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Managing Wound Pain in Patients with Vacuum-Assisted Closure Devices
To cure - occasionally. To relieve - often. To comfort - always. - Ancient Greek Epigram
Patients 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
Case Vignette
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
Wound bed/granulation tissue pain. For many patients, a considerable source of pain is the acute cyclic pain secondary to the disruption of the granulation tissue in the wound bed from VAC sponge removal. The granulation tissue may stick to the VAC sponge or literally grow into the sponge. When the sponge is removed, the trauma may be a source of intense acute cyclic pain. To minimize this experience, consider one or several of the following strategies:
- Line the wound bed with a white, polyvinyl alcohol (PVA) soft-foam sponge, a nonadherent oil-emulsion type dressing (eg, Adaptic, Johnson and Johnson, Somerville, NJ), a contact layer (eg, Mepitel, Mölynlycke Health Care, Eddystone, Pa.), a thin layer of amorphous hydrogel (eg, Intrasite Gel, Smith and Nephew, Largo, Fla.), or a calcium alginate (eg, Sorbsan, Bertek Pharmaceuticals, RTP, NC) before the gray sponge application (see Figure 5). Avoid the use of petrolatum gauze, which is too oily and may disrupt adherence of the VAC drape.5
- Reassess the frequency of VAC dressing changes. If granulation tissue is growing into the sponge, increase the frequency of the dressing changes. The manufacturer of the VAC recommends dressing changes every 48 hours for most wounds. Doing so will prevent the ingrowth of granulation tissue and resulting pain upon dressing removal.5
- Instill 10 cc to 30 cc of normal saline into the VAC tubing to soak underneath the foam and let it sit for 15 to 30 minutes before gently removing the dressing. Saline also can be injected directly into the foam while low vacuum is applied to the dressing. Clamp the tube once the saline starts to flow into the dressing tube. Wait 15 to 30 minutes before gently removing the dressing.5
- Instill 1% lidocaine solution through the VAC tubing, with the pump turned down at a lower pressure (ie, 50 mm Hg) and clamp the tubing for 15 to 20 minutes before gently removing the dressing. Caution: Beware of systemic absorption of the lidocaine and toxicity in large wounds.5,6
- To prevent drying of the granulation tissue, which causes pain during dressing changes, consider the following strategies. Change one wound site at a time if multiple sites are present. Cover any exposed granulation tissue with a normal saline gauze compress until ready to apply the VAC sponge. Use sufficient personnel to minimize procedure performance time.
Wound margin pain. Denuded wound margins are frequently noted by patients and researchers to be a common source of wound pain.7 Initially, to protect intact wound margins under the occlusive, adhesive VAC drape, two approaches should be taken:
1. Cut the VAC sponge to the exact size of the wound. Avoid overlapping of the sponge onto good skin unless bridging is necessary to prevent skin maceration.
2. Apply a water-soluble skin sealant to intact skin on the periwound margins as primary prevention. If the skin on the periwound margins breaks down, apply 1-inch strips of thin hydrocolloid or thin adhesive foam to protect the open areas before applying the VAC drape.
Debridement pain. For acute noncyclic pain from a sharp debridement, topical anesthetics can effectively decrease the pain of the procedure. Some options include:
1. EMLA®. Eutectic Mixture of Local Anesthetics (EMLA®, Astra Pharmaceutics, Wayne, Pa.) applied topically 30 to 60 minutes before debridement under occlusion with a film dressing. Note: EMLA® has been used safely in open wounds and is approved worldwide for such use. However, the FDA has not approved its use in open wounds in the United States. Such use is considered off-label.
2. 4% lidocaine solution
3. 2% lidocaine gel
4. 1% lidocaine solution.
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.
Wound care and pain management are not black and white - care must be individualized to each patient (the gray). The goal always should be to provide comfort and to relieve pain and suffering whenever possible.
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.
