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Wound Pain Management. Frank D. Ferris, MD Rosene D. Pirrello, RPh San Diego Hospice & Palliative Care University of California San Diego School of Medicine / School of Pharmacy. Objectives. Experience of wound pain Wound pain Pathophysiology Assessment Management
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Wound PainManagement Frank D. Ferris, MD Rosene D. Pirrello, RPh San Diego Hospice & Palliative Care University of California San Diego School of Medicine / School of Pharmacy
Objectives • Experience of wound pain • Wound pain • Pathophysiology • Assessment • Management • Acute intermittent pain, eg, dressing changes • Constant + breakthrough pain
Slides / Resources • Downloadable www.cpsonline.info • presentations
Dynamics of venous ulcer experiences… Catherine A. Eager, RN, BC, ET/WOCN, CWS Providence Healthcare, Portland, Oregon
Patient Interviews • 150 patients with venous insufficiency • Open interviews • Recorded patients’ words
Pain is the 5th Vital Sign… Record pain intensity ratings along with temperature, heart and respiratory rate, blood pressure.
Pain An unpleasant sensory and emotional experience associated withactual or potential tissue damage,or described in terms of such damage IASP: http://www.iasp-pain.org
Pain pathophysiology • Acute pain • identified event, • resolves days–weeks • usually nociceptive • Chronic pain • cause often not easily identified, multifactorial • indeterminate duration • nociceptive and / or neuropathic
Pain Nociceptive acute prolonged protective non-protective reflexes inflammationand repair
Nociceptive pain . . . • Direct stimulation of intact nociceptors • 4 types nociceptors • Pressure • Stretch • Temperature • Chemical • Transmission along normal nerves • Tissue injury apparent
Infection / Inflammation • Multiple inflammatory products • Histamine • Substance P • Stimulate chemical receptors • Sensitize nociceptors • Recruit silent nociceptors
Patient Experience • Sharp • Aching • Throbbing • Somatic / cutaneous • easy to describe, localize • Visceral • difficult to describe, localize
. . . Nociceptive pain • Management • opioids • adjuvants / coanalgesics
Pain Nociceptive Neuropathic acute prolonged chronic protective non-protective peripheral central “Pain exceeds observable injury” reflexes inflammationand repair
Ischemia Diabetic, arterial insufficiency Demyelinization Herpes, chemotherapy, ALS, HIV Entrapment / transection Sciatica, phantom limb, pressure, plexopathies Compression Edema, tumors Infiltration Tumors Underlying Causes
Sensitization Allodynia –pain from normally painless stimuli 10 8 6 4 2 0 Hyperalgesia – increased pain to noxious stimuli Injury Pain Intensity Normal Pain Response Stimulus Intensity Gottschalk A, Smith DS. Am Fam Physician. 2001;1979-84.
Long Term Effects • Don’t delay for investigations or disease treatment • Unmanaged pain nervous system changes • permanent damage ( wind-up ) • amplify pain • Treat underlying cause, eg, infection
Stabbing Shooting Radiating Burning Tingling Numbness Pressure Freezing “On fire” Patient Experience
. . . Neuropathic Pain • Management • opioids • adjuvants / coanalgesics
The Chronic Wound Pain Experience (CWPE) Diane Krasner, 1995 Assessment Intensity Duration Specific characteristics Noncyclic acute wound pain Cyclic acute wound pain Chronic wound pain sharp debridement or drain removal daily dressing changes turning and repositioning persistent pain plan plan plan Targeted Interventions Pharmacologic/ Non-pharmacologic Pain-reducing dressings Time-outs during changes Pressure-relieving devices Targeted Interventions Pharmacologic/ Non-pharmacologic Regularly scheduled analgesia Relaxation strategies TENS Targeted Interventions Pharmacologic/ Non-pharmacologic Topical or local anesthetics Evaluation Evaluation Evaluation
Pain Assessment • Location • Quality (type) • Nociceptive • Neuropathic • Mixed • Temporal profile • Severity • Effect of medications / therapies • Benefit • Adverse
Temporal Profile • Constant • Breakthrough • IntermittentAcute
Cognitively Impaired web.missouri.edu/~proste/tool/cog/painad.pdf
Fear of Pain • Listen for clues that the patient’s pain extends beyond each visit • Listen and watch for behaviors of fear during every visit
Acute Intermittent Pain • Cyclic • Dressing removal • Repositioning • Non-cyclic • Debridement • Drain removal
Multi-national Survey • Pain and trauma at dressing removal Most: Dried out dressings and adherent products Least: Soft silicones
Before Changing a Dressing • Anticipate the response when dressings are removed • Understand how to remove tape • Does the patient have a good method to remove the tape / dressing ? • Let the patient ask for ‘ time-out ’
Plan for the Pain • Pre-medicate patient with analgesics • Before leaving home • On arrival in clinic • Use anaesthetics • Topical • Injectable
EMLA,* Eutectic Mixture of Local Anesthetics • Lidocaine 2.5% / prilocaine 2.5% cream • Liquid when cold, solid at room temp. • Apply thick coat, “icing on a cake” • Leave on 30-60 minutes • Need complete seal eg, plastic wrap, transparent film (adhesive) *Approved for use on open wounds in Canada / Europe, but not US FDA
Local Anesthetics LidocaineAmide - less allergy Topical Quick onset of action Injectable < 200 mg / dose + Epinephrine bleeding Onset 10-15 min Max action 30-60 min Risk of tachycardia Benzocaine (ester) is a topical sensitizer
Lidocaine Topical Solution • 2 % (2 gm / 100 ml) or 4 % (4 gm / 100ml) • Spray or drip on • 2 % 10 ml = 200 mg or4 % 5 ml = 200 mg • Acidic • Buffer with sodium bicarbonate • ~ 5 mL of 1 mEq / ml NaHCO3 + ~ 45 mL 2 % or 4 % lidocaine • Test with pH paper • Warm
