Most surgical patients - up to 82% - report acute pain from their wounds for up to two weeks after they have left hospital (Apfelbaum et al, 2003).
Gillian S. Ross, RGN, DipHE.
Surgical Practitioner in Upper Gastro-intestinal/Hepato-Pancreatico-Biliary (HPB) Surgery, at the Department of General Surgery, Manchester Royal Infirmary
Unrelieved postoperative pain causes clinical and psychological changes and can increase mortality and morbidities, including poor wound healing (Brewik, 1998; Carr and Goudas, 1999).
Minimising surgical wound pain requires a multimodal approach which involves choosing the correct wound dressing as well as appropriate analgesia.
Day surgery patients are generally less satisfied with pain medication than inpatients (Dealey, 1999). This may stem from an unwillingness to prescribe patients long-acting opioids before their discharge because of the potential safety concerns. It may also be significant that 72% of patients prefer non-narcotic drugs for postoperative pain relief, believing them to be less addictive (McNeil et al, 1998).
Many patients believe it is necessary to experience some pain after surgery (Apfelbaum et al, 2003). This may affect the type and frequency of analgesia administered.
General lack of awareness of the efficacy of current analgesics could account for the problems relating to medically managed wound pain (McNeil et al, 1998). But pain does have its place in the postoperative period. The inflammatory phase of healing is often perceived as harmful because of its associated pain, yet it plays an important protective role (Gould, 1999). For example, an increase in localised wound pain may be one of the early indicators of wound infection (Chang et al, 1996). Others include pyrexia, redness and swelling.
The significant morbidities attributed to pain (Page, 1996) highlight the need for robust methods of assessing and controlling it.
Box 1 outlines some of the practices in the department of general surgery at Manchester Royal Infirmary that involve non-medical staff, including the surgical practitioner.
A surgical wound which has good apposition is sealed from pathogenic invasion by epithelialisation in approximately 48-72 hours (Winter, 1962; Dealey, 1999). However, the new cells are still delicate and easily damaged and need protecting. Hence dressings applied in the operating theatre are commonly allowed to remain intact until the second or third day after the operation. However, gauze materials are prone to adhere and can cause pain and trauma when they are removed (Hollingworth and Collier, 2000).
Wounds which have sustained greater tissue loss such as ulceration, wide debridement, incision and drainage of abscesses and some trauma wounds, for example gunshot wounds or burns, require more granulation tissue to heal.
Healing in these instances is mainly by secondary intention (Gould, 1999). The inappropriate selection of dressing materials for use on wounds healing by secondary intention can result in significant pain and distress at dressing change, delayed wound healing and excessive scarring (Gould, 1999; Hollingworth and Collier, 2000).
Pain on applying or removing a dressing can contribute to patient distress and increase the potential for non-compliance with treatment. Patients may avoid attending clinic appointments or delay replacing dressings themselves if they are at home and are undertaking their own wound care (Gould, 1999).
Because of contemporary emphasis on early discharge from hospital and day-case surgery, this poses an increasing problem.
Selecting appropriate dressings
Selecting the most appropriate dressing material for each wound is important to ensure comfort, reduce pain and promote prompt healing, free of complications. Dziewulski et al (2003) recommend that surgical wound dressings meet certain criteria (see Box 2). But perhaps surprisingly, as with many wound-care assessment tools, the criteria for a quality wound dressing listed pay little attention to selecting a dressing material which minimises pain and tissue damage during removal.
Reducing pain at dressing change
Pain and tissue damage resulting from the removal of old dressings can be avoided by selecting a suitable product. Hydrocolloids are less painful when removed because they adhere to the wound bed far less than gauze dressings (Biggins, 2001; Dealey, 1999).
As a consequence of a longitudinal study at Manchester Royal Infirmary, Aquacel ribbon was introduced to replace the traditional gauze-based ribbon dressings. This was found to significantly reduce wound pain at dressing change. Inpatient hospital stays were significantly reduced as patients no longer needed help with administering narcotics at the first dressing change (Biggins, 2001).
Following a review of dressing materials used to pack postoperative pilonidal excisions and peri-anal abscess cavities, hydrofibre dressings were introduced at my place of work.
A hydrofibre ribbon dressing (Aquacel) was found to be most effective at satisfying the surgeon’s requirement for haemostasis following surgery, while still retaining its property of non-adherence at dressing change. In some cases irrigating the wound with warm saline rather than cleaning it with a gauze swab reduces pain (Hollingworth, 1997). Soaking dressings before a dressing change may help to make removal more comfortable - although some argue that this is no longer appropriate (Moffatt et al, 2002). Alginate dressings, which can be removed by irrigating away the old dressing with saline, can also significantly reduce pain and trauma at dressing changes (Bruno and Kerstein, 1994).
Many patients would benefit from pain relief administered before a dressing change, as long as time is allowed for the analgesic to take effect (Gould, 1999). A multimodal approach can be most effective. Practitioners could consider modalities such as Entonox and local anaesthetic agents, along with more traditional medicated pain relief. Choice of analgesics is dependent on the type and level of pain experienced. For example, ongoing or acute postoperative pain may be better managed through the routine administration of non-steroidal anti-inflammatory drugs (NSAIDs). Chronic wounds (often healing by secondary intention) may only require the administration of strong analgesia (opioids for example) as required before dressing changes (Gould, 1999).
Non-drug or alternative pain relief techniques are worth considering, including the use of music, distraction and relaxation therapies, humour, therapeutic touch and aromatherapy.
But because of lack of research, non-drug methods should be used alongside, not instead of, conventional methods (McCaffrey, 2002).
If pain continues to be uncontrolled during dressing changes it may be appropriate to select a product that requires changing less frequently (Hollingworth, 1997), such as alginates, foam dressings or to use vacuum-assisted closure.
It may be necessary, on occasions, to re-dress complex wounds under general anaesthesia. However, patients’ anaesthetised status could lead to less attention being paid to minimising tissue damage when old dressings are removed. Theatre staff need to take steps to minimise trauma when removing old dressings, regardless of the patient’s state of consciousness.
The perception of pain
A range of physiological and psychological factors such as perception, emotion and physical disruption may influence the pain pathway (Briggs and Torra i Bou, 2002; Dealey, 1999). Anxiety, cultural differences and personality can affect a patient’s perception of pain. When planning postoperative wound care and pain management, psychological and sociological factors need considering, along with physical factors, such as the patient’s ability to detect and respond to painful stimuli (Gould, 1999).
Effective wound and wound pain management demands sound patient education and willingness by the patient or carer to participate. A holistic approach, including pre-operative patient and carer education, has many benefits such as:
- Relieving anxiety
- Increasing self-esteem and self-efficacy
- Speeding recovery
- Decreasing the amount of perceived immediate and residual pain (Vanaermas and Lindeman, 1971).
The surgical practitioner
As a permanent member of the surgical team the surgical practitioner is well placed to interact with the patient for longer, both before and after the operation, and to evaluate care over longer periods of time. Their involvement in the patient’s episode of care means they can pre-operatively assess and postoperatively review the patient, on the ward or in outpatient clinics or specialist wound-healing clinics (Box 3).
The importance of thorough assessment, continuing evaluation and effective documentation of selected wound dressing materials is often understated - more so in view of the possibility that different dressings or combinations of dressings may be required during different stages of the healing process. In many aspects of wound care, nursing and medical notes also do not correlate, and this leads to fragmented care and poor communication (Cutting, 1998). Accurate assessment and documentation is vital when more than one person or department is involved in wound care.
Managing surgical wounds healing by primary intention is likely to become less problematic with the development of more effective advanced wound dressings; increasingly effective methods of medicated pain management; education; and advances in minimal access surgical (MAS) techniques.
Future research is likely to focus on management of patients with surgical wounds healing by secondary intention. If so, management of surgical wound pain must become an integral part of assessment.
Theatre practitioners, clinical nurses and surgical practitioners, working as part of the multidisciplinary team, are ideally placed to undertake this work and to include multimodal, holistic approaches to caring for surgical wounds and controlling surgical wound pain (Gould, 1999).
Patient support and education is likely to become an increasing priority, particularly in view of the significant move from inpatient care to short-stay and day-case surgery.
World Union of Wound Healing Societies’ guide to dressing-related pain
A new publication, Principles of Best Practice: Minimising pain at wound dressing-related procedures - a consensus document, has been prepared by an international expert working group convened by the World Union of Wound Healing Societies. The guide recognises that pain can often be an issue with wound dressing-related procedures, and advises that professionals should adopt best practice in order to avoid unnecessary pain. www.wuwhs.org
NICE guidance on debriding agents for difficult-to-heal wounds
NICE issued guidance on debriding agents for difficult-to-heal surgical wounds in April 2001. The NICE guidance document states that alginate, foam, hydrocolloid, hydrogel and polysaccharide (beads or paste) dressings, as well as maggots, may reduce pain from difficult-to-heal surgical wounds. However, because there is insufficient evidence to support one debriding agent over another NICE advise that the choice of advanced wound dressings used should be based on factors such as patient acceptability (including factors such as comfort and odour control), type and location of the surgical wound and total cost (including time for changing the dressings).
Author contact details
Gillian S. Ross, Department of General Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL. Email: email@example.com
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