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ANALGESIA FOR WOUND DRESSING RELATED PROCEDURES

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

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  1. Introduction
  2. Types of pain
  3. Assessment of Pain
  4. Management

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Content

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Content

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INTRODUCTION

  • Pain is an important aspect of wound care.
  • “Unresolved pain negatively affects wound healing and has an impact on the quality of life.
  • Pain at wound dressing procedures can be managed by a combination of:
    • accurate assessment
    • suitable dressing choices
    • skilled wound management and individualized analgesic regimens.
    • For therapeutic as well as humanitarian reasons, it is vital that clinicians know how to assess, evaluate and manage pain (ref 2)’.

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TYPES OF PAIN

  1. Background pain
  2. Incident (breakthrough) pain
  3. Procedural pain

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  1. Background Pain
  2. The pain felt at rest, when no wound manipulation is taking place.
  3. May be continuous (e.g. like a toothache) or intermittent (e.g. like cramp or night-time pain).
  4. Related to the underlying cause of the wound, local wound factors (e.g. ischemia, infection and maceration) and other related pathologies (e.g. diabetic neuropathy, peripheral vascular disease, rheumatoid arthritis and dermatological conditions).

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  1. Incident (breakthrough) Pain
  2. The pain that may occur during day-to-day activities (e.g. mobilisation, coughing, repositioning).

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  1. Procedural Pain
  2. Results from a procedure such as dressing change and simple wound debridement.

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ASSESSMENT OF PAIN

  1. Ask the patient about his/her pain
  2. At regular intervals, whenever the BP/P/RR/Temp (vital signs) are taken (Pain as the 5th Vital sign).
  3. Before, during and after dressing change.
  4. Before, during and after a procedure (e.g. debridement).
  5. At any other time when the patient complains of pain.

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  1. When asking the patient about pain, record the Pain Score using any of the following pain scales
  2. Visual Analogue Scale / Numerical Rating Scale for adults and older children.
  3. Wong-Baker Faces Scale for children aged 1-4 years.

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  1. The analgesic administered should follow the pain score
  2. (mild = pain score 1-3, moderate = pain score 4-6, severe = pain score more than 6)

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MANAGEMENT OF PAIN

  1. Background pain

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    • Non-pharmacological management

a. splinting

b. immobilization

c. relaxation / imagery

  • Pharmacological management
    • Analgesics are given according to the severity (pain score) of pain. (Refer analgesic ladder and List of Drugs used as analgesics.

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    • Regular (6 - 8 hourly) Oral Paracetamol

  1. Regular NSAIDS or COX2 inhibitors (dosage depends on the drug):
  2. caution in patients with thrombocytopenia, coagulopathies, asthma and renal, hepatic or cardiac impairment.
  3. contraindicated for patients with hypovolemia, active peptic ulceration or with a history of sensitivity to aspirin or other NSAIDS.

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    • Regular (6 - 8 hourly) Weak Opioids (Dihydrocodeine (DF118) or Tramadol) dosage to follow the analgesic ladder, depending on the level of pain (mild, moderate or severe).

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  • In patients who are unable to take orally, the drugs may be replaced by any of the following:
    • Rectal Paracetamol - Regular (6 - 8 hourly)
    • Rectal Diclofenac - Regular (8 hourly)
    • COX2 inhibitor – IV Parecoxib - (but can only be given for maximum of 2 days)
    • Subcutaneous Morphine 2.5-5 mg - Regular (4 hourly) or
    • Tramadol 50-100 mg - (6hourly) (max dose for tramadol is 400mg in a day)

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  • For patients with severe pain refer to Acute Pain Service (APS) or anaesthesiologist if no APS available.

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  • As all analgesics are associated with adverse effects, it is important to be aware of the contraindications and potential adverse effects and to treat side effects (e.g. nausea/vomiting) when they occur.

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ANALGESIC LADDER FOR �ACUTE PAIN MANAGEMENT

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FORMULATIONS AND DOSAGE OF �COMMONLY USED ANALGESICS

DRUG

FORMULATION AVAILABLE

DOSAGE

Paracetamol

Tablet 500mg,

Suspension 500mg/5ml,

Suppositories

 

500 mg – 1gm qid

NSAIDs

 

Diclofenac

Tablet 50mg & 25mg,

IM injections

Suppositories 12.5mg, 25mg, (50mg & 100mg)*

Gel

Oral 25 - 50mg tds, (max 3 doses/day)

IM 25-50mgs tds ( max 3doses/day) (not encouraged)

Sup: 50mg-100mg stat

Topical: PRN

Mefenamic Acid (Ponstan)

Capsule 250mg

250 mg – 500mg tds

Ibuprofen ( Brufen)

Tablet 200mg & 400mg*

200 mg – 400 mg tds

Naproxen (Naprosyn, Synflex)

Tablet 250mg, 550mg

500mg-550 mg bd

Ketoprofen (Orudis, Oruvail)

Capsule 100mg *, Injection 100mg,

Patch 30mg, Gel

Oral: 100mg daily, IV: 100mg bd

Patch: 30mg - 60mg bd, Topical: PRN

Meloxicam (Mobic)

Tab 7.5mg

Daily or bd

COX 2 inhibitors

 

Celecoxib

Capsule 200 mg, 400mg

200 mg bd /400mg OD (max 1 week)

Etoricoxib

Tablet 90 mg & 120 mg

120 mg daily (max 1 week)

Parecoxib

Injection 20 mg/ml

40 mg bd ( 20 mg bd for elderly) max for 2 days

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WEAK OPIOIDs

 

Tramadol

Capsule 50mg, Injection 50mg/ml

50mg -100mg tds or qid (max 400mg/day)

IM not encouraged

Dihydrocodeine (DF118)

Tablet 30 mg

30mg-60mg qid (max 360mg/day)

STRONG OPIOIDs

 

Morphine ( 1st line )

 

Tablet SR 10mg,30mg

Aqueous 10mg / 5ml

Injection 10 mg/ml,

SR morphine for severe background pain

Aq morphine to be given at least 30 minutes prior to procedure

Inj - to be given Subcut. 30 minutes prior to procedure

Dosage: #

< 60yrs : 5mg -10mg

> 60yrs : 2.5mg -5mg

 

Oxycodone

Tablet SR Oxycontin, 10mg,20mg

 

Immediate release –

Capsule. Oxynorm 5mg,10 mg

SR Oxycontin 10-20mg bd for severe background pain

 

IR oxynorm 5-10mg 4 hrly

Pethidine

 

Use of pethidine is not encouraged due to the risk of norpethidine toxicity and higher addiction potential.

Injection 50mg/ml

100mg/2ml

IV/ IM / SC

<60 yrs 50mg-100 mg 4hrly

>60yrs 25mg-50mg 4hrly

Reduce dose in renal and hepatic impairment

 

Fentanyl

FOR APS USE ONLY

Injection 50 mcg/ml,

Patch 25 mcg/h, 50 mcg/h

IV only to be prescribed by APS team.

Patch to be used for severe background pain in cancer pain; NOT in Acute Pain

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  1. Incident Pain

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  • All patients must be allowed to have “PRN” doses of analgesics to cover incident pain.
  • The actual analgesic and the dose depend on the analgesia prescribed for the background pain.
  • However, if there is a lot of breakthrough pain present, it will be necessary to review the background analgesics.

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    • Non-pharmacological management
      1. Adequate preparation of the patient
      2. Relaxation / imagery

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  • Pharmacological management
  • For patients not requiring any regular analgesics (i.e. background pain is none or mild), prescribe PRN Paracetamol or NSAID (e.g. diclofenac).

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  1. For patients on regular paracetamol and/or NSAIDs (max dose for diclofenac is 50 mg 3 doses) or COXIBs, prescribe PRN Tramadol 50 mg or DF118 30-60 mg.

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  • For patients on regular PCM plus NSAIDs/COXIBs plus weak opioid (Tramadol or DF118) - prescribe additional (PRN) dose of the weak opioid (maximum dose of tramadol is 400 mg / day and maximum dose of DF118 is 240 mg/day).

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  • Patients requiring strong opioids (e.g. morphine) should be co-managed with the APS or anaesthesiologist.

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  1. Procedural Pain

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  • Non-pharmacological management:
    1. adequate preparation of the patient
    2. use of non-traumatic dressings
    3. soaking dressings before removal
    4. allowing patient control (e.g. allowing the patient to determine the time of the dressing)
    5. relaxation / imagery

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  • Pharmacological management
  • Most analgesics can be administered before a painful event.
  • Analgesia may be continued post-procedure, but if wound pain persists and is poorly controlled, background medication should be reviewed.
  • Oral route
  • Subcutaneous route
  • Intravenous route
  • Topical local anaesthethics
  • Inhalational

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    • Oral route

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  • Paracetamol and NSAIDs should be given at least 1 hour prior to the procedure. It can be given together with oral weak opioids like DF118 or Tramadol.

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  • When pain is difficult to control, strong opioids like immediate release formulations of oxycodone (Oxynorm 5- 10mg 4hrly PRN) and aqueous morphine (2.5-5mg 4hrly PRN).

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  • May also be administered orally half an hour prior to the procedure.

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    • Subcutaneous route

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  • Used for severe pain during the procedure, when the above oral analgesics are inadequate to control the pain.

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  • S/C Morphine;
  • to be given at least 30 minutes before the procedure is performed
  • dose depends on age of patient and severity of pain

e.g. < 65yrs : 5mg -10mg

> 65yrs : 2.5mg -5mg

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    • Intravenous route

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  • IV morphine 0.5 -1 mg bolus
    • Analgesia may be achieved using the morphine pain protocol.
    • This involves the administration of IV morphine 0.5 -1 mg bolus, repeated every 5 minutes, titrated to effect (i.e. a reduction in pain score) and monitoring for side effects (drowsiness and respiratory depression) using the respiratory rate and the sedation score.
    • Monitoring of SpO2 can also be done if available.
    • If PCA is available, IV PCA morphine with a bolus dose of 1-2 mg and a lockout interval of 5 minutes may be used during the procedure, with the advice of the Acute Pain Service anaesthetist

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    • Intravenous route

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  • IV Fentanyl 0.5 mcg/kg
    • Slow bolus to be given 5-10 minutes before the procedure, repeated during the procedure if necessary, up to a maximum of 2 mcg/kg (total dose), with the advice of the Acute Pain Service anaesthetist.
    • If PCA is available, IV PCA fentanyl with a bolus dose of 10-20 mcg and a lockout interval of 2-3 minutes may be used during the procedure, with the advice of the Acute Pain Service anaesthetist

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  • Note:

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  • Difference between IV Morphine and IV Fentanyl:
    • The onset and duration of action, with IV Fentanyl having a faster onset but shorter duration of action.
    • IV Fentanyl is also more potent than morphine and can rapidly cause profound sedation and respiratory depression.
  • Before removing the dressing, assess the pain by pressing over the wound. If the patient gives a pain score of 3 or more, further analgesia is required.

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    • Intravenous route

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  • IV Ketamine - 0.25 - 0.5 mg/kg titrated to effect.
    • Usually used in children, but may be used in adults in selected cases.
    • Note that the patient may have hallucinations with the use of this drug and IV Midazolam 1-2 mg may have to be used concomitantly

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    • Topical local anaesthethics

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  • Lignocaine (2% in 5-10 mls of normal saline)
    • Plain lignocaine max dose 3mg/kg body wt;
    • lignocaine with adrenaline max dose is 7mg/kg body wt,
    • soaked gauze over the wound; allow to sit on the wound for 3-5 mins before procedure.
    • Can provide a degree of numbness.

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    • Inhalational

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  • Methoxyflurane (Penthrox)
    • Used as an inhaler 5 minutes prior to procedure
    • Each inhaler can be used multiple times by the same patient
    • The maximum dose of methoxyflurane via the inhaler is:
    • 3mL to 6 mL for a single episode of severe pain
    • 15mL in any 7 day period (5 x 3mL bottles)
  • Can only be used once in 48 hours (alternate day administration)

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  • Methoxyflurane (Penthrox)
    • Contraindications:

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    • Precautions:
    • Diabetic patients
    • Liver disease

Severe renal impairment with reduced glomerular infiltration rate (GFR) <30 mL per minute

Patients unable to hold the inhaler due to impaired consciousness/cooperation

Renal failure

Patients who are intoxicated with alcohol or illicit drugs

Hypersensitivity to fluorinated anaesthetics

Patients with respiratory depression, airway obstruction or airway burns

Cardiovascular instability

Patients susceptible to or having a family history of Malignant Hyperthermia

A history of possible adverse reactions in either patient or relatives

Concurrent use of tetracycline and other antibiotics of known nephrotoxic potential are not recommended as it may result in fatal renal toxicity

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  • Uncontrolled Pain
    • Patients whose pain is not controlled despite all the above methods should be referred to the Acute Pain team (APS).
    • There are other methods including the use of regional blocks (e.g. epidural, peripheral nerve block) which can be used in selected cases but this can only be done with the appropriate expertise and monitoring.

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  • Antiemetics
  • Nausea and vomiting are common side effect of opioids.
  • There is no need to stop the opioids but it is necessary to treat the nausea and vomiting with antiemetics.
  • Metoclopramide (maxalon) 10-20mg IV/SC/oral - give one dose stat and repeat if necessary 6-8hrly
  • If the patient continues to vomit or have nausea, then use
  • Odansetron 4mgIV – give one dose stat and repeat if necessary 8 hrly OR
  • Granisetron 1mg IV - give one dose stat and repeat if necessary 8 hrly

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  • Patient Education
    • It is necessary to educate patients with regards to their analgesic usage.
    • They must understand that in the beginning for the first 3-7 days, they will require to take their analgesics on a regular basis and then as the wound heals, it can be on a PRN basis.
    • It should be emphasized that prior to any procedure that they may require, they will need to ingest their analgesic 1 hour before the procedure. This may mean they take the medication at home before arriving at the clinic.

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REFERENCES

  • Ezike HA et al Oral ketamine for wound care procedures in adult patients with burns South Africa J Anaesth Analg 2011;17(3): 242-248
  • Principles of Best Practice A world union of wound healing Societies Initiative – Minimising pain of wound dressing related procedures. A concensus document
  • Sussman C et al Wound Care: a collaborative practical manual
  • J LatarjetMD.Consultant in Anaesthesiology and Intensive Care; Chief, Burn Centre St Joseph and St Luc Hospital Lyon, France -The management of pain associated with dressing changes in patients with burns

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REFERENCES

  • Choiniere M, Melzack R, Rondeau J, Girard N, Paquin MJ. The pain of burns: characteristics and correlates. J Trauma 1989; 29(11): 1531-9.
  • Choiniere M, Auger FA, Latarjet J. Visual analogue thermometer: a valid and useful instrument for measuring pain in burned patients. Burns 1994; 20(3): 229-35.
  • McGrath PG. Pain in Children. New York: Guildford Press, 1990.
  • Recommendations from the Prince of Wales Drug and Therapeutic Committee, Dec 2005 .
  • Grindlay, J., Franz Babl E.F., Review article: Efficacy and safety of methoxyflurane analgesia in the emergency department and prehospital setting. Emergency Medicine Australasia, 2009, 21: 4–11.

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REFERENCES

  • Cousins, M.J, Mazze R.I, Methoxyflurane Nephrotoxicity. A Study of Dose Response in Man. JAMA, 1973, Vol 225, 13: 1611-1616
  • Marshall, M. A, Ozoria, H.P.L, Analgesia for Burns Dressing using Methoxyflurane. British Journal of Anaesthesia, 1972, 44:80-82
  • Tomi, K., et al. Alterations in pain threshold and psychomotor response associated with subanaesthetic concentrations of inhalation anaesthetics in humans. British Journal of Anaesthesia, 1993; 70:684-686
  • Pain as the 5th Vital Sign , Guidelines for Doctors – Management of Adult Patients Ministry of Health, Malaysia

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THANK YOU

Wound Care Training Module - National Wound Care Committee