International Journal of Surgery Open 47 (2022) 100549

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International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Wound-related procedural pain management in a resource limited setting:

Systematic review
Belete Muluadam Admassie, Yonas Admasu Ferede, Biresaw Ayen Tegegne, Girmay Fitiwi Lema,
Biruk Adie Admass *
Department of Anesthesia, School of Medicine, College of Medicine & Health Sciences, P.O. Box: 196, University of Gondar, Gondar, Ethiopia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Wound care procedures, commonly performed on open wounds, are associated with moderate to
Wound severe pain. Untreated or poorly controlled pain during the procedure affects patient’s quality of life. The aim of
Wound care this review was to develop evidence-based protocol for pain management of wound-related procedural pain in a
Procedural pain
resource limited setting.
Pain management
Methods: After formulating the key questions, scope, and eligibility criteria for the articles to be included,
advanced search strategy of electronic sources from data bases and websites was conducted. Screening of lit­
eratures was conducted with proper appraisal checklist. This review was reported in accordance with preferred
reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement.
Results: A total of 266 articles were identified from data bases and websites using an electronic search. 42 articles
were removed for duplication and 58 studies were excluded after reviewing titles and abstracts. At the screening
stage, 68 articles were retrieved and evaluated for eligibility. Finally, 33 studies met the eligibility criteria and
were included in this systematic review.
Conclusion: Managing wound-related procedural pain improves patient’s quality of life. Proper assessment and
monitoring of the pain is a key concept. Non-pharmacological strategies are equally important in managing the
pain as drugs. Control of the baseline pain is essential to control the breakthrough pain associated with wound
procedures. Stratifying risks for wound care related pain and appropriate intervention are important for good
quality of care.

1. Introduction
Wound care is a method of removing dead tissue, cleaning the
wound, providing a protective environment due to disruption of struc­
tural and functional integrity of tissue. It includes dressing change,
packing, irrigation and debridement [1,2]. Pain from wounds is cate­
gorized as baseline or background pain. Baseline pain is the pain that is
present without manipulation or movement of the wound and is related
to the underlying pathological processes of the wound such as ischemia,
inflammation, infection, and maceration [3]. Breakthrough pain is
defined as transitory exacerbation of pain experienced by the patient
who has relatively stable and adequately controlled baseline of pain.
Procedural pain results from a routine intervention such as dressing
removal, cleansing or dressing application [4].
Wound care procedures (WCP) commonly performed procedure on
open wounds may cause moderate to severe pain in 74%; and 36% of
patients experience severe pain during dressing changes and wound
cleaning [5]. The incidence of moderate to severe wound related pain
may rise up to 94.1% [7].
Inadequate pain control during the procedure may lead to incom­
plete cleansing and packing, increase risk of infection, delay wound
healing, increase hospital stay [6]. Unresolved wound-related pain in­
volves both physiological (underlying cause of the wound, pain from
clinical interventions) and psychological components (negative
thoughts towards pain, emotional distress, anticipatory pain and anxi­
ety) play a great role in perception of that affects wound care practice
and may have negatively impacts both wound healing and patient’s
quality of life [4].
Wound related pain might be underestimated or poorly managed due
to clinician’s prior focus is on the wound care not the whole patient [5,

* Corresponding author.
E-mail addresses: uogbelete@gmail.com (B.M. Admassie), yonasadmasu2010@gmail.com (Y.A. Ferede), ayenbiresaw@gmail.com (B.A. Tegegne), tsagir.fitiwi@
gmail.com (G.F. Lema), birukadie@yahoo.com (B.A. Admass).

https://doi.org/10.1016/j.ijso.2022.100549
Received 12 August 2022; Received in revised form 6 September 2022; Accepted 7 September 2022
Available online 14 September 2022
2405-8572/© 2022 The Author(s). Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
B.M. Admassie et al. International Journal of Surgery Open 47 (2022) 100549

6]. Pain control strategies should be started from the first part of the Table 1
assessment and it has to be an ongoing process that requires identifi­ Level of evidence and degree of recommendation, Good clinical practice, GCP,
cation of the cause, nature, frequency, timing, site and severity of the WHO, 2011.
pain and how it is affecting the patient’s quality of life [6]. Level of Types of evidence Degree of
Patients’ with younger age, female gender, high anxiety, depressed evidence recommendation
mood, pain, high levels of anticipatory pain, chronic pain condition, 1a Meta analysis, systematic review of Strongly recommended
opioid tolerance, shorter duration of injury, chronic wounds, clinical RCT, Evidence based guidelines and directly applicable
inflammation and high levels of resting wound pain are at risk of 1b Systematic review Highly recommendable
and directly applicable
developing high intensity of pain during wound care procedures [5,7,8].
1c Randomized control/clinical trials Recommended and
Despite increased knowledge of pain, wound care procedures are applicable
performed either without analgesia or chasing with opioids which may 2a Systematic review of cohort or case Extrapolated evidence
end up with repeated administration, and post procedural sedation [8]. control studies from other studies
Therefore, Pain is a complex psycho-social phenomenon that requires 3a Non analytical studies like case report Extrapolated evidence
and case series, clinical audit, from other studies
multiple pharmacological and non pharmacological management commentaries and export opinions
approach [9].

2. Rationale of the review 3.2. Eligibility criteria

Despite advances in pain and pain management, the incidence of
wound related procedural pain is still a public health problem. It has
been reported that the incidence of moderate to severe wound related
pain may rise up to 94.1%.
Wound care procedures are performed either without analgesia or
chasing with opioids which usually have a negative impact in the wound
healing process and moreover, repeated administration of opioids may
expose the patient for opioid related side effects such as prolonged
sedation, respiratory depression, nausea and vomiting.
Despite the availability of different pharmacologic and non phar­
macology techniques that can help to prevent and reduce the severity of
wound-related pain during wound care procedures, there is a clear gap
on the application of evidence based protocols for wound related pro­
cedural pain management among health care providers. Thus, devel­
oping a local evidence-based protocol on the management of wound-
related procedural pain is essential for good quality care and outcome.
All studies related to wound pain management protocols reported in
English language, with full text available for search and conducted
across the globe were included in this systematic review. Those studies
that reported duplicated sources, unrelated articles, case reports, and
articles without full text available with attempts to contact the corre­
sponding author via email were excluded in this systematic review.
3.3. Study selection
Three independent authors selected the candidate articles for the
study, which were exported in to endnote reference manager software to
remove duplicates, and independently screened the titles and abstracts
(BA, BM, and YA). Any disagreement was resolved through discussions
lead by a third author.
3.4. Study quality assessment

3. Methods
3.1. Search strategy
After formulating the key questions, scope, and eligibility criteria for
the evidences to be included, a comprehensive search strategy of elec­
tronic sources was conducted. Terms like ‘wound’, ‘wound pain’, and
‘wound pain management’ were keywords of the review question.
Synonyms of the keywords were identified from national library of
medicine via medical subject headings (MeSH) browser. Keywords were
combined properly by a boolean operators “AND” or “OR”. We applied
search terms in combination as: ‘pain OR ‘wound pain’ OR ‘procedural
pain’ AND ‘pain management’.
The literatures were searched using advanced methods from data
bases like cochrane library, pub med, scopus, embase and websites such
as google scholar. The electronic literature search was performed from 3
June 2022 to 16 June 2022. All of the accessible studies that had been
published in English language from inception up to 16 June 2022 were
included in this systematic review.
Duplication of literatures was removed by Endnote. Further
screening of literatures was conducted based on the level of significance
by proper appraisal of the title, abstract and full text of the articles. A
total of 33 articles were included and reviewed. The strength of evidence
and grade of recommendation was made based on WHO 2011 level of
evidence (Table 1).
This review was reported in accordance with the preferred reporting
items for systematic reviews and meta-analyses (PRISMA) 2020 criteria
(34) (Fig. 1). This review was registered in research registry with unique
identifying number of reviewregistry1424.
The two independent authors appraised the standard of the study
using AMSTAR 2 methodological quality appraisal checklist. Any
disagreement was discussed and resolved by the authors. The critical
analysis checklist has 16 parameters [35]. The quality of this review
after critical appraisal of its method was reported as high.
Operational definitions.
Short duration of procedure: When the procedure takes <14min
[7].
Shorter duration of injury: When inflammatory period is proposed
to last 3–5 days in acute wounds [28].
Chronic wound: Wound that lasts ≥3 months was considered as
chronic wounds [29].
Chronic wound pain: Wound pain that lasts for ≥3 months was
considered as chronic wound pain [30].
Anxiety: The six-item state-trait anxiety inventory tool, in which the
total score is the sum of all six scores and multiplied by 20/6 which
ranges from 20 to 80, was used to determine the level of anxiety. A total
score of greater than 20 is considered as having anxiety [31].
Depressed mood: Personal health questionnaire depression scale
(PHQ-9), in which the total score for the nine questions are added up and
can range from 0 to 27, was used to determine the level of mood of the
patient. A score of 5 or greater can be considered as depression [32].
Pain catastrophizing: The 13 items pain questionnaires, which
measure 3 domains (magnification, rumination, & helplessness) about
pain, were applied to measure the level of pain catastrophizing. Items
are rated on a 5-point scale with anchors being “not at all” and “all the
time” and scores can range from 0 to 52. A score of 30 represents a
clinically relevant level of pain catastrophizing [33].
Opioid tolerance: is a predictable physiological decrease in the ef­
fect of opioids over time that required progressive increase in the
amount of that drug to get desired effect [24].

2
B.M. Admassie et al.
Fig. 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 [34].
Large wound size: when the wound size is > 10 cm [7].
4. Results
4.1. Study selection
A total of 266 articles were identified from data bases and websites
using an electronic search. Of these articles, 42 were removed for
duplication and 58 studies were excluded after reviewing their titles and
abstracts. At the screening stage, 68 articles were retrieved and evalu­
ated for the eligibility. Finally, 33 studies related to wound care pain
management were included in this review (Fig. 1).
4.2. Description of included studies
Out of 68 articles retrieved, 33 studies met the eligibility criteria and
were included in this systematic review. Out of all articles included, 9
were systematic reviews and meta-analysis, 7 were cross-sectional
studies, 6 were guidelines, 6 were cohort studies and 5 were
controlled trials.
5. Discussion
This systematic review provides an evidence-based working protocol
for wound related procedural pain management in a resource limited
setting. This protocol guides health care providers to perform wound
care procedures with proper pain management techniques.
5.1. Risk stratification
Wound related procedural pain is associated with many contributing
3
International Journal of Surgery Open 47 (2022) 100549
factors. A cross-sectional study done in 2017 on factors associated with
wound related pain revealed that younger patients had greater pain than
older patients before and after wound care procedure, while no differ­
ences between genders in pain severity during wound care procedures
[5].
A cohort study conducted on 412 patients in Great Britain on pain
perception during dressing change revealed that dressing drying out,
wound products adhering to the wound and adherent dressing had
greatest pain intensity during wound care procedures (WCP) but no
differences between gender and age of the patients [2].
A review done in USA on effect of gender on perception of pain and a
retrospective study on 11,000 medical records revealed that women
exhibiting greater pain sensitivity, enhanced pain facilitation and
reduced pain inhibition than men due to bio-psychosocial mechanisms
such as sex hormones, endogenous opioid function, genetic factors, pain
coping, catastrophizing, oral contraceptive drug usage and low testos­
terone leads reduced pain related activation in pain inhibitory brain
region [10,11].
A case control study on 140 patients done in Turkey on factors that
influence perception of pain stated that anxiety increase perception of
pain. However; sex, age and depression did not show influence on the
perception of pain [12]. A cross -sectional study done in University of
Lowa revealed that patients with younger age, female sex, recent injury,
extremity location, large wound size, adhesive dressing, and long
duration to complete the procedure, and inflammation are at risk of
severe pain during WCP [13].
A systematic review done by Orsted H on effect of wound infection in
severity of pain stated that wound infection increase inflammatory
mediators that could sensitize the nervous system during dressing
removal, wound cleansing and dressing application [14].
A systematic review done in Canada on risks that contribute for
B.M. Admassie et al.
severity of wound care related pain stated that pain catastrophe, anxi­
ety, depression, fear, anger, past pain experience, location of the wound
and timing of the wound are factors related to severity of pain during
wound care procedure [9].
A cross-sectional study conducted on 424 patients in North West
Ethiopia on severity of wound related pain during wound care proced­
ures stated that patient’s pre-procedure anxiety level, acute wound,
having baseline pain, and time and amount of analgesia intake were
strongly associated with increase severity of wound-related pain during
wound care procedures [7].
5.2. Management of wound-care pain
5.2.1. Pharmacological interventions
A guideline done in Netherlands suggested that severity of wound
related pain may reduce through topical administration of lidocaine
30–45 min before the procedure, paracetamol, NSAID, opiod adminis­
tration and infiltration of the wound with lidocaine or prilocaine 10–15
min before the procedure. In addition, low risk patients were managed
by paracetamol and NSAID with precaution and for high risk patients,
pain is addressed with opioids. It also suggested WHO pain ladder for
persistent wound care pain management [15].
A systematic review done in Canada recommends that combination
of pharmacological and non pharmacological techniques depends on
degree of pain severity. Administration of topical agents, including
morphine, tricyclic antidepressants, Ibuprofen (200–400 mg q 4–6 h),
Diclofenac (1–1.5 mg/kg), paracetamol (325–650 mg q 4 h), capsaicin,
ketamine, and lidocaine/prilocaine provides pain relief with minimal
side effects [9].
A cohort study conducted on 412 patients in Great Britain recom­
mended that administration of pharmacologic treatments such as opi­
oids, sedatives for high risk patients, non steroidal anti-inflammatory
drugs (NSAIDS), lidocaine injection before the procedure and topical
eutectic mixture of local anesthetic (EMLA) cream may reduce the
severity of wound-related pain [2].
A systematic review of RCT done on the efficacy of IV lidocaine
suggested that 125 mg intravenous administration of plain lidocaine
over 30 min infusion had superior effect over IV morphine and direct IV
lidocaine in terms of rapid onset of analgesia, enduring analgesia and
acceptable side effects. In addition, the infusion of intravenous lidocaine
over 30 min reduces the likelihood of cardiovascular effects known to
occur with administration of lidocaine 1–1.5 mg/kg bolus over 1–3 min
[16,17].
A randomized control trial on 11 patients to determine the effect of
small dose of ketamine and morphine versus morphine alone recom­
mended that combined small dose ketamine and morphine together has
a great advantage in reducing the severity of wound related pain. In this
study, patients received either 0.1 mg/kg of IV morphine, maximum
dose of 8 mg or administration of 0.05 mg/kg of morphine, maximum
dose of 4 mg administered 20 min before the WCP followed by admin­
istration of ketamine 0.25 mg/kg IV 5 min before the procedure found
that combination of ketamine and morphine significantly reduce wound
related pain intensity within 10 min. However, ketamine might have
psychotomimetic side effects and higher diastolic BP,but it will decrease
by premedication with benzodiazepine and alpha two agonist [18].
A study done by Jones ML. in 2008 stated that administration of
analgesics with enough time to begin working before the procedure for
appropriate pain relief during the procedure is necessary. Weak opioids
such as tramadol given an hour before the procedure and non-steroidal
anti-inflammatory drugs are used for mild to moderate pain. Strong
opioids such as morphine is used for severe pain with anticonvulsant and
antidepressant drugs as adjuvant [19].
A review study done by Gallagher R in 2013 revealed that break­
through or procedural pain reaches maximum intensity in 15 min and
lasts only 60 min. For such type of pain, opioids with fast onset and short
duration of action such as fentanyl can be used. Breakthrough pain may
4
International Journal of Surgery Open 47 (2022) 100549
not be addressed by short acting opioids only; it may require adjuvant
such as sub anesthetic doses of ketamine 0.5 mg/kg per dose once daily.
1 h prior to dressing change, midazolam can be used for procedural
sedation and for procedural pain relief from dressing changes [3].
A systematic review of RCT done by Peng L and his colleagues in
2019 regarding topical analgesia showed that application of topical 5%
compound lidocaine cream (containing 2.5% lidocain/2.5% prilocaine)
applied 10 min before dressing change, with a dose of 0.2 g/10 cm2 were
associated with more reduced severity of pain and heart rate and
increased patient comfort than 10 mg morphine tablet [20,21].
A review done by Dissemond J in 2014 suggested that soaking a
dressing for at least 30 min prior to removal in ringer solution, crust
softening using compresses soaked in olive oil or ointment and remove
using a wooden spatula with local anesthetics in the form of lidocaine
and prilocaine cream applied for at least 60 min before cleaning would
significantly lessen pain severity. In addition to this, morphine hydro
gels applied directly to the wound and left in place for 24 h was effective
in reducing pain intensity [22].
A review study done by Lillieborg S in 2017 recommended that
lidocaine-prilocaine cream (EMLA) effectively reduces the pain severity
after application for 30 min while the plasma concentrations of lidocaine
and prilocaine after application of 10 g EMLA cream before debridement
of leg ulcers are well below the threshold for CNS toxicity [23].
A review done by Marshall S and Jackson M on acute pain man­
agement for opioid tolerant patients recommended that use of sub an­
esthetics dose of ketamine with benzodiazepine decrease total opioid
consumption and pain severity score. They also suggested that addition
of 200 mg ketamine and 5 mg midazolam to 50 ml of 0.9% saline at
infusion rate of 2 ml/h decreases pain severity [24].
World union of wound healing Societies in 2004 stated that NSAID
are important to dampen sensitivity and useful for controlling the
throbbing or aching pain after a procedure such as a wound dressing but
Enoch et al. in 2006 suggested that NSAIDs affect the inflammatory
phase of wound healing and reduction in the tensile strength of the
wound. In addition, world union of wound healing society stated that
administration of paracetamol and NSAID before 1–2 h before the pro­
cedure is appropriate [25].
5.2.2. Non pharmacologic techniques
Evidence based guideline done in Netherlands by Bro FE and his
collegues in 2014 recommended that non pharmacological methods like
psychological treatment (diversion, distraction, time-outs, education/
information, encouragement of day planning, exercise, relaxation and
social activity), and non pharmacological local analgesia (use of non
adhesive dressing, introduce time out moment, cleaning wound gently
with warm water, treat co morbidity like edema by compression ther­
apy, preserve moist wound environment, protect surrounding skin) re­
duces the pain intensity [15].
A cohort study on 412 patients done in Great Britain in 2004 rec­
ommended that the use of non-pharmacologic treatments such as by
selecting a certain type of dressing, soaking the dressing before
removing reduces the pain severity. This study also revealed that humor,
distraction,and deep breathing, provided information, and usage of a
calming voice reduced pain before the procedure compared with during
the procedure, while interventions (i.e. Gentle touch, humor, or infor­
mation) did not decrease pain [2].
A pilot study done by Gibson MC. and his collegues in 2003 on effect
of educational intervention for management of acute procedure related
wound pain under by giving information about the procedure, discussed
strategies they could use to make it as comfortable as possible, and
explained how they could use a rating scale to denote any physical and
emotional distress decrease wound related pain during wound care
procedure [26].
A review study done by Jones ML in 2013 revealed that pain at
wound dressing-related procedures can be managed by combining ac­
curate assessment, appropriate dressing choices, appropriate analgesia
B.M. Admassie et al.
and skilled wound management. In addition, discussing with the patient
the best option for removing the dressing and pulling a dressing off faster
rather than slower reduces pain at dressing change [27].
A clinical guideline developed by Orsted H. in 2010 suggested that
treating wound infection reduces bacterial load and hence reduction in
pain severity. In addition to this, giving adequate time for drugs
maximum efficacy during dressing changes, music or some other form of
distraction and choice of dressing are helpful in reducing pain severity
[14].
A review by Gallagher R in 2013 revealed that minimization of the
time to carry out the procedure, use warm fluids to skin temperature,
giving sufficient time for preventive analgesia, provision of information
to the patient, patient involvement throughout the procedure about
their comfort and pain, and ensuring that the patient is aware they can
ask any supportive methods to reduce discomfort or anxiety such as:
distraction or music can reduce or prevent severity of pain during
dressing change [3].
6. Strength and limitation
This review provides evidence-based working protocol on pain
management for patients undergoing day case surgery in a resource
limited setting. This protocol guides the physicians to provide
Fig. 2. Evidence based risk stratification and management of pain during wound care procedures.
5
International Journal of Surgery Open 47 (2022) 100549
appropriate interventions for wound related procedural pain.
However, this review was conducted from different articles that are
not homogenous in methods and study type. Moreover, this work em­
phasizes on the qualitative review of recommendations on pain man­
agement for day case surgical patients. Therefore, we recommend future
researchers to conduct a meta-analysis of studies on wound related
procedural pain management.
7. Conclusion and recommendation
Wound related procedural pain is common and many factors affect
its intensity. In general, younger age, female gender, high anxiety,
depressed mood, high levels of anticipatory pain, large wound size, long
duration of procedure, extremity wound, chronic pain condition, opioid
tolerance, shorter duration of injury, chronic wounds, clinical inflam­
mation and high levels of resting wound pain are important factors
associated with high levels of wound related procedural pain (Fig. 2).
Topical administration of lidocaine 30–45 min, infiltration of the
wound with lidocaine or prilocaine 10–15 min before the procedure
reduces pain related with wound care procedures. Administration of
paracetamol and NSAID for low risk patients, strong opioids for high risk
patients reduces procedure related wound pain (Fig. 2).
Procedural pain reaches maximum intensity in 15 min and lasts only
B.M. Admassie et al. International Journal of Surgery Open 47 (2022) 100549

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