1. 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

2. Objectives • Experience of wound pain • Wound pain • Pathophysiology • Assessment • Management • Acute intermittent pain, eg, dressing changes • Constant + breakthrough pain

3. Slides / Resources • Downloadable www.cpsonline.info • presentations

4. Patient / family experiencewith wounds…

5. Dynamics of venous ulcer experiences… Catherine A. Eager, RN, BC, ET/WOCN, CWS Providence Healthcare, Portland, Oregon

6. Patient Interviews • 150 patients with venous insufficiency • Open interviews • Recorded patients’ words

7. Location of Pain

8. Activity that IncreasedPain the Most

9. Provided Most Pain Relief

10. Activities that Relieved Pain without Medication

11. Most Significant Issues

12. Concerns by Age

13. Pain is the 5th Vital Sign… Record pain intensity ratings along with temperature, heart and respiratory rate, blood pressure.

14. Pain can be madeworse by…

16. Pathophysiology…

17. 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

18. 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

19. Pain Nociceptive acute prolonged protective non-protective reflexes inflammationand repair

20. Nociceptive pain . . . • Direct stimulation of intact nociceptors • 4 types nociceptors • Pressure • Stretch • Temperature • Chemical • Transmission along normal nerves • Tissue injury apparent

21. Infection / Inflammation • Multiple inflammatory products • Histamine • Substance P • Stimulate chemical receptors • Sensitize nociceptors • Recruit silent nociceptors

22. Patient Experience • Sharp • Aching • Throbbing • Somatic / cutaneous • easy to describe, localize • Visceral • difficult to describe, localize

23. . . . Nociceptive pain • Management • opioids • adjuvants / coanalgesics

24. Pain Nociceptive Neuropathic acute prolonged chronic protective non-protective peripheral central “Pain exceeds observable injury” reflexes inflammationand repair

25. Ischemia Diabetic, arterial insufficiency Demyelinization Herpes, chemotherapy, ALS, HIV Entrapment / transection Sciatica, phantom limb, pressure, plexopathies Compression Edema, tumors Infiltration Tumors Underlying Causes

26. 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.

27. 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

28. Stabbing Shooting Radiating Burning Tingling Numbness Pressure Freezing “On fire” Patient Experience

29. . . . Neuropathic Pain • Management • opioids • adjuvants / coanalgesics

30. Wound-related Pain…

31. 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

32. Wound Pain Assessment…

33. Pain Assessment • Location • Quality (type) • Nociceptive • Neuropathic • Mixed • Temporal profile • Severity • Effect of medications / therapies • Benefit • Adverse

34. Temporal Profile • Constant • Breakthrough • IntermittentAcute

35. SDHPC Severity Assessment Scales

36. Cognitively Impaired web.missouri.edu/~proste/tool/cog/painad.pdf

37. 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

38. Acute Intermittent Pain…

39. Acute Intermittent Pain • Cyclic • Dressing removal • Repositioning • Non-cyclic • Debridement • Drain removal

40. Multi-national Survey • Pain and trauma at dressing removal Most: Dried out dressings and adherent products Least: Soft silicones

41. When Most Painful

42. Minimizing Trauma and Pain

43. Prepare Patient for Dressing Changes…

44. 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 ’

45. Plan for the Pain • Pre-medicate patient with analgesics • Before leaving home • On arrival in clinic • Use anaesthetics • Topical • Injectable

46. PreemptiveAnesthesia / Analgesia…

47. 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

48. 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

49. 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

50. Analgesic Selection…