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We are thankful for Dr Hunter's comments on our recent work.1Martínez-Monsalve A. Selva-Sevilla C. Gerónimo-Pardo M. Analgesic effectiveness of topical sevoflurane to perform sharp debridement of painful wounds.J Vasc Surg. 2019; 69: 1532-1537Abstract Full Text Full Text PDF Scopus (18) Google Scholar We fully agree with her appreciation about the need to reduce costs. Coincidentally, we are currently performing a retrospective cost-effectiveness analysis in patients with refractory pain due to leg ulcers who are noneligible for revascularization. These patients were referred to a pain unit for analgesic palliative treatment, and self-administered topical sevoflurane was compared against other conventional analgesic treatments. Preliminary results showed that topical sevoflurane is by far the most cost-effective treatment for this specific condition. Regarding her four specific comments: Our institutional Pharmacy Regulatory Commission asked us to create a specific registry to record information about efficacy and safety, but such information was required only for patients treated with sevoflurane. Thus, information for patients treated with standard of care was lacking, which precluded us from performing a retrospective case-control study. Anyway, this limitation does not invalidate our conclusion about the topical analgesic/anesthetic effect of sevoflurane. First, patients treated with topical sevoflurane had severe pain at rest, and they did not receive any additional analgesic treatment before, during, or immediately after the wound care procedures; thus, the local application of this drug seems to be the most likely reason for the dramatic pain changes reported by the patients. Second, the robust topical analgesic/anesthetic effect of sevoflurane has also been described in small series of cases previously reported by other authors.2Fernandez Ginés F.D. Cortiñas-Sáenz M. Mateo-Carrasco H. Navajas de Aranda A. Navarro-Muñoz E. Rodríguez-Carmona R. et al.Efficacy and safety of topical sevoflurane in the treatment of chronic skin ulcers.Am J Health Syst Pharm. 2017; 74: e176-e182Google Scholar, 3Imbernon-Moya A. Ortiz-de Frutos F.J. Sanjuan-Alvarez M. Portero-Sanchez I. Merinero-Palomares R. Alcazar V. Treatment of chronic venous ulcers with topical sevoflurane: a retrospective clinical study.Br J Anaesth. 2017; 119: 846-847Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar As stated, patients suffered from severe pain at rest (median of 7 points) in spite of being treated with systemic analgesics. Therefore, it is very unlikely that these drugs played a significant role in controlling the acute pain induced by sharp wound debridement. Although additive or synergistic analgesic effects following coadministration of topical sevoflurane in patients under treatment with other pain killer drugs have not been ruled out, sevoflurane irrigation decreased the baseline pain rapidly, prevented the pain caused by debridement, and maintained low levels of wound pain in the vast majority of patients. In addition, topical sevoflurane has had a similar analgesic profile in the challenging setting of severe wound pain, which was refractory to systemic analgesics, including major opioids or even invasive techniques.4Padilla del Rey M.L. Gerónimo-Pardo M. García Fernández M.R. Cartagena Sevilla J. Painful diabetic foot ulcer amputation avoided thanks to topical sevoflurane.https://doi.org/10.20986/resed.2018.3683/2018Google Scholar We agree with Dr Hunter's comment about the lack of a definition for duration of analgesia. However, this is a minor limitation as the striking point was to enable debridement to be performed. Also, patients could ask for more analgesics, as for any postsurgical pain. Allergy to sevoflurane and family or personal history of malignant hyperthermia are rare conditions, which none of our patients had. Obviously, if that had been the case, topical sevoflurane would not have been applied. We hope these comments are helpful to better understand our paper1Martínez-Monsalve A. Selva-Sevilla C. Gerónimo-Pardo M. Analgesic effectiveness of topical sevoflurane to perform sharp debridement of painful wounds.J Vasc Surg. 2019; 69: 1532-1537Abstract Full Text Full Text PDF Scopus (18) Google Scholar on the potential off-label use of sevoflurane as a topical analgesic/anesthetic drug. Off label, on target?Journal of Vascular SurgeryVol. 70Issue 3PreviewI read with great interest the article by Martínez-Monsalve et al1 in a recent issue of the Journal. The authors performed a retrospective study of 152 patients undergoing wound debridement and concluded that topical application of sevoflurane to painful wounds produced a rapid, robust, and long-lasting analgesic effect that allowed a high degree of wound debridement. The authors should be applauded for performing a well-designed study of an important topic (acute pain) in patients undergoing wound debridement. Full-Text PDF Open Archive