Pain and Negative Pressure Wound Therapy Protection Status

by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN

The Patient Assessment

You've been asked to evaluate a patient for negative pressure wound therapy (NPWT). It turns out they're a perfect candidate, so you start the process to have the unit placed immediately! The order is entered into the EHR for the recommended settings, and the initial dressing application is scheduled.

Let us pause for a moment and consider the following questions:
- Does the patient have pain?
- Has their pain been adequately assessed?
- What type of medication does the patient currently have ordered?
- Has anything been ordered for dressing change or breakthrough pain that often occurs with NPWT?
- Have any adjunctive methods been identified to implement in the event the patient's pain is not well controlled?
- Does the hospital have a guideline for managing pain in patients with NPWT?

There are so many factors to consider before treatment even begins!

The Problem with Pain

NPWT is very advantageous in that it promotes tissue growth and proliferation via tissue strain, encourages wound contraction, provides exudate management, and reduces bioburden. The adherence of the typical NPWT foam dressing to the wound bed can be a source of significant pain during dressing changes.

Despite the evidence available that pain slows healing and recovery, many studies demonstrate that the health care system has not improved with regards to providing adequate pain control. The consequences of unrelieved pain can include activation of the body's stress response and disruption of the normal wound healing cascade. Pain, especially associated with wound dressings and NPWT in particular, is a multifaceted problem that must be managed with multiple modalities to facilitate an environment of holistic patient care.

Does the Literature on NPWT Provide Any Solutions?

A literature review reveals a multifaceted approach, including topical anesthetics prior to NPWT dressing changes and treatment variable modulation (pressure setting, wound contact layer, type of foam, etc.) can be effective in augmenting patient pain experience and decreasing opioid analgesic requirements.

A Proposed Guideline for Pain Management

The appraised evidence suggests that when formulating an individualized pain management plan for NPWT, the provider should consider the following interventions:

  • Instill lidocaine topically into NPWT foam dressing of no more than 3mg/kg after inactivating therapy, 15-30 minutes before scheduled dressing change (to decrease pain associated with foam dressing removal). Use clinical judgment with large wounds, or wounds with vasculature, organs, or other structures exposed to minimize potential for systemic absorption.
  • Apply a wound contact layer between the wound bed and NPWT foam (to reduce pain on removal and with reapplication)
  • Utilize an alternative foam dressing such as PVA foam (to decrease ingrowth of tissue and pain on removal)
  • Titrate pressure settings downward in increments of 25mmHg after initial 24 hours of therapy (to decrease ingrowth of tissue and decrease pain on removal
  • Change NPWT settings to continuous from intermittent or dynamic therapy (to decrease pain during therapy)
  • Consider substituting a gauze-based NPWT system if the above interventions fail to appropriately manage pain (to decrease ingrowth of tissue and pain on removal of dressing)

*Note that manufacturer guidelines should still be observed, and some of the above interventions should not be combined (e.g. PVA foam at less than 125mmHg). Consulting the representative of the company for the device is always a prudent idea when troubleshooting the device and settings to increase patient comfort.

We should always be our patients' most fierce advocates, especially where pain is involved. Working with the patient to manage pain not only fosters an environment of trust, but hastens the healing process. I plead with you to never forget that, and always keep the patient's best interests at the forefront of your thoughts.

I enjoy learning through the feedback of others, so please feel encouraged to share your thoughts, ideas, and experiences! Until we blog again…I leave you with this quote:

"A lack of compassion can be as vulgar as an excess of tears."
- Lady Grantham, Downton Abbey

This blog is based on a poster presentation given by the author at the National Association of Clinical Nurse Specialists 2015 Annual Conference in Coronado, California held on March 5-7, 2015. See below for the sources used for that presentation, or click here [PDF] to view the poster.

• Birke-Sorensen H, Ferreira F, Martin R, et al. Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) – Steps towards an international consensus. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2011;64:S1-S16. doi: 10.1016/j.bjps.2011.06.001.
• Christensen TJ, Thorum T, Kubiak EN. Lidocaine Analgesia for Removal of Wound Vacuum-Assisted Closure Dressings. Journal of Orthopaedic Trauma. 2013;27(2):107-112. doi: 10.1097/BOT.0b013e318251219c.
• European Wound Management Association. (2002). Pain at Wound Dressing Changes. [Position document] London, UK: Medical Education Partnership. Accessed October 7, 2014 from
• Evans E, Gray M. Do topical analgesics reduce pain associated with wound dressing changes or debridement of chronic wounds? Journal of Wound, Ostomy and Continence Nursing. 2005;32(5):287-290.
• Fraccalvieri M, Ruka E, Bocchiotti M, Zingarelli E, Bruschi S. Patient's pain feedback using negative pressure wound therapy with foam and gauze. International Wound Journal, 2011;8(4):492-499. doi: 10.1111/j.1742-481X.2011.00821.x.
• Franczyk M, Lohman RF, Agarwal JP, Rupani G, Drum M, Gottlieb LJ. The impact of topical lidocaine on pain level assessment during and after vacuum-assisted closure dressing changes: A double-blind, prospective, randomized study. Plastic and Reconstructive Surgery. 2009;124(3):854-861. doi: 10.1097/PRS.0b013e3181b038b4.
• Hurd T, Chadwick P, Cote J, Cockwill J, Mole T, Smith J. Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds. International Wound Journal. 2010;7(6):448-455. doi: 10.1111/j.1742-481X.2010.00714.x.
• Kinetic Concepts, Inc. (Acelity) (2014). KCI Healing by design: Clinical guidelines, vac therapy. Retrieved from
• Mouës C, Heule F, Hovius S. A review of topical negative pressure therapy in wound healing: sufficient evidence? The American Journal of Surgery. 2011:201(4);544-556. doi: 10.1016/j.amjsurg.2010.04.029.
• Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. Journal of General Internal Medicine. 2006;21(6):607-612. doi: 10.1111/j.1525-1497.2006.00415.x
• Orgill D, Manders E, Sumpio B, et al. The mechanisms of action of vacuum assisted closure: More to learn. Surgery. 2009;146(1):40-51. doi: 10.1016/j.surg.2009.02.002.
• Senecal SJ. Pain management of wound care. The Nursing Clinics of North America. 1999;34(4):847-60.
• Upton D, Andrews A. Negative pressure wound therapy: improving the patient experience. Journal of Wound Care. 2013;22(10):552-557.
• Wiegand C, Springer S, Abel M, Wesarg F, Ruth P, Hipler U. Application of a drainage film reduces fibroblast ingrowth into large-pored polyurethane foam during negative-pressure wound therapy in an in vitro model. Wound Repair and Regeneration. 2013;21(5):697-703. doi: 10.1111/wrr.120.

About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


Removal of the sticky drape is often the most painful part of many dressings. I have to remind staff all the time about adhesive remover. Instilling NS into the sponge works well if done 30 mins before removal. The other thing I find people forget is that if sticky drape is put on under tension (either by pulling over the foam or pressing heavily on the foam when securing) this can cause severe skin pain. Patients find it hard to describe this kind of pain and it is under reported I think. Having patients remove the drape themselves works really well, especially for youngsters.


Thank you for your comment! I completely agree that adhesive releaser is a lifesaver, especially in the peds population. I also continuously remind staff not to stretch the drape to fit, but more to apply smaller strips instead one large sheet. This usually decreases the tendency to want to pull the drape across the wound. I do find that moistening the sponge with either saline or lidocaine tends to loosen the drape to the immediate periwound, especially after powering the therapy off. I generally finish removing drape with moistened gauze, and using the tegaderm removal method (pulling tangentially versus vertically). Thank you again for your input and all the great work you do for your patients!

NPWT quality of life issues go far beyond procedural (dressing change) pain. One man told me that NPWT is like a spoiled toddler, tugging at your pantleg screaming, "I want candy! I want candy!" 24/7. The word he used was "incessant." Patients on NPWT have to arrange every aspect of their lives around their wound care. They often don't sleep well. They can never forget that they have a wound, even for a moment. Some people like this "attention," because it makes them feel as if they are being cared for, but many do not. If there are good alternatives, and I believe there are, I would not wish this experience upon anyone.

Linda, thank you so much for reading, and for your comment!
I can definitely relate to this patient's experience and agree that it is something we should be very cognizant when prescribing NPWT. I by no means advocate for NPWT to be used across the board for all wounds. There are definitely patients that stand to benefit much more than others, or patients whose lifestyle causes us to consider different type of therapy. Having said that, I also know patients who may not have reached the same level of functionality they did without using NPWT, and greatly benefited from a NPWT pain management plan as described above. My main goal with this project was to attempt to address the pain experience for individuals which stand to benefit greatly from or require therapies such as NPWT for healing, where therapy may be discontinued or hospital discharge delayed due to uncontrolled pain. I agree that we must treat all patients individually and avoid providing the dreaded "cookie cutter" interventions and protocols that do not promote patient centered care.

Awesome article. Very timely. This issue is not often addressed clinically. Pain management is a very real and challenging issue as a wound care nurse. I find surgical technique also plays a role in pain management, unfortunately we have no control of this.

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