Managing Wound Pain in Patients with Vacuum-Assisted Closure Devices
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To cure - occasionally.
To relieve - often.
To comfort - always.
- Ancient Greek Epigram
P atients with complex wounds treated with the vacuum-assisted closure (VAC) device (Kinetic Concepts, Inc., San Antonio, Tex.) may or may not experience pain. For example, certain patients with severe diabetic neuropathy experience no pain when the VAC device is applied to the foot. Other patients with heavily exudating wounds may find that removing irritating exudates and reducing built-up exudate pressure on the wound bed by using the VAC relieves their pain.
For many patients, the application and removal of the VAC is a source of procedural pain. Furthermore, just having the VAC sponge in the wound bed or the VAC drape pulling on the periwound margin can be a source of psychological (nonprocedural) pain. Conceptualized another way, according to Krasner's Chronic Wound Pain Experience Model,1 the patient with a chronic wound using a VAC device may experience acute noncyclic pain, acute cyclic pain, and/or chronic pain1 (see Figure 1).
Multiple strategies may be needed to adequately manage the complex pain experience for people on the VAC. Patients' pain (present pain intensity) should be assessed regularly using a valid and reliable pain assessment tool (eg, a 0 to 10 visual analog scale [VAS] or the Faces scale.2 The American Pain Society urges all healthcare providers to consider pain assessment as the fifth vital sign. Clinicians also should determine each individual's acceptable level of pain and develop an individualized pain management plan that achieves that goal.3
Mrs. S was a 48-year-old, nondiabetic patient undergoing a "routine" arteriogram, which went terribly wrong. At the groin site, she developed a hemorrhage, necrosis, and eventually underwent repair with a myocutaneous flap from the abdomen to the groin. Subsequently, for unexplained reasons, she developed a necrotizing fasciitis to three wound sites: the abdomen, the groin, and the inner thigh (see Figures 2, 3, and 4). Mrs. S was transferred from the hospital where the arteriogram and initial surgery were performed to another facility for hyperbaric oxygen treatments. On admission, her wounds were debrided in the OR by a plastic surgeon and the VAC device was applied to all three wound sites.
Mrs. S experienced multiple types of pain and suffering. She had acute noncyclic pain from occasional sharp debridements of the wound beds. She had acute cyclic pain from several sources - VAC dressing changes, transfers to stretchers and into the hyperbaric chamber for hyperbaric treatments, and turning and repositioning in bed.
She experienced chronic burning pain from the wound infections and the denuded margins of her wounds. Additionally, pain and suffering kept her awake at night, so she had become sleep deprived over the several weeks since, in her words, "this nightmare started."
Strategies for Managing Wound Pain for Patients with VAC Devices
Pain related to routine dressing change. For acute cyclic pain from dressing changes, pain medication administered 30 to 60 minutes before the procedure can reduce pain and relieve anxiety associated with the procedure. Selection of medication should follow the World Health Organization (WHO) three-step analgesic ladder, proceeding from the nonopioids (with or without adjuvants) up to the opioids (with or without adjuvants) as needed to achieve an adequate and acceptable (to the patient) level of pain relief.4
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.