In this episode, I’ll discuss how to manage pain associated with wound VAC dressing changes.
A wound VAC is a vacuum-assisted closure device that applies negative pressure to a wound. This is also referred to as negative pressure wound therapy, and has become a common way for various surgical disciplines to promote the healing of acute or chronic wounds.
The purpose of the vacuum is to remove the excess fluid from the extravascular space. This, in turn, allows for improved circulation and enhanced proliferation of reparative granulation tissue.
A wound VAC may be applied to a diabetic foot ulcer, or various orthopedic wounds such as infected wounds after debridement, open fracture wounds, fasciotomy wounds after compartment syndrome, surgical wounds that are difficult to close, and many other types of wounds.
Wound VAC dressing changes can be particularly painful for patients. The wound VAC dressing is a sponge that is placed on top of the wound. During the healing process, the granulation tissue and regenerating nerve endings can grow into the sponge. Significant pain then occurs as a result of the sponge being removed.
IV or oral opioids are often given prior to a dressing change in a proactive attempt to lessen the pain. In an opioid naive adult patient with no additional risks for respiratory depression, 2 to 4 mg of morphine IV or 5 to 10 mg of oxycodone PO may be given prior to a dressing change. An important step is to give the opioid far enough in advance of the dressing change with enough time for the peak. This is generally 5 to 10 minutes after IV administration or 30 to 60 minutes after oral administration.
Two main concerns with giving opioids for wound VAC related pain are 1) They do not always bring the pain from a dressing page down to a satisfactory level and 2) Patient-specific concerns may exist related to potentially serious opioid-related side effects, especially in elderly patients or those with sleep apnea.
The addition of topical lidocaine prior to a wound VAC dressing change has been shown in a randomized controlled trial to lower patient-reported pain scores and subsequent prn opioid doses by a significant amount.
To utilize lidocaine in this setting, turn off and disconnect the suction canister. Then, 20 minutes before the dressing change, inject topical lidocaine in a retrograde fashion up the wound VAC suction tubing to saturate the sponge. This step should be done prior to manipulating the occlusive dressing. The dose of lidocaine to use is 4.5 mg/kg up to a maximum of 300 mg or 30 mL of a 1% topical solution. This is the generally accepted safe limit for topical lidocaine doses.
Members of my Hospital Pharmacy Academy have access to the Masterclass training on the safe and effective use of opioids in ICU patients. To learn more go to pharmacyjoe.com/academy.
I have found just using normal saline when removing the dressing significantly decreases the pain when applied on the sponge prior to removal. Would you think this would be ok to do?
This section was very helpful to me! I was recently put on a wound vac system for a surgical wound that wouldn’t heal and kept getting infected. So they did a wash out and I woke up to the wound vac. I was under the impression the sponge was in my wound not on top of it and I just knew when I went for a dressing change it was going to hurt severely! Knowing that the sponge isn’t inside my wound on my foot but on top of the wound, puts me at better ease! The medication suggestion and knowing they will use topical numbing agent helps as well!
I am a Surgical nurse from way back. I have been in many surgeries where a wound vac is applied. I truly had no understanding of what a patient went through on awakening and thereafter wearing a wound vac. I got my first woundvac after a bad infection of my midline abdominal incision after colon surgery. It is truly a painful device. I had and still have (on my second go round) a wound vac for this same wound. I have a amazing home health nurse who does all she can do to comfort me as we’ve been through nearly 4 months of this together. So, definitely use saline on removing sponges and as much as I dislike it, take the pain med about 45 minutes prior. I’ve done this with and without pain meds but absolutely a little easier w pain meds. God bless you all!
Thanks, I have a wound vac on since November / 2021. It wasn’t as painful at first but now there is something else going on . I am going to go back to the hospital for them to check it.
Hi Danielle,
I can definitely relate to you waking up to a wound VAC on your foot. I was under general anesthesia for a surgical debridement and when I woke up I had a wound vac on my arm. The pain was almost immediate but I chalked it up to the surgery.
I pictured this device to be kind of like a blood pressure cuff. Boy was I wrong! I went in for my first vac change this afternoon. They didn’t tell me how painful it was going to be.
Furthermore I had no idea that it’s basically packing styrofoam that gets compressed down! Now I know why I had such pain.
I even asked the nurses if I could get any kind of numbing agent like lidocaine before they took off the wound VAC, they simply said “no” and proceeded to rip!
I know ! What is up with the wound care nurses ! It is painful . They should give all patients a lidocaine shot before changing the sponge on the wound . Or give you a pain med to decrease the of pain that you are in.
Pam,
No… The sponge is hydrophobic – saturating it with fluid doesn’t impact removal like it would with gauze-based or foam-based dressings.
The intent of the topical is to ‘numb’ the free nerve endings and nociceptors at the wound/skin barrier where the A-type nerve fibers are.