Case report: Minimising pain and trauma during wound dressing procedures
opinion is that a Hydrofiber would be easier to apply to the unevenly shaped ulcers around the exposed proximal phalanges. In addition, the dressing was chosen for its antimicrobial properties — due to the inclusion of silver — since it was suspected that the ulcer was critically colonised. The patient’s SPP improved to 64mmHg at the dorsum of the foot and 60mmHg at the sole of the foot, one month after treatment began. The SPP measurements were taken approximately 5cm away from the ulcer on the dorsal and plantar skin of the foot — therefore, the SPP improvement was considered to be due to the effects of the cilostazol and the patient’s strict adherence to a smoking cessation programme, rather than to the dressing itself. Similarly, one month after initial treatment
had commenced, the wound had contracted to the exposed proximal phalanx of the second, third and fourth toes and epithelialisation was present [Fig 3]. Since the SPP had now risen to more than 35mmHg, surgical removal of the exposed proximal phalanges was performed. The necrotic tissue on the first and fifth toes was also excised [Fig 4]. Secondary hyperalgesia in the skin
surrounding the ulcer had been present since admission, therefore, a soft silicone dressing material was used after the debridement (Mepilex®
Border; Mölnlycke Health Care). Three weeks after the excision of the
exposed bones and necrotic tissue, granulation tissue began to cover the bone at the amputation site, and skin from the abdomen was grafted under local anaesthesia [Figs 5 and 6]. Two weeks following the skin graft, an
impression of the foot was taken so that therapeutic footwear could be designed. After another two weeks, the therapeutic footwear was provided and the patient was discharged. After discharge, the patient was followed up as an outpatient [Figs 7 and 8], and chronic pain disappeared with the healing of the ulcer.
DISCUSSION Since the US Congress declared a ‘Decade of pain control and research’ beginning in 2001, the idea that ‘receiving treatment for pain is a patient’s right’ has become widespread[6,7]
. In
wound treatment, the conventional method of focusing solely on healing the wound is being revised and the importance of patient-
Principles 3 and 6b: cleanse the wound gently and treat local factors Since the patient’s skin had become hypersensitised, warmed physiological saline was used to cleanse the wound instead of the room temperature saline. Inflammation due to contact dermatitis was treated using topical steroids.
Principle 6a and 7: select appropriate dressing and treat infection Due to the exposed distal phalanges, the ulcer base was not flat and it was necessary to prevent dead space between the ulcer base and dressing material, as accumulated exudate in this space can damage the ulcer base as well as the periwound area. Appropriate moisture balance was required to prevent periwound maceration. A Hydrofiber was used in this case as they swell and convert into a gel, which fills dead space[8]
. Hydrofibers are
activated by moisture in the wound, absorbing and trapping fluid within the structure of the dressing. Silver was chosen for its proven
centered care, such as pain control, is being increasingly acknowledged[4]
. Pain that is transmitted continuously and
for extended periods by chronic wounds can lead to complex pain, such as hyperalgesia and allodynia[3]
. Clinicians who treat wounds need
to consider chronic and acute wound pain separately and be aware that chronic pain is not simply prolonged acute pain. Therefore, the World Union of Wound Healing Societies’ consensus statement, Principles of Best Practice: minimizing pain at wound dressing-related procedures, and the 10 principles that were introduced in it, has been proposed as a tool to prevent complex pain[4] [Table 1].
The following principles from those 10 (in no
particular order) were considered vital when treating the case presented in this article.
Principle 1: identify and treat the cause of the chronic wound The patient was diagnosed with Buerger’s disease and type 2 diabetes mellitus. The main cause of the chronic wound was thought to be peripheral arterial disease. Because the stenosis of the superficial femoral artery had been improved by endovascular treatment using a catheter, cilostazol was administered for the peripheral arterial disease. Smoking cessation may also have helped in this case.
Figure 7. The wound at two years post healing.
Figure 6. Skin from the abdomen was grafted onto a section of the wound.
Figure 8. After the wounds were healed, the patient wore therapeutic shoes to prevent the recurrence of ulcers.
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