The Patient Assessment

You've been asked to evaluate a patient for negative pressure wound therapy (NPWT). It turns out they're a perfect candidate, so you start the process to have the unit placed immediately! The order is entered into the EHR for the recommended settings, and the initial dressing application is scheduled.

Let us pause for a moment and consider the following questions:
- Does the patient have pain?
- Has their pain been adequately assessed?
- What type of medication does the patient currently have ordered?
- Has anything been ordered for dressing change or breakthrough pain that often occurs with NPWT?
- Have any adjunctive methods been identified to implement in the event the patient's pain is not well controlled?
- Does the hospital have a guideline for managing pain in patients with NPWT?

There are so many factors to consider before treatment even begins!

The Problem with Pain

NPWT is very advantageous in that it promotes tissue growth and proliferation via tissue strain, encourages wound contraction, provides exudate management, and reduces bioburden. The adherence of the typical NPWT foam dressing to the wound bed can be a source of significant pain during dressing changes.

Despite the evidence available that pain slows healing and recovery, many studies demonstrate that the health care system has not improved with regards to providing adequate pain control. The consequences of unrelieved pain can include activation of the body's stress response and disruption of the normal wound healing cascade. Pain, especially associated with wound dressings and NPWT in particular, is a multifaceted problem that must be managed with multiple modalities to facilitate an environment of holistic patient care.

Does the Literature on NPWT Provide Any Solutions?

A literature review reveals a multifaceted approach, including topical anesthetics prior to NPWT dressing changes and treatment variable modulation (pressure setting, wound contact layer, type of foam, etc.) can be effective in augmenting patient pain experience and decreasing opioid analgesic requirements.

A Proposed Guideline for Pain Management

The appraised evidence suggests that when formulating an individualized pain management plan for NPWT, the provider should consider the following interventions:

• Instill lidocaine topically into NPWT foam dressing of no more than 3mg/kg after inactivating therapy, 15-30 minutes before scheduled dressing change (to decrease pain associated with foam dressing removal). Use clinical judgment with large wounds, or wounds with vasculature, organs, or other structures exposed to minimize potential for systemic absorption.
• Apply a wound contact layer between the wound bed and NPWT foam (to reduce pain on removal and with reapplication)
• Utilize an alternative foam dressing such as PVA foam (to decrease ingrowth of tissue and pain on removal)
• Titrate pressure settings downward in increments of 25mmHg after initial 24 hours of therapy (to decrease ingrowth of tissue and decrease pain on removal
• Change NPWT settings to continuous from intermittent or dynamic therapy (to decrease pain during therapy)
• Consider substituting a gauze-based NPWT system if the above interventions fail to appropriately manage pain (to decrease ingrowth of tissue and pain on removal of dressing)

*Note that manufacturer guidelines should still be observed, and some of the above interventions should not be combined (e.g. PVA foam at less than 125mmHg). Consulting the representative of the company for the device is always a prudent idea when troubleshooting the device and settings to increase patient comfort.

We should always be our patients' most fierce advocates, especially where pain is involved. Working with the patient to manage pain not only fosters an environment of trust, but hastens the healing process. I plead with you to never forget that, and always keep the patient's best interests at the forefront of your thoughts.

I enjoy learning through the feedback of others, so please feel encouraged to share your thoughts, ideas, and experiences! Until we blog again…I leave you with this quote:

"A lack of compassion can be as vulgar as an excess of tears."
- Lady Grantham, Downton Abbey

This blog is based on a poster presentation given by the author at the National Association of Clinical Nurse Specialists 2015 Annual Conference in Coronado, California held on March 5-7, 2015. See below for the sources used for that presentation, or click here [PDF] to view the poster.

Sources:
• Birke-Sorensen H, Ferreira F, Martin R, et al. Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) – Steps towards an international consensus. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2011;64:S1-S16. doi: 10.1016/j.bjps.2011.06.001.
• Christensen TJ, Thorum T, Kubiak EN. Lidocaine Analgesia for Removal of Wound Vacuum-Assisted Closure Dressings. Journal of Orthopaedic Trauma. 2013;27(2):107-112. doi: 10.1097/BOT.0b013e318251219c.
• European Wound Management Association. (2002). Pain at Wound Dressing Changes. [Position document] London, UK: Medical Education Partnership. Accessed October 7, 2014 from aawconline.com.
• Evans E, Gray M. Do topical analgesics reduce pain associated with wound dressing changes or debridement of chronic wounds? Journal of Wound, Ostomy and Continence Nursing. 2005;32(5):287-290.
• Fraccalvieri M, Ruka E, Bocchiotti M, Zingarelli E, Bruschi S. Patient's pain feedback using negative pressure wound therapy with foam and gauze. International Wound Journal, 2011;8(4):492-499. doi: 10.1111/j.1742-481X.2011.00821.x.
• Franczyk M, Lohman RF, Agarwal JP, Rupani G, Drum M, Gottlieb LJ. The impact of topical lidocaine on pain level assessment during and after vacuum-assisted closure dressing changes: A double-blind, prospective, randomized study. Plastic and Reconstructive Surgery. 2009;124(3):854-861. doi: 10.1097/PRS.0b013e3181b038b4.
• Hurd T, Chadwick P, Cote J, Cockwill J, Mole T, Smith J. Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds. International Wound Journal. 2010;7(6):448-455. doi: 10.1111/j.1742-481X.2010.00714.x.
• Kinetic Concepts, Inc. (Acelity) (2014). KCI Healing by design: Clinical guidelines, vac therapy. Retrieved from http://www.kci-medical.ie/IE-ENG/vac-ulta#
• Mouës C, Heule F, Hovius S. A review of topical negative pressure therapy in wound healing: sufficient evidence? The American Journal of Surgery. 2011:201(4);544-556. doi: 10.1016/j.amjsurg.2010.04.029.
• Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of General Internal Medicine. 2006;21(6):607-612. doi: 10.1111/j.1525-1497.2006.00415.x
• Orgill D, Manders E, Sumpio B, et al. The mechanisms of action of vacuum assisted closure: More to learn. Surgery. 2009;146(1):40-51. doi: 10.1016/j.surg.2009.02.002.
• Senecal SJ. Pain management of wound care. The Nursing Clinics of North America. 1999;34(4):847-60.
• Upton D, Andrews A. Negative pressure wound therapy: improving the patient experience. Journal of Wound Care. 2013;22(10):552-557.
• Wiegand C, Springer S, Abel M, Wesarg F, Ruth P, Hipler U. Application of a drainage film reduces fibroblast ingrowth into large-pored polyurethane foam during negative-pressure wound therapy in an in vitro model. Wound Repair and Regeneration. 2013;21(5):697-703. doi: 10.1111/wrr.120.

About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.