Case reports
Minimising pain and trauma during wound dressing procedures
Author: Kyoichi Matsuzaki
The incidence of chronic wounds has been increasing globally with the rise in the number of diabetic patients and an ageing population. It is expected that the incidence of neuropathic pain due to chronic wounds will also increase. This case features a patient diagnosed with Buerger’s disease and type 2 diabetes mellitus who presented with gangrene of the left toes and associated pain.
INTRODUCTION Endurance is often seen as a virtue but when it comes to wound care, ‘putting up’ with pain can have a negative effect on healing[1]
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1. Patients experience most pain at dressing change
2. Traditionally, the majority of
wound-related pain management has targeted acute pain
3. The incidence of chronic wounds has been increasing recently, due in part to the rise in the number of diabetic patients and an ageing population
patient’s protestations are perceived as an over-reaction. An apparently normal-looking periwound
. Traditionally,
the majority of wound-related pain management has targeted acute pain resulting from surgery or trauma. However, the incidence of chronic wounds has been increasing recently, due in part to the rise in the number of diabetic patients and an ageing population. It is expected that, because of this, the incidence of neuropathic pain due to chronic wounds will increase. Pain signals are transmitted through the
peripheral nerves to the spinal cord and muscle tension increases with the excitation of reflex motor nerves. This sympathetic excitement contracts the blood vessels, causing increased metabolism in the muscles and localised reduction in blood flow, leading to ischaemia in the tissue. Pain-causing substances (eg cations and bradykinin) and pain-amplifying substances (ie prostaglandins) released from hypoxic tissue further stimulate the peripheral nerves and spinal cord, causing a vicious cycle of pain that inhibits wound healing[2]
. In addition, when pain is not taken seriously,
peripheral and central sensitisation occur, causing a subsequent reorganisation in the central nervous system and leading to complex and chronic pain[3]
Figure 1. The fingertips of both the patient’s hands had been amputated due to Buerger’s disease.
area can also be hyperalgesic (secondary hyperalgesia), and even mild stimulation, such as that caused by peeling off an adhesive dressing, may cause unbearable pain. Non-nociceptive stimuli, such as pressure and contact, do not normally cause pain, however, in chronic wounds they may begin to do so (allodynia), meaning that abrasive clothing or even the slight movements of passers-by may be perceived as pain. Finally, if vessels that nourish the nerves are damaged due to peripheral arterial disease, neuropathic pain, as well as nociceptive pain, can occur in the wound area[2]
. Patients with wounds experience the
greatest amount of pain at dressing change and it is recommended that they are treated in accordance with relevant consensus statements[4]
. . The patient’s ‘firing
threshold’ perception of pain also decreases in chronic wounds, due to repetitive stimulation by inflammatory mediators. This can cause strong pain during wound treatment, even from slight nociceptive stimuli (primary hyperalgesia), leading to situations where the
46 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012
CASE REPORT This case features a 64-year-old man who had been diagnosed with Buerger’s disease at the age of 30 and also had type 2 diabetes mellitus. As a consequence of the peripheral vascular disorder caused by Buerger’s disease, he had undergone fingertip amputations of both hands [Fig 1] and had gangrene of his left toes with associated pain (he rated this as 10 on a numerical rating scale). A cardiovascular physician in the
hospital where the patient had undergone endovascular treatment, but who could not provide limb salvage, had referred the
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