Analgesia for Pediatric Arteriovenous Fistula Cannulation in Hemodialytic Patients: A Comparison of Lidocaine Gel, Lidocaine Spray, and Needle Plate

Introduction

End-stage kidney disease (ESKD) is considered a major public health problem whose prevalence and associated costs are increasing.[1] Nearly two million patients worldwide are dialysis-dependent, and of these, approximately 90% receive hemodialysis (HD) thrice weekly.[2] HD is the most frequently used renal replacement therapy for ESKD patients, and arteriovenous fistula (AVF) is the gold standard for vascular access in these patients.[3] Pain caused by the entrance of cannula into the AVF is a major root of concern and pain in children undergoing HD. On average, a patient undergoing regular HD experiences 20 AVF punctures a month and would have it throughout her life. Therefore, patients' comfort is an important factor for long-term compliance with the treatment.[4] There are several ways to reduce the pain inflicted by the insertion of cannula. Researchers showed that cutaneous stimulation is associated with pain reduction in patients.[5] The effect of cutaneous stimulation is best explained by the gate control theory. In this theory, repeated stimulation of the skin can be effective in reducing the flow of pain and relieving it.[6] Cutaneous stimulation modalities, such as needle plate, can be clubbed with acupressure to increase its effectiveness in pain management.[7] Previous research has also shown that topical local anesthetic creams and sprays are effective in reducing pain during AVF cannulation.[8] The eutectic mixture of local anesthetics (EMLA) was formulated to penetrate intact skin. EMLA significantly reduces puncture pain and represents an acceptable alternate method for topical anesthesia in venous cannulation.[9] This study was therefore undertaken to investigate the effect of needle plate, lidocaine gel, and spray on pain due to AVF cannulation in children undergoing chronic HD.

Methods

This randomized clinical trial included children under chronic HD via AVF in Sheikh Children's Hospital Hemodialysis Center in February 2014. Informed consent was obtained from all patients or their parents prior to the study after the local ethics committee approved the research protocol with the code IR.MUMS.fm.REC.1394.368. Samples were selected by a purposive non-probability method according to the inclusion and exclusion criteria. Inclusion criteria consisted of: Children at least 8 years old under weekly HD, having informed consent, having full consciousness, having the ability to determine pain and respond to it, having a healthy hearing and vision system, receiving no pain-killers, opioid or sedative 6 h prior to the trial, absence of severe pain elsewhere in the body, and started HD at least 3 months before. Exclusion criteria consisted of: Known neuropathy, skin problems or numbness at the vascular access site, lidocaine hypersensitivity, and any pain at the injection area before starting the study, infectious signs at the injection site, and patient's inaccessibility during 4 weeks of study. Before the first intervention, the patients were informed about the study drugs and on how to use the visual analogue scale (VAS) for pain assessment. Demographic information such as age and gender, and severity of HD needle pain after cannulation were recorded. Patients were studied for almost 4 weeks and were evaluated in four different modes: In the first week (every week contained three sessions), they went under the routine protocol of HD (control mode). Then cannulation was randomly administered at the injection site after lidocaine spray, lidocaine gel (EMLA), and an elliptical plate containing numerous plastic needles.

HD needle injection protocol, consisting of syringe type, solution volume, air bubble, injection site, and physical state of patients at the time of injection, disinfectant, and injection angle for all patients were the same. We used arterial HD needle number 16 at least 5 cm away from the AVF site at an angle of 30–45° with the diagonal edge of needles superior.

The order of interventions for each patient was determined randomly. In the first state, lidocaine spray was sprayed two puffs (20 mg) from a pressure pack, at a distance of ~5 cm for 2 s. Liquid on the skin was allowed to evaporate for 10 s, and the venipuncture was performed 5 min later after the disinfection of the skin. In the second state, 2 ml of lidocaine gel were applied on the targeted area, and cannulation was performed 5 min later. In the last intervention, we used an elliptical plate (60 × 80 mm) consisted of multiple plastic needles (6 pins per cm) containing a central hole for dialysis needle passage. At the time we used the device, the injection was performed slowly and without plate removal.

The degree of pain was expressed as a pain score. Pain perception was expressed by patients 1 min after cannulation on a VAS, consisting of a non-graduated 100 mm horizontal line ranging from “0 = did not hurt at all” to “10 = as painful as it could be.” VAS scores over 3 were considered as moderate pain and over 5 as severe pain.[10]

We used one-sample Kolmogorov–Smirnov test for variables' distribution, and results showed that data were not normally distributed; therefore, Wilcoxon test was performed to compare pain intensity in four case groups. A P value of <0.05 was considered statistically significant.

Results

This study was performed to compare different types of analgesics for venous cannulation in children undergoing chronic HD. A total of 20 patients were included. Out of them, 13 (65%) were male and 7 (35%) were female. The average age of patients was 12.12 ± 4.61 years. VAS mean in the lidocaine spray state was 47.87, in the lidocaine cream state was 51.31, and in the needle plate state was 49.43, which were significantly less than the control state with VAS mean of 60.06 (lidocaine spray vs. control P value = 0.001, lidocaine gel vs. control P value = 0.001, and needle plate vs. control P value = 0.003).

VAS mean in lidocaine spray and lidocaine gel after injection had no significant difference (P value = 0.267). Also, VAS mean in lidocaine spray after injection and needle plate had no significant difference (P value = 0.394). Similarly, VAS mean in lidocaine gel after injection and needle plate had no significant difference (P value = 0.509).

Discussion

Based on the results of this study, the utility of lidocaine gel, lidocaine spray, and needle plate before venous cannulation in children undergoing chronic HD is effective in reducing pain. Arab et al. conducted a similar study to assess the effect of lidocaine gel on intravenous cannulation during hemodialysis. They reported that 2% lidocaine gel can lower the pain in these patients. The mean pain score was also significantly lower in the 2% lidocaine gel group compared with the control group.[11]

In a study performed on 160 patients requiring an insertion of intravenous cannula, I R Selby et al. concluded that using commonly available local anesthetics like lignocaine, ethyl chloride spray, and eutectic mixture of local anesthetics cream (EMLA) can reduce both pain and fear during venipuncture.[12] In another study by MR Nott et al., the effectiveness of local anesthesia after 5 min of topical application of lignocaine-prilocaine cream was evaluated. They concluded that the agent can be used to reduce the pain of all routine injections.[13]

Gülperi Çelik et al. compared the use of ethyl chloride vapocoolant spray and lidocaine/prilocaine cream for reducing the pain of venipuncture in adults undergoing chronic HD.[8] They showed that venipuncture for AVF cannulation can cause mild to moderate pain in HD patients which affects their quality of life. They indicated that vapocoolant spray is as effective as EMLA cream in preventing cannulation pain in patients undergoing chronic HD.[8] Similarly, Dalvandi et al. conducted another study to assess the effect of EMLA cream and vapocoolant spray in reducing intravenous cannulation in children. They reported that both EMLA and vapocoolant were effective in reducing pain in these patients.[14] However, our study showed no notable difference regarding the use of lidocaine gel as a local anesthetic agent in reducing patients' pain. This difference can be due to the combination form of this anesthetic agent as it is composed of lignocaine and procaine.[15] Moreover, as Vapocoolant is presented in spray form, it has rapid action and thus acts more effectively.[16]

Sabitha P. B. et al. investigated the effect of cryotherapy on AVF puncture-related pain in HD patients. They assessed 60 patients undergoing HD using AVF in their randomized control trial. They found that pain scores were significantly (P = 0.001) reduced within the experimental group with the application of cryotherapy.[4] In a similar study, Hamad S Al Amer et al. discussed the efficacy of cryotherapy intervention on AVF cannulation related pain among HD patients.[13] They concluded that cryotherapy can be considered to relieve AVF cannulation-related pain among adult patients undergoing HD. Therefore, they recommended using cryotherapy as a complementary intervention for reducing pain related to AVF cannulation.[17]

Bond M et al., in their systematic review article, tried to discover the most effective local anesthetic for adult peripheral venous cannulation. They found that all applications of local anesthetic were less painful than cannulation without local anesthetic. Therefore, they suggested that local anesthetic prior to cannulation should become a normal practice and a marker of high-quality care.[18]

Conclusion

Our study showed that the use of needle plate, lidocaine spray, and lidocaine gel are all equally effective ways in controlling the degree of pain in AVF needling in children undergoing HD.