Page 68 - Wound Care at End of Life Content: A Guide for Hospice Professionals - DEMO

Contraindications to NPWT: 10,11
 fistulas to organs or body cavities
 necrotic tissue
 untreated osteomyelitis
 malignancy in the wound
 exposed blood vessels or organs
If the potential for hemorrhage exists NPWT can be used but with caution

The cost of NPWT is significant; in addition to the machine (pump) itself, it is necessary to purchase
disposable foam dressings, drainage tubes, canisters, and adhesives drapes. This cost may cause some
clinicians to be reluctant to use it. 10,11

KETAMINE TOPICAL GELS & SOLUTIONS
Ketamine is an NMDA antagonist used as a surgical general anesthetic and as adjuvant therapy with
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opioids for refractory pain syndromes. Topical ketamine preparations for management of neuropathic
pain have limited evidence to support their use. Topical ketamine cream was not more effective than
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placebo in a study of use for diabetic peripheral neuropathy. Frequently, topical ketamine preparations
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include other ingredients to boost effectiveness including amitriptyline and lidocaine. Ketamine,
compounded as a 5‐10 mg/ml gel, may relieve pain related to postherpetic neuralgias and Reflex
Sympathetic Dystrophy (RSD), as well as other neuropathic types of pain. 15,16 Ketamine mouthwash has
also been used for oral mucositis pain refractory to usual “magic mouthwash” solutions (e.g.,
diphenhydramine, lidocaine, magnesium/aluminum hydroxide). 17,18

LIDOCAINE TOPICAL GELS & SOLUTIONS
Lidocaine is a local anesthetic available in both injectable and topical dosage forms. Injectable lidocaine is
also used as an anti‐arrhythmic agent. Lidocaine reduces peripheral nociceptor sensitization by blocking
sodium ion channels to prevent initiation and conduction of nerve impulses producing anesthesia. 19,20
Topical lidocaine formulations may be used to manage wound pain associated with dressing changes,
debridement, or other wound care procedures. 19‐23 While the risk is low, even when applied to open
wounds, there is some potential for systemic absorption of lidocaine from topical application. 20‐22 Larger
wounds, relative to the body size of the patient, may increase the risk of systemic absorption. Due to
smaller body size, increased skin permeability, and changes in fat‐water distribution of subcutaneous
tissue, infants and small children also have an increased risk. Some topical lidocaine products have
excipients that may cause burning or irritation (e.g., ethanol, benzyl alcohol, menthol, etc). Oral topical
lidocaine 2% solution, also known as viscous lidocaine, is designed specifically for mucous membrane use,
lessening the risk of systemic absorption. Although clinical literature is limited on the use of viscous
lidocaine 2% for use in wound care, widespread availability, ease of use, clinical experience, and anecdotal
evidence indicates it is the formulation of choice. Topical EMLA® (lidocaine‐prilocaine) cream has also
been studied for painful wounds. EMLA® doses may range from 3g – 150g per application and is left in
place for up to 60 minutes. Some patients report an uncomfortable burning sensation for several minutes
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after application.

PHENYTOIN TOPICAL GELS & SOLUTIONS
Topical phenytoin (Dilantin®) use for acceleration of wound healing is based in the medication’s ability to
cause hyperplasia of gingival tissue. Phenytoin seems to stimulate collagen production and deposition in
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the wound and may decrease edema and bacterial load. A small pilot study for treatment of
chemotherapy‐induced oral mucositis, results showed some improvement in pain and healing with use of
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topical phenytoin 0.5% oral rinse solution four times daily. However, topical dressing of phenytoin in
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hydrogel demonstrated no benefit for diabetic foot ulcers in a randomized controlled trial. Systematic
review of the available literature seems to show a trend towards beneficial wound healing effects with the
use of topical phenytoin. However, more data is needed before this treatment can be recommended.

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