges occurred only once with the use of other topical
agents such as antibiotics, it is not uncommon to observe skin irritation in the
skin surrounding the ulcer.
In our experience, cleansing the ulcer with sterile normal saline and covering it
with a layer of non-adhering, fine mesh gauze followed by a compressive dressing
has produced improvement in the exudate and healing in the majority of cases.
Even though the authors have demonstrated that Elase was no better than the vehicle
ointment, there is a flaw in the study. The authors failed to identify the type
of ulcers they treated. Even though the majority of lower extremity ulcers are venous,
there are other types, including diabetic, arterial, arthritic, traumatic, etc. It would
have been better to identify the type of the ulcer in this study. Also, there is
no mention of the method they used to maintain the thin layer of study drug and the
non-adherent dressing (telfa) in place on an ambulatory patient. Did they use an elastic
stocking or an elastic bandage? Finally, it is assumed that the patients had a culture
done of the purulent exudate present in the ulcer but there is no mention of the
type of microbial flora encountered.
While this study is not ideal, it proves that cleaning an ulcer with normal sterile
saline and covering it with a placebo is just as effective as applying a more expensive
treatment. vdvil100
LONG COTTON WOOL ROLLS AS COMPRESSION ENHANCEMENTS IN MACROSCLEROTHERAPY FOR VARICOSE
VEINS
Tazelaar DJ, Neumann HAM, De Roos KP
Dermatol Surg 1999; 25:38-40
ABSTRACT AND COMMENTARY BY:
Mitchel P. Goldman, MD
La Jolla, California
The authors detail their experience in a prospective study of 100 patients (120 legs)
with primary varicose veins treated with polidocanol as a sclerosant using the empty-vein
technique.
Immediately after injection, a long cotton wool roll is placed over the entire vein
and fixed. Additional compression is applied with a class I compression stocking
worn for 24 hours and a class II compression stocking worn while the patient is ambulatory. The authors measured the interface pressure through an Oxford pressure monitor
and found all pressure sensors measured between 68 and 122 mmHg (average 84 mmHg).
They found 16 patients with minor side effects which needed no treatment. Three
cases (2.5%) required drainage of an intravascular blood clot and one case required excision
and expression for superficial thrombophlebitis.
COMMENTARY
Compression sclerotherapy of varicose veins is a well-established modality for treatment
of almost all types of varicose veins. The authors demonstrate that if one adheres
to the proper techniques of sclerosant concentration and compression, it is possible to treat side-branch varicose veins, anterolateral varicose veins, lesser saphenous
veins, and perforating veins. All patients in this study were examined by venous
Doppler to exclude reflux across the saphenofemoral or saphenopopliteal junction.
Only those veins not demonstrating reflux across the junction were treated.
A point lacking in this study is a more detailed analysis of the size and length
of the varicose vein treated but this can be negated as nearly all of the patients
had excellent results.
Although there is no universal agreement regarding the best type and duration of compression
in sclerotherapy, it is clear that the method used in this study is close to the
ideal. vdgol100
EVALUATION OF CLINICAL EFFICACY OF A VENOTONIC DRUG: AN ADREAL ON HEMISYNTHESIS DIOSMINE
IN PATIENTS WITH HEAVY LEGS SYNDROME
Carpentier PH, Mathieu M.
Journal des Malaides Vasculaires (Paris) 1998; 23(2):106-12
COMMENTARY BY:
Henri Boccalon, M.D., Ph.D.
Toulouse, France
This work shows a comparison of the effects of two doses of hemisynthesis diosmine:
One tablet (600 mg) in the morning compared with two tablets (300 mg), one in the
morning and one in the evening for four weeks. This was a multicenter trial done
in France in women suffering from heavy leg syndrome without varicose veins or venous valvular
reflux. The main objectives were an improved symptomatology score recorded by the
angiologist and a self-evaluation score recorded weekly by the patient. Secondary
objectives included the judgment of the angiologist and satisfaction of the patient.
Treatment was stopped in two cases because of undesirable side effects. Three cases
were lost to followup. The patients were primarily paramedical, secretaries, and
teachers. Comparison of treatment showed a weak benefit varying from 6 to 10% in
favor of the 600 mg once daily dosage. The self-evaluation results by the patient showed
an improvement week after week for both groups. The 600 mg dose seemed to develop
a more rapid effect on reduction of discomfort.
COMMENTARY
This study of two doses of hemisynthesis diosmine confirms the fact that venotonic
drugs can be prescribed when there is functional discomfort of venous insufficiency.
Originally, it was planned to include women suffering from heavy leg syndrome without
any varicose veins or valvular reflux as determined by echodoppler.
The study results show that this venotonic drug improved symptomatology at either
dose. A slight superiority was noted for the 600 mg dose. The real efficacy of
this therapy, a comparison with placebo, was not tested. As the self-evaluation
technique was used, it would have been interesting to continue the study for a longer period
of time, such as three months, to see if the results remained the same as after one
month.
At a practical level, the dose of only one tablet per day of this venotonic drug seemed
to be better. This fact could improve therapeutic compliance of patients. ivdfboc
ACUTE PULMONARY EMBOLISM: ASSESSMENT OF HELICAL CT FOR DIAGNOSIS
Drucker EA, Rivitz SM, Shepard JO, et al.
Radiology 1998; 209:235-41
ABSTRACT AND COMMENTARY BY:
Thomas W. Wakefield, MD
University of Michigan
Ann Arbor, Michigan
This study assesses the ability of helical CT scanning to diagnose pulmonary embolism.
A total of 158 patients underwent pulmonary arteriography, 47 of whom also underwent
helical CT scanning. For various reasons, 111 patients were excluded from the study.
Helical CT scanning was performed within 24 hours of pulmonary arteriography. Two
different concentrations of contrast material were used. The scans were interpreted
by two chest radiologists without great experience in CT scanning for the diagnosis
of pulmonary embolism at one institution and with extensive experience in the technique at a second institution. Pulmonary arteriography was performed
using "cut-film" technique and selective injections of the right and left pulmonary
arteries. Pulmonary embolism was characterized as either acute or chronic. Sensitivity, specificity, positive/negative predictive values, and accuracy levels were then
obtained.
Of the 47 patients, 15 (32%) had angiographically proven pulmonary embolism. For
readers at the first institution, sensitivity of helical CT was 60%, specificity
was 81%, positive predictive value was 60%, negative predictive value was 81%, and
overall accuracy was 74%. At the second institution, sensitivity was 53%, specificity was 97%,
positive predictive value was 89%, negative predictive value was 82%, and overall
accuracy was 83%. The degree of contrast enhancement and different concentrations
of contrast agents were also evaluated. No significant difference in results was noted
for either parameter although differences in sensitivity approached significance
for different concentrations of contrast agents.
This study concludes that detection of pulmonary embolism with helical CT may be less
accurate than previously reported with a high specificity but relatively low sensitivity.
The authors suggest four areas where CT scanning sensitivity may be enhanced in the detection of pulmonary embolism. These include: 1) patient selection, especially
with the breath-holding necessary to obtain the CT scan, 2) optimization of the scanning
protocol, 3) optimization of the protocol for use of intravenous contrast agents, and 4) improvement in the method of interpretation of the helical CT scans.
COMMENTARY
The authors of this study have pointed out that helical CT scanning has excellent
specificity but relatively low sensitivity for the diagnosis of pulmonary embolism.
From this data, if a helical CT scan is positive, there is a high likelihood that
the patient has a diagnosis of pulmonary embolism. However, if the scan is negative, the
patient may still need another test. Thus, at the present state of technology, helical
CT scanning is more suitable as a confirmatory study rather than as a screening study for the diagnosis of pulmonary embolism. Importantly, 120 ml of contrast was used
for the CT scans in this study and 40 to 60 ml was used for the pulmonary arteriograms.
Therefore, if one must follow the CT scan with a pulmonary arteriogram, the amount of contrast the patient receives is significant. Although only one patient in this
study had a creatinine level exceeding 1.5 mg/dl after the study, it is noteworthy
that one exclusion criterion was a plasma creatinine level greater than 1.5 mg/dl.
Patients with renal insufficiency on presentation were not evaluated. Thus, use of
helical CT scan in the diagnosis of pulmonary embolism in this group (baseline renal
insufficiency) must be questioned.
One reason for doing the current study is the discrepancy in the literature concerning
the sensitivity and negative predictive value of helical CT scanning. Remy-Jardin
et al.1,2 reported sensitivities between 91 and 100% while Teigen et al.3 reported sensitivities of 65% and Goodman et al.4 of 63%. The latter two are very equivalent to the 60% and 53% sensitivity values
in the current study. The authors of the present study suggest that the differences
in results may be due to the fact that studies with higher sensitivity excluded inconclusive CT scans from analysis or that patients were younger in age with less coexisting
pulmonary parenchymal problems or that standard of reference may have been a single-view
arteriography which can miss small emboli. In addition, CT scans and arteriograms may have been interpreted by the same investigators thereby introducing unintentional
biases. All of these explanations for the differences are plausible and deserve emphasis.
As technology improves, one can assume that helical CT scan sensitivity will increase
and some day such technology may be the preferred method of diagnosing pulmonary
embolism. However, the data presented in this study suggest that at this time, helical
CT scanning remains an inferior test for the diagnosis of pulmonary embolism. Where
it will fit into the algorithm for such diagnosis is still to be determined. vdwak100
REFERENCES
1. Remy-Jardin M, Remy J, Wattinne L, Giraud F. Central pulmonary thromboembolism:
Diagnosis with spiral volumetric CT with the single breath-hold technique. Comparison
with pulmonary angiography. Radiology 1992; 185:381-87.
2. Remy-Jardin M, Remy J, Deschildre F, et al. Diagnosis of pulmonary embolism with
spiral CT: Comparison with pulmonary angiography and scintigraphy. Radiology 1996;
200:699-706.
3. Teigen CL, Maus TP, Sheedy PF et al. Pulmonary embolism: Diagnosis with contrast-enhanced
electron beam CT and comparison with pulmonary angiography. Radiology 1995; 194:313-19.
4. Goodman LR, Curtin JJ, Mewissen MW et al. Detection of pulmonary embolism in
patients with unresolved clinical and scintigraphic diagnosis: Helical CT versus
angiography. Am J Radiol 1995; 164:1369-74.
THE FIBRINOLYTIC EFFECTS OF INTERMITTENT PNEUMATIC COMPRESSION: MECHANISM OF ENHANCED
FIBRINOLYSIS
Comerota AJ, Chouohan V, Harrada RN, et al.
Ann Surg 1997; 226:306-14
ABSTRACT AND COMMENTARY BY:
Lois A. Killewich, MD
Assistant Professor, Dept of Surgery
Section of Vascular Surgery
University of Maryland School of Medicine
Baltimore, Maryland
Dr. Comerota and his colleagues have performed an elegant study in which they evaluated
the effects of five intermittent pneumatic compression (IPC) devices on endogenous
fibrinolytic activity in normal volunteers and postthrombotic patients. This is
a very important topic since it has long been presumed that IPC devices prevent lower
extremity deep venous thrombosis (DVT), not only by reducing stasis through increased
flow but also through enhancement of endogenous fibrinolysis, the body's mechanism
by which excess or inappropriately formed thrombus is lysed. However, when the initial
studies addressing this question were performed, an understanding of the molecular
mechanism of fibrinolysis was limited and the techniques for measurement were crude
and nonspecific. An improved understanding of the mechanism and the development of
assays for the specific enzymatic components of fibrinolysis have allowed for a
more precise assessment of changes associated with IPC devices.
In this study, five IPC devices were applied to the legs of six normal volunteers
and six patients with postthrombotic syndrome in random fashion once a week for
five weeks. These devices included the thigh-length sequential (TSQ), calf-length
sequential (CSQ), thigh-length single chamber (TSC), calf-length single chamber (CSC), and foot
pump (FP). In each case, pumping with the device was continued for three hours.
Antecubital venous blood samples were collected prior to pumping and one, two, and
three hours after pumping. Samples were collected for measurement of von Willebrand factor
(vWF), plasmin a-2-antiplasmin complex, euglobulin lysis performed on fibrin plates
(ELT), and the activity and antigen levels of tissue plasminogen activator (tPA,
the primary biologic activator of fibrinolysis) and plasminogen activator inhibitor-1
(the primary inhibitor).
No changes occurred in vWF or plasmin a-2-antiplasmin at any time with the devices
tested. ELT values were significantly enhanced with all devices although the postthrombotic
patients had significantly lower baseline values and their stimulated values only reached the baseline values of the normal subjects.
All five devices produced a significant enhancement of endogenous fibrinolysis in
the normal volunteers after three hours, manifested as increased tPA activity and
decreased tPA antigen, PAI-1 activity, and PAI-1 antigen. The biggest changes were
seen in PAI-1 activity. In the postthrombotic patients, significant decrease in PAI-1
activity, PAI-1 antigen, and tPA antigen occurred but the increase in tPA activity
did not achieve statistical significance. There were no differences in activity
or antigen levels among the five devices tested.
COMMENTARY
Endogenous fibrinolytic activity is difficult to study since it is affected by multiple
external factors, including age,1 time of day,2 exercise,3 and the presence of disease such as atherosclerosis and diabetes mellitus.4 The present study was carefully controlled and the effects of these confounding
variables were minimized.
Nonetheless, I have some concerns with the study. These are primarily related to
the small magnitude of change in tPA and PAI-1 activity associated with the IPC devices.
tPA activity increased only 3.8% in the normal volunteers after three hours of pumping and the absolute values increased from 0.086 IU/ml to 0.088 IU/ml. Although this
change attained statistical significance, one wonders whether it would have any
clinical significance in terms of preventing the development of DVT. The decrease
in PAI-1 activity, while of greater magnitude (18.4%, absolute values of 9.6 AU/ml decreased
to 7.4 AU/ml), is still relatively insignificant compared to changes observed with
other modalities which affect endogenous fibrinolysis.
Exercise training produced changes in the range of 25 to 30% in both tPA and PAI-1
activities3 and tourniquet compression of the arm produced changes in the range of 300
to 400%.5 Moreover, Dr. Comerota's measured values for PAI-1 antigen (25 to 35 ng/ml) are quite high relative
to published values. This is more likely indicative of a platelet activation with
subsequent release of pre-formed PAI-1 which is known to occur with traumatic blood
drawing techniques rather with a true physiologic change.6
We have performed similar studies in our laboratory on normal volunteers and noted
a direct correlation between the volume of lower extremity tissue compressed and
the degree of enhancement of tPA activity. Thus, the changes produced by the TSQ
device we used (75% increase after one hour) were significantly greater than the changes produced
by the CSQ or the foot pump where essentially no effect was observed. Our protocol
was virtually identical to that of Dr. Comerota and we cannot explain the conflicting results.
In summary, this is an elegantly designed and well-performed study but it leaves questions
unanswered with regard to the benefit of IPC devices in enhancing endogenous fibrinolysis.
More importantly, will the small changes in systemic fibrinolysis engendered by the devices have any real clinical benefit in preventing DVT? To this end,
it may be that placement of the devices is effective but placement on only one leg
or arm and expecting to achieve effective prophylaxis in both lower extremities remains
unproven. It is very possible that regional fibrinolysis in the lower extremities
will be enhanced by placement of the devices on both limbs. This is clearly an important
direction for future research.
Another important unanswered question is what effect IPC devices will have in patients
undergoing surgical procedures where fibrinolysis is decreased in the postoperative
period.7 These studies will be more difficult to perform but they are also important areas
for future research. vdkil034
REFERENCES
1. Stratton JR, Chandler WL, Schwartz RS, et al. Effects of physical conditioning
on fibrinolytic variables and fibrinogen in young and old healthy adults. Circulation
1991; 83:1692-97.
2. Angleton P, Chandler WL, Schmer G. Diurnal variation of tissue-type plasminogen
activator and its rapid inhibitor (PAI-1). Circulation 1989; 79:101-06.
3. Chandler WL, Veith RC, Fellingham J. Fibrinolytic response during exercise and
epinephrine infusion in the same subjects. J Am Coll Cardiol 1992; 19:1412-20.
4. Juhan-Vague I, Alessi MC. Plasminogen activator inhibitor 1 and atherothrombosis.
Thromb Haemost 1993; 70:183-43.
5. Stegnar M, Peternel P, Keber D, Vere N. Poor fibrinolytic response to venous occlusion
by different criteria in patients with deep vein thrombosis. Thromb Res 1991; 64:445-53.
6. Files JC, Malpass TW, Yee EK, et al. Studies of human platelet alpha-granule release
in vivo. Blood 1981; 58:607-18.
7. Killewich LA, Macko RF, Gardner AW et al. Defective fibrinolysis occurs following
infrainguinal reconstruction. J Vasc Surg 1997; 25:858-65.
VENOUS HEMODYNAMICS DURING LAPAROSCOPIC SURGERY: A CAUSE FOR CONCERN
Scott DJA, Wyld L, Paige J, et al.
Min Invas Ther & Allied Technol 1997; 5/6:484-86
ABSTRACT AND COMMENTARY BY:
David W. Easter, MD
Associate Professor of Surgery
University of California San Diego
San Diego, California
The authors studied 14 patients undergoing laparoscopic cholecystectomy in an effort
to measure the changes in femoral vein diameter and blood flow velocity, to compare
the effect of calf compression devices, and to screen for deep venous thrombosis.
Duplex scans measured blood velocity and flow 24 hours' preoperatively, 30 minutes' postoperatively,
and 24 hours' postoperatively. Duplex scans were also used to screen preoperative
and postoperative patients for deep venous thrombosis. Subcutaneous heparin was used throughout the perioperative period.
Compared to the preoperative values, the blood flow velocity was unchanged at induction,
decreased 30% with pneumoperitoneum, decreased 27% at 15 minutes, was unchanged
30 minutes' post procedure, and increased nearly two-fold at 24 hours' postop. Calf
compression augmented the preoperative blood flow velocity by ten-fold but this effect
was limited at induction to only 2.3 times the preoperative non-compression values.
The blood flow velocity did not change appreciably but the femoral vein diameter
increased during surgery. At 24 hours' postoperatively, calf compression blood flow
velocity matched the preoperative value. Femoral vein diameters were not given with
reference to calf compression. No deep venous thromboses were detected.
The authors confirm that "laparoscopic surgery has a marked effect on venous return"
and suggest that these measured effects are a cause for concern that warrant further
study.
COMMENTARY
This interesting article adds to the growing literature detailing the physiologic
changes associated with laparoscopic surgery. It is not surprising that laparoscopic
cholecystectomy increases femoral vein diameter and decreases femoral vein velocities. Neither is it surprising that calf compression stockings improve femoral vein flow.
Indeed, the most notable decline in femoral vein velocity measurements occurred
coincident with the induction of anesthesia. A marginal improvement of blood flow
was associated with pneumoperitoneum and the progression of surgery. Change in femoral
vein diameter occurred coincident to the pneumoperitoneum, and "improvement" (decreased
diameter) was observed with progression of surgery. It is not surprising that deep
venous thromboses were not observed in this small number of patients who were given
both compression devices and low-dose heparin.
Clearly, there are at least two main factors affecting femoral vein physiology and
the associated risk of thrombophlebitis - the intra-abdominal pressure of the pneumoperitoneum
and the circulatory changes associated with general anesthesia. Other important variables include preoperative and intraoperative blood volume status, cardiac
output changes throughout surgery, volume "resuscitation" efforts during surgery,
anesthetic technique, patient positioning, and levels of hypercarbia. Future studies
need to account for these codependent variables if we are to understand which factors
are critical and thus which measures may help prevent thrombophlebitis.
The authors have shown that femoral vein blood velocity is affected by calf compression
devices and induction of general anesthesia. They have also shown that pneumoperitoneum
associated with laparoscopic surgery affects femoral vein diameter. Future studies would be useful if the unique aspects of laparoscopic surgery were controlled
as part of the experimental design. These controls might include using gases other
than CO2, using abdominal lift devices rather than pressure pneumoperitoneum, and using patient
positioning not different than that for open surgery. vdeas100
EMLA CREAM AS A TOPICAL ANESTHETIC FOR THE REPEATED MECHANICAL DEBRIDEMENT OF VENOUS
LEG ULCERS: A DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY
Loc C, et al.
J Am Acad Dermatol 1999; 40:208-13
ABSTRACT AND COMMENTARY BY:
Mitchel P. Goldman, MD
La Jolla, California
The authors assessed the effect of EMLA cream in a randomized, double-blind, placebo-controlled
study of 39 patients with venous leg ulcers. EMLA cream decreased the median number
of debridements necessary for a clean ulcer and decreased pain by 50%. Plasma levels of lidocaine, prilocaine, and their main metabolites were low without
any apparent accumulation.
COMMENTARY
This study confirms a previous study in 1990 by Holm et al. on the use of EMLA cream
for pain control and surgical debridement of leg ulcers.1 The advance in the current study is the confirmation of lack of toxicity in plasma
levels of lidocaine, prilocaine, and their main metabolites. In agreement with previous
studies as well as my own previous experience, EMLA produces satisfactory analgesia for mechanical debridement of leg ulcers. The quality of debridement is also
improved by the anesthetic effect of EMLA cream.
The variation in plasma concentrations of lidocaine, prilocaine and their metabolites
is explained in part by the differences in area and doses of EMLA being used per
patient. In every patient, plasma levels of lidocaine and prilocaine were far below
the levels associated with initial signs of central nervous system toxicity.
This paper provides assurance for the clinician in the use of EMLA in the adequate
debridement of venous leg ulcers. vdgol101
REFERENCES
1. Holm J, Andren B, Grafford K. Pain control in the surgical debridement of leg
ulcers by the use of a topical lidocaine, prilocaine cream, EMLA. Acta Derm Venereol
(Stockh) 1990; 70:132-36.