Perspectives on Pain: Using Topical Negative Pressure with a Lipidocolloid Dressing

  Topical negative pressure (TNP) is a non-pharmaceutical technique for the treatment of complex, acute, chronic, infected or non-infected wounds.^1-10 Reported adverse effects include pain¹⁰ – which most often occurs when the dressing is removed because buds of granulation tissue become fixed in the foam’s open mesh – and/or discomfort.⁷   Although strategies recommended to reduce pain include use of a non-adherent dressing beneath the foam dressing,^10,11 no clinical evaluation has yet been conducted to demonstrate its advantages. In France, practitioners familiar with TNP often use a lipidocolloid non-adherent dressing (Urgotul, Laboratories Urgo, Dijon, France) between the foam and the wound.¹² The small mesh of this dressing prevents granulation tissue from migrating into the foam, reducing the risk of granulation bud damage. Clinically, this translates as painless, or almost painless, removal of the foam dressing, and results in improved patient acceptability.¹²

Methods

  To assess whether a lipidocolloid nonadherent dressing used in conjunction with TNP can be removed without causing pain and trauma to the wound bed and whether it is acceptable to patients, a multicenter clinical evaluation was conducted in eight French hospitals by departments of plastic and reconstructive surgery, vascular surgery, general surgery, and dermatology. Patients under age 18 years old or who were pregnant or lactating were excluded. Wound area tracings were recorded and photographs were taken at study beginning and end. Pain was evaluated and documented by physicians and nurses during each dressing change throughout the follow-up period.

Care procedure.

  After cleansing the wound with saline and/or local antiseptic, the contact layer was applied to the wound bed. The TNP foam dressing was applied as per manufacturer’s instructions; a starting negative pressure of 100 to 125 mm Hg was applied either continuously or intermittently as considered suitable by the investigator.

Results

  Of the 66 patients included in the study, 45 were men, 21 women, with a mean age of 57 years (range 16 - 92). In total, participants received 1,145 days of treatment and underwent 320 documented clinical evaluations and local care procedures. On average, the dressings were removed every 3.8 ± 1.1 days (for all wounds) and the mean treatment duration was 17 days (range 17.4 ± 10.1).   Of the 66 wounds, 64% were acute. Most were postoperative and had been present for an average of 16 days. The remainder (36%) were chronic; these were mainly pressure ulcers and had been present for an average of 226 days.

  Before treatment with the TNP and interface dressings, pain was noted in 62% of care procedures. At baseline, pain was noted in 66% of patients, even though 60% were prescribed oral analgesics (see Table 1).

  Patients rated TNP-interface dressing combination removal as very easy (123 out of 319 cases, 39%), easy (178 out of 319, 56%), difficult (17 out of 319, 5%), and very difficult (one out of 319, 0.3%). The dressing combination adhered to the wound in 39 out of 311 cases (12%); no adherence occurred in the remaining 272 cases (88%).

  The interface dressing did not adhere to the wound in 199 out of 316 cases (63%). Minor adherence occurred in 98 out of 316 cases (31%) and moderate adherence in 19 out of 316 (6%).

  No bleeding at dressing removal was noted in 169 out of 319 (53%) Minor bleeding occurred in 121 out of 318 cases (38%) and moderate bleeding in 28 out of 318 (9%).

  Dressing application was reported as very easy in 49 out of 274 cases (18%), easy in 200 out of 274 (73%), and difficult in 25 out of 274 (9%) (see Table 2).

Discussion

  Topical negative pressure therapy has been adopted by many clinicians. Clinical trials^1-10 have demonstrated its advantages in wounds difficult or impossible to manage with traditional methods. Although TNP use may be restricted by often painful dressing removals,¹⁰ application of a nonadherent dressing under the foam may provide a solution.⁷

  Despite this study’s non-comparative design, more than 320 care procedures were documented by nursing staff. In the majority of cases, dressing changes were less painful when the TNP was used with the interface dressing, most likely because no granulation tissue became attached to the foam dressing. This lack of adherence is similar to that observed with the lipidocolloid dressing in patients with burns and in fragile populations such as children¹³ and in patients with congenital epidermolysis bullosa skin lesions.¹⁴ Painless or almost painless dressing removal meant that care procedures were better accepted and even improved quality of life.

Clarification

  The lipidocolloid dressing cited in this article, Urgotul® (Laboratories URGO, Dijon France), is marketed in the US by Hollister Wound Care LLC as Restore® Contact Layer Dressing with TRIACT™ Technology. In the US, lipidocolloid technology is known as TRIACT™ Technology. This article was excerpted from Teot L, Lampert L, Ourabah Z, et al. Use of topical negative pressure with a lipidocolloid dressing: results of a clinical evaluation. J Wound Care. September 2006;15(8). Perspectives on Pain is a series of occasional articles provided to enhance knowledge and awareness of pain related to wounds and wound care. Support for this series is provided by Hollister Wound Care, Libertyville, IL. This article was not subject to the OWM peer review process.

1. Banwell PE, Teot L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Wound Care. 2003;12(1):22-28.

2. Meara JG, Guo L, Smith JD, et al. Vacuum-assisted closure in the treatment of degloving injuries. Ann Plast Surg. 1999;42(6):589-594.

3. Banwell PE. Topical negative pressure therapy in wound care. J Wound Care. 1999;8(2):79-84.

4. Banwell P, Withey S, Holten I. The use of negative pressure to promote healing. Br J Plast Surg. 1998;51(1):79.

5. Joseph E, Hamori CA, Bergman S, et al. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. Wounds. 2000;12(3):60-67.

6. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet. 2005;366(9498):1704-1710.

7. Avery C, Pereira J, Moody A, Whitworth I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg. 2000;38(4):343-345.

8. Bauer P, Schmidt G, Partecke BD. Possibilities of preliminary treatment of infected soft tissue defects by vacuum sealing and PVA foam. Handchir Mikrochir Plast Chir. 1998;30(1):20-23.

9. Philbeck TE Jr, Whittington KT, Millsap MH, et al. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy Wound Manage. 1999;45(11):41-50.

10. Krasner DL. Managing wound pain in patients with vacuum-assisted closure devices. Ostomy Wound Manage. 2002;48(5):38-43.

11. Terrazas SG. Adjuvant dressing for negative pressure wound therapy in burns. Ostomy Wound Manage. 2006;52(1):16-18.

12. Lambert F, Bey E, Bohbot S. Interet d’une interface lipdo-colloide (Urgoteul) dans le traitment des plaies par pression negative. Conference des Paies et Cicatrisations. Paris, France. 2006.

13. LeTouze A, Voinchet V, Hoecht, B, et al. Using a new lipdocolloid dressing in paediatric wounds: results of French and German clinical studies. J Wound Care. 2004;13(6):221-225.

14. Blanchet-Bardon C, Bohbot S. Using Urgotul dressing for the management of epidermolysis bullosa skin lesions. J Wound Care. 2005;14(10):490-496.