Patient-Centered Care: Reducing Needle Pain and Fear

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on November 7th, 2013.
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?

References

  1. www.akorn.com/documents/catalog/package_inserts/76478-289-30.pdf (package insert)
  2. 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
  3. 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
  4. Centers for Medicare & Medicaid Services. FAQ #3453, questions.cms.gov/faq.php?id=5005&faqId=3453
  5. 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

Comments

  • MKS

    Jun 5, 2014 10:15 AM

    You might want to try the SYNERA patch. It's approved for home-use now:
    http://www.news-medical.net/news/20140604/SYNERA-can-help-prevent-needle-stick-pain-associated-with-superficial-IVs.aspx

    Here's the product website: http://www.synera.com/

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  • caroline winston

    May 14, 2014 6:46 PM

    my brother wants to give me a kidney.i thought this was a bridge to PD but now i believe i was misled just to get this fistula .I want control of my life back.

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    • Beth Witten

      May 15, 2014 12:26 PM

      Is there any possibility of miscommunication/misunderstanding related to your being able to do PD. Dialysis facilities are supposed to assess every patient for candidacy for home dialysis and for referral for transplant evaluation and to describe in the patient's plan of care why he/she is not a candidate for home dialysis or transplant referral. This assessment should occur during your first month of dialysis, after you've been on dialysis 3 months and at least annually after that. Dialysis clinics are supposed to include you as much as you wish in your plan of care. They're supposed to have a plan of care meeting to discuss the goals of treatment. You should be able to participate in-person, while you're on dialysis, or by phone from home. If your clinic has not involved you in your plan of care and so you know the plan for PD and referral for transplant evaluation, you have the right to file a grievance with your clinic, with your ESRD Network and with the State Survey Agency. Your clinic should have your rights as a patient posted along with the contact numbers for who to contact to file a grievance.

      There is an evaluation process for transplant, both for you and for your brother. A transplant evaluation requires education as well as medical and psychological evaluation of the donor and recipient. If after the transplant work-up is complete the transplant program accepts you as a kidney transplant candidate and the transplant program accepts your brother as your donor, your transplant can be scheduled. You can read about the transplant process in the booklet "What Every Patient Needs to Know" at http://www.unos.org/docs/WEPNTK.pdf.

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  • caroline Winston

    May 13, 2014 11:51 PM

    i agree.i am following the correct procedures in applying the cream .it does not work.i want my catheter back.this was not explained to me to where i fully understood thier plan.i am trying to get a transplant and that is the reason they wont let me do PD .in thier thinking a year wait is not very long.i cant help but feel tricked into this .i have been asking for PD from the start. i hate needles .my ex husband used smaller needles on hog injections .my clinic is on your list.i think i am going to have to move out of state to get PD and submit to this until i do.i have lost trust in my care team

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    • Beth Witten

      May 14, 2014 12:58 PM

      Have you tried the spray? That is supposed to work faster. Are you doing dialysis in a clinic or at home? Do you have a possible living donor? If so and if that person is healthy and closely matches you, you could get a transplant soon. If not, there is no way to know how long you might want on the transplant list. Most people wait longer than a year.

      Catheters have the highest risk of infection, highest risk of hospitalization, and toxin removal with a catheter is not as efficient so dialysis adequacy can fall along with how well you feel. If your clinic offers PD, what has your doctor and/or the PD nurse said (besides your goal for a transplant) is a legitimate reason for why you should do HD and not PD while you wait for a transplant? Many people have done PD while waiting for a transplant.

      Have you used the database to look by zip code and distance to see if there is another clinic close to you that you could talk with about doing PD?

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  • caroline Winston

    May 13, 2014 4:15 PM

    i experience severe pain even with the cream.I only agreed to the fistula because i was told i had to have it before i could go on PD.I was told an untruth.I am being denied the treatment that I want.I feel iam being torchered by my care team and i want it to stop .where are my patients rights?

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    • Beth Witten

      May 13, 2014 4:55 PM

      Some, but not all, physicians want patients to have an access for HD (fistula is best) even if they want to do PD so HD can be a back-up if needed.

      To address the pain that you're having from needle sticks for HD in spite of the "cream." As the article says, the cream needs to be applied at least 45 minutes (longer is better) and covered with plastic wrap to assure that it has enough contact with the skin to numb the needle sites before needles are inserted. The cream to contain at least 2.5% lidocaine and 2.5% prilocaine. The amount of cream you apply needs to be enough to work effectively. If any of these are missing, that could be why the cream isn't working. Some other things that might help with needle pain include:
      - Using buttonholes for needle sites (can only be done with fistulas and uses the same hole over and over...kind of like a pierced ear)
      - Listening to music while the needles are being inserted
      - Learning relaxation techniques to reduce needle fear

      Second, are you doing HD as a temporary bridge to PD while your PD catheter is healing? Has your doctor and dialysis clinic taken your wishes related to treatment type into consideration (this is required by regulation)? Is there some reason why you are not considered a PD candidate? PD is only offered at clinics that have Medicare approval to provide it. Clinics that don't offer PD are supposed to educate patients about treatment options including PD and let patients know where it is offered (see the Find a clinic database from the Home Dialysis Central homepage). Some physicians prefer their patients to be on HD vs. PD for various reasons. Unless your doctor knows PD will not work for you because of major abdominal surgeries or other legitimate reasons, you have the right to try PD. Bottom line...if you're not doing HD as a bridge to PD, you may need to consider changing clinics and/or doctors to get the treatment you want.

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