- Email: [email protected]
Pain associated with an adherent polyurethane wound dressing
122
Burns (1985) 12, 122-126
Printed in Great Britain
Pain associated with an adherent polyurethane wound dressing* Carole M. Ehleben,tS tSoutheastem SDepartment
S. Randolph
MaytS§
and Joseph M. Still Jr*
Burn Research Institute, #Humana Hospital Augusta Burn Center, and of Surgery, Medical College of Georgia, Augusta, Georgia, USA
Summary Patient ratings of pain associated with autograft skin donor sites covered by an adherent polyurethane film dressing (Op-Site, Smith & Nephew) were collected using a modified Visual Analogue Scale. Analyses were undertaken to examine differences between pain levels under conditions of rest and activity, and with variations in application technique. It was found that with proper application and with at-rest patients, Op-Sitecovered donor sites could be maintained relatively pain free. However, both specific conditions of application and increases in patient ambulation could result in the patient experiencing donor-site pain of an intensity comparable to concurrent burn-wound pain. To utilize fully their potential for pain control, the polyurethane film dressings must be appropriately applied and maintained, and their use coupled with an adequate analgesic regimen.
INTRODUCTION WHEN a partial
or full thickness sheet of skin is removed for autografting, the resultant donorsite wound becomes the focus for painful sensations (Rudolph et al., 1979). There is ample documentation in the literature that the pain associated with these autograft skin-donor sites can be quite severe and may interfere with patient mobilization and treatment (James and Watson, 1975; Bergman, 1977; Reid, 1977). A number of articles have been published which report that there is a significant alleviation of pain when adherent polyurethane-film dressings are used to cover the donor-site wound (James and Watson, 1975; Bergman, 1977; Birdsell et al., 1979; Dinner et al., 1979; Cavlak,
* Presented at the Geneva International Congress Burns, Geneva, Switzerland, 2-4 May 1985.
on
1980; Lobe et al., 1980; Neal et al., 1981; May, 1984, 1985). However, even those studies which included data derived from controlled assessment of patient pain have either reported relative discomfort only (Neal et al., 1981), or else have sampled only a narrow range of possible patient activity (May, 1984,198s). None of these studies have addressed the issue of the context in which the pain reduction was achieved or have investigated variations in the pain that actually was experienced when using the polyurethane dressings. It has been our clinical experience that polyurethane-film donor-site dressings are not uniformly pain free under all conditions. Patients commonly report feelings of discomfort associated with both the dressings and the underlying donor sites. The perceived level of this pain can be high enough to elicit patient complaints, interfere with movement therapy, or induce the patient to request an alternative donor-site dressing. The goal of this present study was to determine the circumstances under which polyurethane-film dressings are associated with donor-site pain, so that this pain might be kept to a minimum in the future. We investigated the relationship between level of reported pain and several factors, including variations in application technique, the activity level of the patient wearing the polyurethane dressing, and the degree of healing of the donor-site wound. The data support our original clinical observations that polyurethane dressings are not pain free under all circumstances. In fact, we found that if an improper application technique is used, or if there is an increase in the patient’s activity level without
Ehleben et al.: Pain and polyurethane dressing
a corresponding change in pain-management protocol, polyurethane-covered donor sites can produce pain comparable to that of the burn wound itself.
MATERIALS AND METHODS The adherent polyurethane-film dressing used in this study was Op-Site (Smith & Nephew, Hull, UK), a standard covering for donor-site wounds at our Burn Center. The study population consisted of 15 acute burn patients with a mean fs.d. body surface area burn size of 29.4k21.5 per cent, a median of 30 per cent, and a range of S-80 per cent. The patients’ ages ranged from 11 to 70 years with a mean ?s.d. of 33+X513.8 years, and a median of 34 years. Collection of patient pain ratings began 4 to 298 days after the burn injury, with a mean +s.d. of 49.1k82.5 days, and a median of 19 days. Each of the 15 patients had donor sites covered with Op-Site, as well as concurrent burn wounds, or, in one case, a reconstructive surgical site, covered with other dressings or with topical agents. Two standardized instruments were used as the basis for the study: a IO-cm Visual Analogue Scale and the McGill-Melzak Pain Questionnaire. Before collecting any pain ratings for inclusion in the study, the patients were first familiarized with the measurement instruments. The first instrument, a modified version of the lo-cm Visual Analogue Scale, is shown in Fig. 1. The standard use of this scale has been to allow the patient to conceptualize and report degrees of perceived pain by marking a point on a continuous line anchored at ‘No Pain’ on its left terminus and ‘Pain As Bad As It Could Be’ on its right (Sriwatanakul et al., 1983). Because both the pllot study we conducted and prior published work indicated that most of the pain levels associated with Op-Site would be at the lower end of the scale, one of us (C.M.E.) developed a mod-
MODIFIED
123
ified visual analogue scale to include a separate area designated ‘No Pain’ or ‘0’. With this modification of the instrument, the continuous line begins with ‘1’ or ‘Little Pain’, and ends with ‘10’ or ‘Pain As Bad As It Could Be’. The patient markings are scored in numerical increments of I cm. Patients are able to indicate either that they have no pain, or that they have some degree of pain corresponding to a point on a lo-cm unbroken line. Patients were asked to mark the point on the scale which corresponded to their degree of perceived pain for the wound site specified at the time of measurement. Those patients who were unable to write were asked to point to the spot, and the rater made a mark which was then verified by the patient. None of the study patients reported any difficulty in understanding and utilizing this scale. The patients were also familiarized with the adjective categorization portion of the McGillMelzak Pain Questionnaire (Melzak, 1975). This section of the instrument lists a total of 78 adjectives which have been organized into 20 ranked groupings, each grouping reflective of a specific sensation associated with the global experience of pain. Standard administration of the scale requires that the patient choose no more than one adjective from each group that is relevant to his pain experience. Within groups, the adjectives are weighted in order of ascending intensity of sensation. In the current study the checklist was used in two ways. Those patients who were physically able were asked to complete the questionnaire in the standard fashion to describe the sensations associated with at-rest Op-Sitecovered donor sites. Additionally, all patients were asked to use the questionnaire to choose reference words so that standardized descriptions of the pain experience could be constructed for each patient. This latter use also provided additional verification of the intensity of the pain
VISUAL ANALOGUE
Place a mark on the scale to indicate you are feeling RIGHT NOW.
SCALE
how much pain
HI No Pain
Little Pain
Pain As Bad As It Could Be
Fig. 1. Modified Visual Analogue Scale used to score donor-site and burn-wound pain. No perceived pain is indicated by marking the separate segment of the line on the left.
124
Burns (1985) Vol. 12/No. 2
experience as reported by means of the Visual Analogue Scale (Reading, 1980). A total of 50 pain ratings from donor sites covered with Op-Site, or from concurrent burn or surgical wounds, were collected from the 15 study patients. Multiple pain ratings were collected from each patient including, whenever possible, ratings made during periods of both activity and rest. Student’s two-tailed t tests for paired samples were used to determine the statistical significance of differences in mean donor site pain scores obtained while the patients were at rest versus while they were active, and between donor site pain ratings and burn or surgical wound pain ratings. Statistical significance was defined as a PCO-05. RESULTS
The overall mean -ts.d. pain rating on the Visual Analogue Scale for all Op-Site-covered autograft skin donor sites across all patients was 1.36-C2*00 (Table Z). This mean rating included 17 scores of ‘0’ or ‘No Pain’ (47.2 per cent of the total of 36 scores). The pain scores ranged from ‘l’, located at the ‘Little Pain’ end of the scale, to ‘8’, located towards the ‘Pain As Bad As It Gould Be’terminus. A reanalysis of these scores in which perceived donor-site pain ratings obtained while the patient was not active (defined as ‘at rest’) were separated from pain ratings obtained while the patient was engaged in activity (defined as ‘ambulatory’) yielded a somewhat different perspective. The mean +s.d. pain score for Op-Site-covered donor sites obtained while the patient was ‘at rest’ was 0.63fl.11 (Table I). The reported scores ranged from ‘1’to ‘4, and included all 17 ‘0’ responses (63.0 per cent of the 27 ‘at rest’ scores). Thus, over half the ratings obtained while the patient was ‘at rest’ were reports of ‘NO Pain’ perceived from the Op-Site-covered donor sites. Tab/e 1. Skin-donor-site* and burn-wound ings under conditions of rest and activity
Wound Donor site Donor site Donor site Burn wound ??
Skin-donor
Conditions
Ratings n
All ‘At rest’ ‘Ambulaton/’ ‘At rest’
36 27 9 14
pain rat-
Mean 2s.d. pain rating 1.36k2.00 0.63+1.11t,S 3.5622.50t.6 3.71+3.97*,1
sites were covered with Op-Site.
t Statistically significant difference, P=O*OO2. $ Statistically significant difference, P=O.Ol 1. § Difference not statistically significant, P=O.202.
These ‘at rest’ reports of perceived pain were then contrasted with pain ratings obtained when the same patients were ‘ambulatory’. The mean +s.d. pain rating from Op-Site-covered donor sites obtained while the patient was ‘ambulatory’ was 3.56k2.50, with a range of ‘1’to ‘8’(Table I). No patients reported ‘0’ or ‘No Pain’ associated with their Op-Site-covered donor sites while they were active. The t-test between the ‘at rest’ and ‘ambulatory’ donor-site pain scores indicated a statistically significant difference, with a P value of 0.002 (Table I). Pain ratings associated with concurrent burn wounds obtained from these same patients ranged from ‘0’ to ‘10’ with a mean +s.d. burnwound pain rating of 3.71k3.97. As shown in Table I, the pain associated with Op-Site-covered donor sites while the patient was ‘at rest’ (0.63fl.11) was significantly less (P=O.Oll) than the pain reported from burn wounds (3.71k3.97) under the same conditions. However, the pain reported with Op-Site-covered donor sites while the patient was ‘ambulatory’ (356k2.50) was not significantly different (P=O.202) from the pain associated with burn wounds (3.71k3.97) (Table 4.
Based on the adjectives chosen from the McGill-Melzak checklist, the pain that patients experienced from their Op-Site-covered skindonor sites while ‘at rest’ was perceived as essentially mild pain. The eight patients who were able to review and select adjectives from the McGillMelzak checklist to describe their pain while ‘at rest’ chose descriptors yielding a mean +s.d. composite weighted score of 4.25-tl.67, with a range of 2 to 6 (out of a possible 78). This relatively low rating is comparable to the mean +s.d. ‘at rest’ pain score of 0.63k1.11 achieved on the Visual Analogue Scale, indicating ‘Little Pain’. Adjectives indicative of mild pain, such as ‘Sore’, ‘Tender’ and ‘Annoying’, were chosen to describe the ‘at rest’ donor-site pain. When the same patients were asked to choose adjectives describing their donor-site pain while ‘ambulatorv’. the words chosen were indicative of more se&e pain, such as ‘Pulling’, ‘Stinging’ and ‘Burning’. DISCUSSION
There are a number of published reports stating that Op-Site, the adherent polyurethane film dressing, controls pain when it is applied to skindonor-site wounds. Some of these articles, however, only mention pain relief as one of many positive outcomes that can be achieved through
Ehleben et al.: Pain and polyurethane dressing
the use of this dressing (Reid, 1977; Walker 1978; Besst and Wallace, 1979; Myers, 1982). Even those reports which do specifically discuss patient pain relief generally do not document any of the parameters under which the pain control was achieved, nor the extent of the pain relief experienced (James and Watson, 1975; Bergman, 1977; Birdsell et al., 1979; Dinner et al., 1979; Cavlak, 1980; Lobe et al., 1980). Some exceptions to the above generalization can be found in the literature. A quantitative comparison of pain from Op-Site-covered donor sites versus pain from concurrent donor sites covered with other dressings has been undertaken using a three-point verbal scale (May, 1984, 1985). While this study found that Op-Site was associated with significantly less donor-site pain than were the other tested nonpolyurethane film dressings, it was shown that Op-Site was not entirely pain free. Although patients were asked to make pain ratings on a daily basis, data derived under differing conditions of patient activity were not analysed separately. It is also not clear how much discrimination was possible on a three-point scale which had only one rating for the entire category of ‘mild pain’. The study by Neal et al. (1981), while quantitative, assessed relative pain, but did not relate specific pain intensity to specific patient activity. However, data from the Neal et al. study, like that of May, indicated that Op-Site is not entirely pain free, especially under conditions of movement. Pain is not a static measurement, and requires monitoring over a longitudinal time-frame that includes periods of normal patient rest and activity (Perry et al., 1981). Our present study, using standardized instruments. has shown that patients who are at rest when they are being questioned about their donor-site pain will usually report little or no pain associated with these sites when they are covered with Op-Site dressings. Yet these same patients, when ambulatory, can experience significant discomfort from these same Op-Site-covered wounds. Techniques of dressing application can make a significant difference ain the amount of pain associated with donor sites covered by Op-Site. For example, when the Op-Site is applied in such a manner that it extends over joint creases, the subsequent wrinkling and binding in the crease causes the patient a significant amount of pain. This problem can be alleviated by making sure that the dressing does not extend over joint creases. Another potentially painful application technique is the placement of Op-Site over non-
125
depilated areas adjacent to the donor sites; the subsequent pulling and sticking of the hairs under the dressing can cause the patient significant discomfort. A similar problem can arise when a once-depilated area begins to regrow hair under previously applied Op-Site. These problems may be minimized by complete depilation before dressing application and by timely removal of the dressing. Problems caused by application techniques are more likely to surface as the patient becomes active and places additional stress on the Op-Site. Generally, increases in the patient’s activity level will increase the potential for donor-site pain. In addition to the mechanical points related to application over joint creases and nondepilated areas, the Op-Site dressing itself can pull over the wound and cause pain due to shearing forces. This problem will also be encountered if significant amounts of wound-exudate fluid have collected and are being retained under the Op-Site, thereby adding additional weight to the dressing. Syringe evacuation of the dressing (May, 1984, 1985) can help alleviate this source of discomfort. The differential rate of healing of specific areas within the donor site contributes to the potential for patient pain. As the wound heals and the patient becomes more active, portions of the original wounded area may adhere to the dressing, thereby causing a tugging or tearing sensation. While it may not be clinically advisable to change the dressing when the patient becomes active, pain-control protocols should be reviewed at this point. Levels of pain medication which were effective while the patient was ‘at rest’ may not be sufficient to control the pain of an ambulatory patient. Our findings indicate that in an ambulatory patient, Op-Site-covered donor sites may be associated with pain equivalent in intensity to that produced by the burn wound. In summary, we agree with the reports which have stated that Op-Site is a virtually pain-free donor-site dressing. However, the results of our study indicate that this pain-controlling quality is not equally effective under all circumstances, and that it cannot be assumed. Care must be taken to ensure that the patient is indeed receiving the full potential benefit of the adherent polyurethanefilm dressing. This care includes attention to application techniques, to anticipated patient activity levels, and to maintaining adequate painmanagement protocols. Pain assessment should be undertaken under conditions representative of the patient’s regimen of daily activity. When these contingencies have been met, then Op-Site
Ehleben et al.: Pain and polyurethane dressing
126
can provide
effective control of skin-donor-site pain and provide increased patient comfort.
Acknowledgement This research was supported
from Humana,
in part by a grant Inc., Louisville, Kentucky, USA.
REFERENCES
Bergman R. B. (1977) A new treatment of split-skin graft donor sites. Arch. Chir. Neerl. 29, 69. Besst .I. A. and Wallace H. L. (1979) Wound healingintraoperative factors. Nurs. C/in. North Am. 14, 701. Bicdsell D. C., Hein K. S. and Lindsay R. L. (1979) The theoretically ideal donor site dressing. Ann. Plast. Surg. 2, 535. Cavlak Y. (1980) The application of OpSite to donor sites, burns and postoperative wounds. Akt. Traumatol. 10, 311. Dinner M. I., Peters C. R. and Sherer J. (1979) Use of a semipermeable polyurethane membrane as a dressing for split-skin graft donor sites. PM. Reconstr. Surg. 64, 112. James J. H. and Watson A. C. H. (1975) The use of OpSite, a vapour permeable dressing, on skin graft donor sites. Br. J. Plast. Sure. 28. 107. Lobe T. E., Anderson G. F., King D. R. et al. (1980) An improved method of wound management for pediatric patients. J. Pediatr. Surg. 15, 886. May S. R. (1984) Physiology, immunology, and clinical efficacy of an adherent polyurethane wound dres-
Correspondence should be addressed fo: MS Car& Gray Circle, Augusta, GA 30909, USA.
sing: Op-Site”. In: Wise D. L. (ed.) Burn Wound Coverinps. Vol. II. Boca Raton. CRC Press. D. 53. May S. R. ’(1985) Properties of an adherent’ polyurethane wound dressing, Op-Site’r”. In: May S. R. and Dogo G. (eds) Care ofthe Burn Wound. Base], S. Karger, p. 204. Melzak R. (1975) The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1, 277. Myers J. A. (1982) Wound healing and use of a modern surgical dressing. Pharmaceut. J. 229, 103. Neal D. E., Whalley P. C., Flowers M. W. et al. (1981) The effects of an adherent polyurethane film and conventional absorbent dressing in patients with small partial thickness burns. Br. .J. Clin. Pratt. 35, 254.
Perry S., Heidrich G. and Ramos E. (1981) Assessment of pain by burn patients. .I. Burn Care Rehab. 2,322. Reading A. E. (1980) A comparison of pain rating scales. J. Psychosom. Res. 24, 119. Reid W. H. (1977) Free grafts--skin and other tissues. Nurs. Tim& 2O’Octob&,
1627.
Rudoloh R.. Fisher J. C. and Ninnemann J. L. (1979) Skin’Gra&g. Boston, Little, Brown and Company: p. 133. Sriwatanakul K., Kelvie W., Lasagna L. et al. (1983) Studies with different types of visual analog scales for measurement of pain. Clin. PharmacoL Ther. 34, 234.
Walker D. H. (1978) Burn management-a scene. South Afrikan T. Chir. 16, 65.
changing
Paper accepted 17 July 1985.
M. Ehleben, Southeastern
Burn Research Institute, Suite 303,3623
.I. Dewey
Burns (1985) 12, 122-126
Printed in Great Britain
Pain associated with an adherent polyurethane wound dressing* Carole M. Ehleben,tS tSoutheastem SDepartment
S. Randolph
MaytS§
and Joseph M. Still Jr*
Burn Research Institute, #Humana Hospital Augusta Burn Center, and of Surgery, Medical College of Georgia, Augusta, Georgia, USA
Summary Patient ratings of pain associated with autograft skin donor sites covered by an adherent polyurethane film dressing (Op-Site, Smith & Nephew) were collected using a modified Visual Analogue Scale. Analyses were undertaken to examine differences between pain levels under conditions of rest and activity, and with variations in application technique. It was found that with proper application and with at-rest patients, Op-Sitecovered donor sites could be maintained relatively pain free. However, both specific conditions of application and increases in patient ambulation could result in the patient experiencing donor-site pain of an intensity comparable to concurrent burn-wound pain. To utilize fully their potential for pain control, the polyurethane film dressings must be appropriately applied and maintained, and their use coupled with an adequate analgesic regimen.
INTRODUCTION WHEN a partial
or full thickness sheet of skin is removed for autografting, the resultant donorsite wound becomes the focus for painful sensations (Rudolph et al., 1979). There is ample documentation in the literature that the pain associated with these autograft skin-donor sites can be quite severe and may interfere with patient mobilization and treatment (James and Watson, 1975; Bergman, 1977; Reid, 1977). A number of articles have been published which report that there is a significant alleviation of pain when adherent polyurethane-film dressings are used to cover the donor-site wound (James and Watson, 1975; Bergman, 1977; Birdsell et al., 1979; Dinner et al., 1979; Cavlak,
* Presented at the Geneva International Congress Burns, Geneva, Switzerland, 2-4 May 1985.
on
1980; Lobe et al., 1980; Neal et al., 1981; May, 1984, 1985). However, even those studies which included data derived from controlled assessment of patient pain have either reported relative discomfort only (Neal et al., 1981), or else have sampled only a narrow range of possible patient activity (May, 1984,198s). None of these studies have addressed the issue of the context in which the pain reduction was achieved or have investigated variations in the pain that actually was experienced when using the polyurethane dressings. It has been our clinical experience that polyurethane-film donor-site dressings are not uniformly pain free under all conditions. Patients commonly report feelings of discomfort associated with both the dressings and the underlying donor sites. The perceived level of this pain can be high enough to elicit patient complaints, interfere with movement therapy, or induce the patient to request an alternative donor-site dressing. The goal of this present study was to determine the circumstances under which polyurethane-film dressings are associated with donor-site pain, so that this pain might be kept to a minimum in the future. We investigated the relationship between level of reported pain and several factors, including variations in application technique, the activity level of the patient wearing the polyurethane dressing, and the degree of healing of the donor-site wound. The data support our original clinical observations that polyurethane dressings are not pain free under all circumstances. In fact, we found that if an improper application technique is used, or if there is an increase in the patient’s activity level without
Ehleben et al.: Pain and polyurethane dressing
a corresponding change in pain-management protocol, polyurethane-covered donor sites can produce pain comparable to that of the burn wound itself.
MATERIALS AND METHODS The adherent polyurethane-film dressing used in this study was Op-Site (Smith & Nephew, Hull, UK), a standard covering for donor-site wounds at our Burn Center. The study population consisted of 15 acute burn patients with a mean fs.d. body surface area burn size of 29.4k21.5 per cent, a median of 30 per cent, and a range of S-80 per cent. The patients’ ages ranged from 11 to 70 years with a mean ?s.d. of 33+X513.8 years, and a median of 34 years. Collection of patient pain ratings began 4 to 298 days after the burn injury, with a mean +s.d. of 49.1k82.5 days, and a median of 19 days. Each of the 15 patients had donor sites covered with Op-Site, as well as concurrent burn wounds, or, in one case, a reconstructive surgical site, covered with other dressings or with topical agents. Two standardized instruments were used as the basis for the study: a IO-cm Visual Analogue Scale and the McGill-Melzak Pain Questionnaire. Before collecting any pain ratings for inclusion in the study, the patients were first familiarized with the measurement instruments. The first instrument, a modified version of the lo-cm Visual Analogue Scale, is shown in Fig. 1. The standard use of this scale has been to allow the patient to conceptualize and report degrees of perceived pain by marking a point on a continuous line anchored at ‘No Pain’ on its left terminus and ‘Pain As Bad As It Could Be’ on its right (Sriwatanakul et al., 1983). Because both the pllot study we conducted and prior published work indicated that most of the pain levels associated with Op-Site would be at the lower end of the scale, one of us (C.M.E.) developed a mod-
MODIFIED
123
ified visual analogue scale to include a separate area designated ‘No Pain’ or ‘0’. With this modification of the instrument, the continuous line begins with ‘1’ or ‘Little Pain’, and ends with ‘10’ or ‘Pain As Bad As It Could Be’. The patient markings are scored in numerical increments of I cm. Patients are able to indicate either that they have no pain, or that they have some degree of pain corresponding to a point on a lo-cm unbroken line. Patients were asked to mark the point on the scale which corresponded to their degree of perceived pain for the wound site specified at the time of measurement. Those patients who were unable to write were asked to point to the spot, and the rater made a mark which was then verified by the patient. None of the study patients reported any difficulty in understanding and utilizing this scale. The patients were also familiarized with the adjective categorization portion of the McGillMelzak Pain Questionnaire (Melzak, 1975). This section of the instrument lists a total of 78 adjectives which have been organized into 20 ranked groupings, each grouping reflective of a specific sensation associated with the global experience of pain. Standard administration of the scale requires that the patient choose no more than one adjective from each group that is relevant to his pain experience. Within groups, the adjectives are weighted in order of ascending intensity of sensation. In the current study the checklist was used in two ways. Those patients who were physically able were asked to complete the questionnaire in the standard fashion to describe the sensations associated with at-rest Op-Sitecovered donor sites. Additionally, all patients were asked to use the questionnaire to choose reference words so that standardized descriptions of the pain experience could be constructed for each patient. This latter use also provided additional verification of the intensity of the pain
VISUAL ANALOGUE
Place a mark on the scale to indicate you are feeling RIGHT NOW.
SCALE
how much pain
HI No Pain
Little Pain
Pain As Bad As It Could Be
Fig. 1. Modified Visual Analogue Scale used to score donor-site and burn-wound pain. No perceived pain is indicated by marking the separate segment of the line on the left.
124
Burns (1985) Vol. 12/No. 2
experience as reported by means of the Visual Analogue Scale (Reading, 1980). A total of 50 pain ratings from donor sites covered with Op-Site, or from concurrent burn or surgical wounds, were collected from the 15 study patients. Multiple pain ratings were collected from each patient including, whenever possible, ratings made during periods of both activity and rest. Student’s two-tailed t tests for paired samples were used to determine the statistical significance of differences in mean donor site pain scores obtained while the patients were at rest versus while they were active, and between donor site pain ratings and burn or surgical wound pain ratings. Statistical significance was defined as a PCO-05. RESULTS
The overall mean -ts.d. pain rating on the Visual Analogue Scale for all Op-Site-covered autograft skin donor sites across all patients was 1.36-C2*00 (Table Z). This mean rating included 17 scores of ‘0’ or ‘No Pain’ (47.2 per cent of the total of 36 scores). The pain scores ranged from ‘l’, located at the ‘Little Pain’ end of the scale, to ‘8’, located towards the ‘Pain As Bad As It Gould Be’terminus. A reanalysis of these scores in which perceived donor-site pain ratings obtained while the patient was not active (defined as ‘at rest’) were separated from pain ratings obtained while the patient was engaged in activity (defined as ‘ambulatory’) yielded a somewhat different perspective. The mean +s.d. pain score for Op-Site-covered donor sites obtained while the patient was ‘at rest’ was 0.63fl.11 (Table I). The reported scores ranged from ‘1’to ‘4, and included all 17 ‘0’ responses (63.0 per cent of the 27 ‘at rest’ scores). Thus, over half the ratings obtained while the patient was ‘at rest’ were reports of ‘NO Pain’ perceived from the Op-Site-covered donor sites. Tab/e 1. Skin-donor-site* and burn-wound ings under conditions of rest and activity
Wound Donor site Donor site Donor site Burn wound ??
Skin-donor
Conditions
Ratings n
All ‘At rest’ ‘Ambulaton/’ ‘At rest’
36 27 9 14
pain rat-
Mean 2s.d. pain rating 1.36k2.00 0.63+1.11t,S 3.5622.50t.6 3.71+3.97*,1
sites were covered with Op-Site.
t Statistically significant difference, P=O*OO2. $ Statistically significant difference, P=O.Ol 1. § Difference not statistically significant, P=O.202.
These ‘at rest’ reports of perceived pain were then contrasted with pain ratings obtained when the same patients were ‘ambulatory’. The mean +s.d. pain rating from Op-Site-covered donor sites obtained while the patient was ‘ambulatory’ was 3.56k2.50, with a range of ‘1’to ‘8’(Table I). No patients reported ‘0’ or ‘No Pain’ associated with their Op-Site-covered donor sites while they were active. The t-test between the ‘at rest’ and ‘ambulatory’ donor-site pain scores indicated a statistically significant difference, with a P value of 0.002 (Table I). Pain ratings associated with concurrent burn wounds obtained from these same patients ranged from ‘0’ to ‘10’ with a mean +s.d. burnwound pain rating of 3.71k3.97. As shown in Table I, the pain associated with Op-Site-covered donor sites while the patient was ‘at rest’ (0.63fl.11) was significantly less (P=O.Oll) than the pain reported from burn wounds (3.71k3.97) under the same conditions. However, the pain reported with Op-Site-covered donor sites while the patient was ‘ambulatory’ (356k2.50) was not significantly different (P=O.202) from the pain associated with burn wounds (3.71k3.97) (Table 4.
Based on the adjectives chosen from the McGill-Melzak checklist, the pain that patients experienced from their Op-Site-covered skindonor sites while ‘at rest’ was perceived as essentially mild pain. The eight patients who were able to review and select adjectives from the McGillMelzak checklist to describe their pain while ‘at rest’ chose descriptors yielding a mean +s.d. composite weighted score of 4.25-tl.67, with a range of 2 to 6 (out of a possible 78). This relatively low rating is comparable to the mean +s.d. ‘at rest’ pain score of 0.63k1.11 achieved on the Visual Analogue Scale, indicating ‘Little Pain’. Adjectives indicative of mild pain, such as ‘Sore’, ‘Tender’ and ‘Annoying’, were chosen to describe the ‘at rest’ donor-site pain. When the same patients were asked to choose adjectives describing their donor-site pain while ‘ambulatorv’. the words chosen were indicative of more se&e pain, such as ‘Pulling’, ‘Stinging’ and ‘Burning’. DISCUSSION
There are a number of published reports stating that Op-Site, the adherent polyurethane film dressing, controls pain when it is applied to skindonor-site wounds. Some of these articles, however, only mention pain relief as one of many positive outcomes that can be achieved through
Ehleben et al.: Pain and polyurethane dressing
the use of this dressing (Reid, 1977; Walker 1978; Besst and Wallace, 1979; Myers, 1982). Even those reports which do specifically discuss patient pain relief generally do not document any of the parameters under which the pain control was achieved, nor the extent of the pain relief experienced (James and Watson, 1975; Bergman, 1977; Birdsell et al., 1979; Dinner et al., 1979; Cavlak, 1980; Lobe et al., 1980). Some exceptions to the above generalization can be found in the literature. A quantitative comparison of pain from Op-Site-covered donor sites versus pain from concurrent donor sites covered with other dressings has been undertaken using a three-point verbal scale (May, 1984, 1985). While this study found that Op-Site was associated with significantly less donor-site pain than were the other tested nonpolyurethane film dressings, it was shown that Op-Site was not entirely pain free. Although patients were asked to make pain ratings on a daily basis, data derived under differing conditions of patient activity were not analysed separately. It is also not clear how much discrimination was possible on a three-point scale which had only one rating for the entire category of ‘mild pain’. The study by Neal et al. (1981), while quantitative, assessed relative pain, but did not relate specific pain intensity to specific patient activity. However, data from the Neal et al. study, like that of May, indicated that Op-Site is not entirely pain free, especially under conditions of movement. Pain is not a static measurement, and requires monitoring over a longitudinal time-frame that includes periods of normal patient rest and activity (Perry et al., 1981). Our present study, using standardized instruments. has shown that patients who are at rest when they are being questioned about their donor-site pain will usually report little or no pain associated with these sites when they are covered with Op-Site dressings. Yet these same patients, when ambulatory, can experience significant discomfort from these same Op-Site-covered wounds. Techniques of dressing application can make a significant difference ain the amount of pain associated with donor sites covered by Op-Site. For example, when the Op-Site is applied in such a manner that it extends over joint creases, the subsequent wrinkling and binding in the crease causes the patient a significant amount of pain. This problem can be alleviated by making sure that the dressing does not extend over joint creases. Another potentially painful application technique is the placement of Op-Site over non-
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depilated areas adjacent to the donor sites; the subsequent pulling and sticking of the hairs under the dressing can cause the patient significant discomfort. A similar problem can arise when a once-depilated area begins to regrow hair under previously applied Op-Site. These problems may be minimized by complete depilation before dressing application and by timely removal of the dressing. Problems caused by application techniques are more likely to surface as the patient becomes active and places additional stress on the Op-Site. Generally, increases in the patient’s activity level will increase the potential for donor-site pain. In addition to the mechanical points related to application over joint creases and nondepilated areas, the Op-Site dressing itself can pull over the wound and cause pain due to shearing forces. This problem will also be encountered if significant amounts of wound-exudate fluid have collected and are being retained under the Op-Site, thereby adding additional weight to the dressing. Syringe evacuation of the dressing (May, 1984, 1985) can help alleviate this source of discomfort. The differential rate of healing of specific areas within the donor site contributes to the potential for patient pain. As the wound heals and the patient becomes more active, portions of the original wounded area may adhere to the dressing, thereby causing a tugging or tearing sensation. While it may not be clinically advisable to change the dressing when the patient becomes active, pain-control protocols should be reviewed at this point. Levels of pain medication which were effective while the patient was ‘at rest’ may not be sufficient to control the pain of an ambulatory patient. Our findings indicate that in an ambulatory patient, Op-Site-covered donor sites may be associated with pain equivalent in intensity to that produced by the burn wound. In summary, we agree with the reports which have stated that Op-Site is a virtually pain-free donor-site dressing. However, the results of our study indicate that this pain-controlling quality is not equally effective under all circumstances, and that it cannot be assumed. Care must be taken to ensure that the patient is indeed receiving the full potential benefit of the adherent polyurethanefilm dressing. This care includes attention to application techniques, to anticipated patient activity levels, and to maintaining adequate painmanagement protocols. Pain assessment should be undertaken under conditions representative of the patient’s regimen of daily activity. When these contingencies have been met, then Op-Site
Ehleben et al.: Pain and polyurethane dressing
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can provide
effective control of skin-donor-site pain and provide increased patient comfort.
Acknowledgement This research was supported
from Humana,
in part by a grant Inc., Louisville, Kentucky, USA.
REFERENCES
Bergman R. B. (1977) A new treatment of split-skin graft donor sites. Arch. Chir. Neerl. 29, 69. Besst .I. A. and Wallace H. L. (1979) Wound healingintraoperative factors. Nurs. C/in. North Am. 14, 701. Bicdsell D. C., Hein K. S. and Lindsay R. L. (1979) The theoretically ideal donor site dressing. Ann. Plast. Surg. 2, 535. Cavlak Y. (1980) The application of OpSite to donor sites, burns and postoperative wounds. Akt. Traumatol. 10, 311. Dinner M. I., Peters C. R. and Sherer J. (1979) Use of a semipermeable polyurethane membrane as a dressing for split-skin graft donor sites. PM. Reconstr. Surg. 64, 112. James J. H. and Watson A. C. H. (1975) The use of OpSite, a vapour permeable dressing, on skin graft donor sites. Br. J. Plast. Sure. 28. 107. Lobe T. E., Anderson G. F., King D. R. et al. (1980) An improved method of wound management for pediatric patients. J. Pediatr. Surg. 15, 886. May S. R. (1984) Physiology, immunology, and clinical efficacy of an adherent polyurethane wound dres-
Correspondence should be addressed fo: MS Car& Gray Circle, Augusta, GA 30909, USA.
sing: Op-Site”. In: Wise D. L. (ed.) Burn Wound Coverinps. Vol. II. Boca Raton. CRC Press. D. 53. May S. R. ’(1985) Properties of an adherent’ polyurethane wound dressing, Op-Site’r”. In: May S. R. and Dogo G. (eds) Care ofthe Burn Wound. Base], S. Karger, p. 204. Melzak R. (1975) The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1, 277. Myers J. A. (1982) Wound healing and use of a modern surgical dressing. Pharmaceut. J. 229, 103. Neal D. E., Whalley P. C., Flowers M. W. et al. (1981) The effects of an adherent polyurethane film and conventional absorbent dressing in patients with small partial thickness burns. Br. .J. Clin. Pratt. 35, 254.
Perry S., Heidrich G. and Ramos E. (1981) Assessment of pain by burn patients. .I. Burn Care Rehab. 2,322. Reading A. E. (1980) A comparison of pain rating scales. J. Psychosom. Res. 24, 119. Reid W. H. (1977) Free grafts--skin and other tissues. Nurs. Tim& 2O’Octob&,
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changing
Paper accepted 17 July 1985.
M. Ehleben, Southeastern
Burn Research Institute, Suite 303,3623
.I. Dewey