Patient-Centered Care: Reducing Needle Pain and Fear
Do you have patients for whom nothing you say will convince them to get a fistula or graft? Do you have patients who have had a blown stick and bruising of their access site who skip treatments? There may be many root causes for these reactions, but two common ones include fear of needles and fear of and desire to avoid pain.
Anyone could expect to be frightened by the size of hemodialysis needles. This is especially true for new hemodialysis patients. Dialysis patients have more than 300 opportunities a year to feel pain from needle cannulation on two access sites three or more times a week. You may have better luck getting patients to accept permanent accesses and to come to every treatment if you allow patients to have the opportunity to use a skin numbing creams (EMLA® or other 2.5% lidocaine 2.5% prilocaine) or ethyl chloride vasocoolant spray prior to cannulation.
A 2011 randomized, placebo controlled crossover clinical trial of 41 patients in Turkey compared relief of hemodialysis cannulation pain with EMLA, ethyl chloride vasocoolant spray, and a placebo:
- EMLA and the placebo were applied following EMLA manufacturer's (at that time AstraZeneca) directions for use. The prescribed dose of EMLA cream was applied to both needle sites for 45 minutes to an hour and covered with an occlusive dressing (e.g., plastic wrap) before disinfection and cannulation. NOTE: Current manufacturer's recommendations say to wait for an hour or more.1 (This means that a numbing cream must be applied prior to arrival at dialysis to be most effective without inconveniencing the patient.)
- The vasocoolant was sprayed on the access sites at a distance of about 10 cm for 2 seconds. The wetness was allowed to dry for 10 seconds. The skin was then disinfected and the access site was cannulated within 20 seconds.
EMLA provided slightly better pain relief overall, but the vasocoolant spray provided relief from mild to moderate pain—with greater staff convenience, since it could be applied right before cannulation. In the study, these products had very few side effects, and no patients reported severe cannulation pain when using either product. However five patients at baseline (control) and eight in the placebo group reported severe cannulation pain.2
Medicare covered topical anesthetics for needle pain under the composite rate even before the ESRD prospective payment system (PPS) took effect. Medicare now covers these products under the dialysis bundle, so clinics must provide them when physician ordered.3,4,5 Telling patients that your clinic can provide these products to help make their treatments less stressful and painful could pay off in improving scores on the In-center Hemodialysis CAHPS and KDQOL-36 surveys, reducing the percentage of central venous catheters over 90 days, and keeping patients healthier and out of the hospital for infections and missed treatments. These outcomes could result in higher clinic revenues for a low financial cost. Doesn't it seem unnecessarily cruel as well as penny wise and pound foolish to not offer pain relief to patients?
- www.akorn.com/documents/catalog/package_inserts/76478-289-30.pdf (package insert)
- Celik G, Osbek O, Yilmaz M et al. Vapocoolant Spray vs Lidocaine/Prilocaine Cream for Reducing the Pain of Venipuncture in Hemodialysis Patients: A Randomized, Placebo-Controlled, Crossover Study. Int J Med Sci 2011; 8(7):623-627. www.medsci.org/v08p0623.htm
- CMS Pub 100-02, Medicare Benefit Policy Manual, Chapter 11 – End Stage Renal Disease (ESRD), Section 20.3F, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf
- Centers for Medicare & Medicaid Services. FAQ #3453, questions.cms.gov/faq.php?id=5005&faqId=3453
- Centers for Medicare & Medicaid Services. Medicare Program, End Stage Renal Disease Prospective Payment System; Final Rule and Proposed Rule, Federal Register, Table 4, August 12, 2010, www.gpo.gov/fdsys/pkg/FR-2010-08-12/pdf/2010-18466.pdf