Managing Wound Pain in Patients with Vacuum-Assisted Closure Devices

Author(s): 
Diane L. Krasner, PhD, RN, CWOCN, CWS, FAAN



Clinicians are cautioned about systemic absorption of lidocaine with resulting side effects in especially large wounds. Clinical judgment is required in such cases.6

Psychological Issues

Mrs. S found that watching the procedure increased her pain and suffering. This psychological "ache and anguish" can be addressed by using diversionary tactics, such as playing music during the procedure and providing eye shields so the patient does not have to watch.

To minimize the pain of frequent transfers from bed to stretcher to hyperbaric chamber and back, transfer assist devices should be considered. For chronic pain related to ongoing wound infection and the presence of the VAC device, a long-acting analgesic patch changed every 12 hours or a time-released narcotic analgesic every 12 hours orally should be considered. For sleeplessness secondary to pain from multiple sources, consider nightly medication for sleep.

Case Vignette Summary

The following is an initial prescription for addressing Mrs. S's wound pain with the VAC device (Mrs. S's acceptable pain level: VAS level 3):

   1. Assess pain level (present pain intensity) using the VAS with all vital sign assessments and immediately before all procedures and document findings on the pain assessment flow sheet.

   2. For debridement pain, apply EMLA® topically under occlusive transparent film dressing 30 minutes before the debridement.

   3. For dressing change pain:

       - Administer morphine 2 mg PO, 1 hour before dressing change.

       - Instill 100 cc of normal saline into each VAC sponge and clamp for 1 hour before VAC dressing changes.

       - Provide music and eye shields during all dressing changes.

       - Utilize two or more healthcare professionals to change dressings to minimize procedure time.

       - Line all three wound beds after cleansing with normal saline solution and pat the wound margins dry with an oil emulsion dressing before applying the VAC sponges.

       - Protect wound margins with a 1-inch border of thin hydrocolloid dressing before applying the VAC drapes.

   4. For chronic pain, apply a long-acting narcotic analgesic patch every 12 hours (not as needed)

   5. Consider nightly medication for sleep, not just as needed.

   6. For all transfers, use air mattress overlay at all times.

Conclusion

The more you know about wound care and pain management, the grayer it gets. Wound care and pain management are not black and white.

- Diane L. Krasner


Complex wounds, managed with treatments such as the vacuum-assisted closure device often result in a complex pain experience for wound patients, requiring multiple strategies for each individual patient to adequately address the sources of pain from the VAC and related procedures. Even then, with a number of strategies in place, clinician's may only be able to "take the edge off" the patient's pain. From the patient's perspective, knowing the wound care team is attending to this issue is critical and may, in fact, offer some placebo effect in and of itself, as well as reduce anxiety and the stress response.8

The most important strategy involves listening to VAC patients who complain of pain, developing a pain management plan, and implementing and revising the plan as necessary. If the benefits of using the treatment of choice become marginal and the disadvantages do not outweigh potential benefits, treatment should be discontinued.

References: 

1. Krasner D. The chronic wound pain experience: a conceptual model. Ostomy/Wound Management. 1995;41(3):20-27.
2. Acute Pain Management Guideline Panel. Clinical Practice Guideline Number 1: Acute pain management: Operative or medical procedures and trauma. Rockville, Md: U.S. Department of Health and Human Services. Agency for Health Care Policy and Research, Public Health Service; 1992. AHCPR Publication 92-0032.
3. Krasner DL. Caring for the person experiencing chronic wound pain. In Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, Pa.: HMP Communications; 2001.
4. World Health Organization. WHO three-step analgesic ladder. Cancer Pain Relief, 2nd Edition. Geneva, Switzerland: World Health Organization; 1996.
5. Kinetic Concepts, Inc. VAC Physician and Caregiver Reference Manual. San Antonio, Tex.: Kinetic Concepts, Inc; 2001.
6. McCaffery M, Pasero C. Pain Clinical Manual, 2nd ed. St. Louis, Mo.: Mosby; 1999.
7. Hofman D, Ryan TJ, Arnold F, et al. Pain in venous leg ulcers. Journal of Wound Care. 1997;6(5):222-224. 8. Morris DB. The Culture of Pain. Berkeley, Calif.: University of California Press; 1991.



Anonymoussays: January 4.2012 at 14:49 pm

I usually put in 2% lidocaine gel directly onto the wound bed as I'm pulling away a well-soaked foam sponge (soaking these down with normal saline really helps in removal). This generally is less painful; especially if the patient's routine nurse has administered oral or IV pain meds prior to the changing. Unfortunately, there is usually a gap of a few seconds between my tugging and the patient's experiencing relief from the lidocaine.

I really appreciate the non-adhesive layer put down into the wound bed under the gauze dressings used by some companies; this prevents ripping out the wound bed tissue while pulling the foam sponges. Most people who are using the gauze dressings placed over the nonadherent stuff; do not experience pain or distress. There are no studies that report that foam is better than gauze; just some opinion pieces and case dialogues.

Reply to this comment »
Anonymoussays: October 23.2011 at 09:59 am

what about using Lidocaine directly injected to the wound site through the dressing prior to the dressing change?

Reply to this comment »
Anonymoussays: October 15.2012 at 13:37 pm

I have injected Lidocaine solution thru the tubing towards the wound which saturated the wound and allow that to set for 5 minutes.

Also silver being used on the wound bed can reduce pain

Hope that helps

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.