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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 597-603
Management of pain at arteriovenous fistula puncture: Cryotherapy versus lidocaine/prilocaine

Department of Nephrology, Dialysis and Renal Transplantation, Ibn Rochd University Hospital; Faculty of Medicine and Pharmacy of Casablanca, Hassan II University, Casablanca, Morocco

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Date of Submission04-Jan-2019
Date of Decision16-Feb-2019
Date of Acceptance24-Feb-2019
Date of Web Publication10-Jul-2020


Pain at arteriovenous fistula (AVF) puncture is common in hemodialysis (HD) patients. The purpose of our work is to determine its frequency, to evaluate the efficiency of two techniques: anesthetic cream (Emla™) and cryotherapy, and to compare their efficiency. A prospective and interventional analytical study of HD patients was conducted in our structure. We included all patients with pain at AVF puncture. We evaluated the pain intensity using a visual analogue scale before and after our intervention: Emla™ cream during three consecutive HD sessions, then cryotherapy (ice cubes placed in latex gloves, during 5 min, directly applied on the puncture sites) during three consecutive HD sessions. The statistical analysis was performed using the Epi Info software. Eighty-four patients are undergoing HD in our structure, of which 32 (38%) report pain at AVF puncture. The mean value of the visual analog scale before the puncture was 7.19 ± 1.95 (4-10). Pain decrease was statistically significant for both techniques. Comparative analysis of the two techniques revealed a significant reduction in pain in favor of cryotherapy (P 0.001). The analgesic effect has been proved for both techniques. Cryotherapy provides higher efficiency, with fewer constraints, and could be proposed for the management of pain at AVF puncture.

How to cite this article:
Kortobi L, Belymam H, Chkairi NM, Zamd M, Medkouri G, Gharbi MB, Ramdani B, El Khayat SS. Management of pain at arteriovenous fistula puncture: Cryotherapy versus lidocaine/prilocaine. Saudi J Kidney Dis Transpl 2020;31:597-603

How to cite this URL:
Kortobi L, Belymam H, Chkairi NM, Zamd M, Medkouri G, Gharbi MB, Ramdani B, El Khayat SS. Management of pain at arteriovenous fistula puncture: Cryotherapy versus lidocaine/prilocaine. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2022 Dec 2];31:597-603. Available from: https://www.sjkdt.org/text.asp?2020/31/3/597/289446

   Introduction Top

Hemodialysis (HD) is the most common procedure used among other extrarenal epuration techniques. The first vascular access exploited is arteriovenous fistula (AVF).[1]

The AVF puncture in HD is a repetitive care (generally 3 times a week, approximately 300 punctures per year), requiring a needle of large caliber to guarantee the flow of the AVF required for the efficiency during HD. The AVF puncture can be a painful experience and a source of anxiety for some patients. Pain at AVF puncture has been poorly studied, and its prevalence is variable (40%–60%).[2],[3],[4] Many factors are associated with its intensity: mainly diameter and length of the needle.[5] The problem arises as to the management of this pain within HD patients.

Many therapies were assessed in order to lower this pain: the “Buttonhole” technique,[6] Lidocaine with its different presentations (gel/spray/dermic patch),[7],[8] and also hypnosis.[9] However, each therapy proposed has its disadvantages: contraindications, side effects, accessibility, high financial cost, and time constraint.

Cryotherapy is a well-known technique practiced in multiple areas in the therapeutic field (rheumatology and oncology). It was assessed in the management of pain at AVF puncture and seems to reduce its intensity.[10],[11],[12]

The objective of the present study is to evaluate the frequency of pain at AVF puncture, and the efficiency of two techniques: local application of anesthetic cream Emla™ (Lidocaine 2.5% + Prilocaine 2.5%) versus cryotherapy.

   Materials and Methods Top

Type of study

We performed an analytical prospective study lead among all patients undergoing conventional HD in our structure.

Inclusion criteria

Every patient experiencing pain at AVF puncture.

Exclusion criteria

Exclusion criteria include Raynaud syndrome, diabetic neuropathy, vascular diseases, and cognitive dysfunctions. We began the trial after a full explanation of the procedure and after obtaining the consent of each patient.

Pain assessment before the procedure

We evaluated pain intensity at AVF puncture with visual analog scale (VAS). We synthetized three degrees of pain severity: low (VAS between 1 and 4), moderate (VAS between 5 and 6) and severe (VAS between 7 and 10).

We applied the same procedure of AVF puncture with the same operator for each patient using 16 Gauge needle, with the bevel up.

First intervention

During three consecutive HD sessions, we used Emla™ cream (Lidocaine 2.5%+ Prilocaine 2.5%), with a thick layer application on the two puncture areas, during 1 h before AVF puncture and covered it with an adhesive hermetic bandage. We initiated puncture right after bandage removal.

Second intervention

During three consecutive HD sessions, we used cryotherapy before AVF puncture. The patient applied a latex glove full of ice cubes frozen before hand at -20°C, directly on the two puncture areas with the contralateral hand during 5 min [Figure 1]. The intervention was initiated right after the glove removal.

We took into consideration the side effects of the two techniques and asked the patients about the tolerance and the efficiency of each procedure.
Figure 1: Cryotherapy applied by a patient who is undergoing hemodialysis in Ibn Rochd University Hospital, using ice cubes in a latex glove, applied directly on the puncture sites.

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   Statistical Analysis Top

We used Epi Info software for statistical analysis. We collected each patient’s data (age, sex, HD period, AVF localization, and previous complications). Student t test and Chi-square test were applied for comparative analysis. We adopted a significance threshold of P =0.05.

   Results Top

Patients’ data

Eighty-four patients are undergoing HD in our center. Thirty-two reported pain at AVF puncture; therefore, the prevalence is 38%.

The mean age of this population is 44.83 years old ±15.02 (20–71). A slight female predominance was noted [Table 1].
Table 1: Main characteristics of patients who had pain at arteriovenous fistula puncture in hemodialysis unit of Ibn Rochd University Hospital.

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Pain intensity before intervention

VAS assessed before intervention was: 6.3% low, 37.5% moderate and 56.2% severe [Table 2]. Mean VAS was 7.19 ±1.95.
Table 2: Pain intensity within all the patients with pain at arteriovenous fistula puncture in hemodialysis unit of Ibn Rochd University Hospital, evaluated with the visual analog scale at the beginning of our study, then after the use of Emla™, and after the use of cryotherapy before the puncture.

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Pain intensity following Emla™ application

The VAS was: low in 65% of cases, moderate in 22% and severe in 13% of cases. Mean VAS was 3.93 ± 2.01. The difference was statistically significant [Table 3].
Table 3: Comparative analytical study between the beginning of our study, after using Emla™, and after using cryotherapy before the arteriovenous fistula puncture, within patients with pain at arteriovenous fistula puncture in hemodialysis unit of Ibn Rochd University Hospital.

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Pain intensity outcome after cryotherapy

The VAS was: low in 78% of cases, moderate in 22%. No case of severe pain was noted [Figure 2]. Mean VAS was 1.8 ± 1.7. The difference was statistically significant.
Figure 2: Pain intensity according to the technique, evaluated by Visual Analog Scale, within all the patients with pain at arteriovenous fistula puncture in hemodialysis unit of Ibn Rochd University Hospital.

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Comparison between the two techniques

Cryotherapy was significantly efficient, compared to Emla™ in lowering pain at AVF puncture with a P =0.001.

Side effects

There was no cutaneous reaction after Emla™ application. Meanwhile, six patients experienced a discomfort in cryotherapy spontaneously resolving.

General appreciation

Twenty-five patients preferred the cryotherapy for experiencing a lower pain and a better comfort at AVF puncture. In the opposite, seven patients appreciated Emla™ efficiency.

   Discussion Top

Pain is one of the most frequent symptoms among HD patients: more than 60% of patients have chronic pain, with several etiologies.[13]

The AVF puncture is a repetitive technical care, perceived as aggressive (two separate puncture areas needed per session, three times a week as a rule) for patients whose HD management can last for several years, or even for life. The pain induced by AVF puncture has been poorly studied, and would be mainly related to the diameter and length of needles used. Thus, the management of pain is now a recurrent and challenging problem in HD to the extent that chronic pain impairs patients’ quality of life.

In our study, pain at AVF puncture is common in HD patients in our department (38% of patients), consistent with the results of several studies.[3] Indeed, a study conducted in 2013, within our structure, by Kaza et al revealed a significant incidence of pain at AVF puncture: 60.9%.[4]

The Emla™ cream is composed of two anesthetic substances (Lidocaine 2.5% and Prilocaine 2.5%), and is used in many situations (before venipuncture, arterial puncture or subcutaneous puncture, and before superficial surgery). To ensure its efficiency, Emla™ must be applied in a thick layer, at least 30 min before the invasive procedure, and covered with an adhesive hermetic bandage. The results of our study show a clear reduction in pain after the application of Emla™, thus comforting certain data from the literature.[3],[4],[5],[6],[7] In a study published in 2011 by Çelik et al that included 41 HD patients, every patient randomly received Emla™, vapocoolant spray, and placebo cream before AVF puncture: the analgesic efficiency of Emla™ was statistically more significant, compared to other techniques used.[3] On the other hand, in a survey on the pain felt at AVF puncture, carried out within 66 patients undergoing HD in the Limousine Association for the use of Artificial Kidney at Home (ALURAD) in France, the results revealed that pain at AVF puncture persisted despite the use of Emla™' since 60.5% of patients with pain at AVF puncture were using it during the study.[14]

In addition to its controversial efficiency in the literature, its use presents certain constraints, mainly related to its duration of action (between 30 and 60 min), and its contraindications (congenital methemoglobinemia, porphyria, hypersensitivity to one of the constituents). In addition, its application is likely to induce certain undesirable effects (erythema, pruritus, burning sensation, purpura, edema at the site of application, or even contact dermatitis). Also significant, the anesthetic cream Emla™ is not easily accessible in our country, and very few structures can get it. Another element is also to take into consideration, its financial cost which is not very affordable for most patients: about 370 Moroccan Dirhams (equivalent to 35 Euros) monthly, for three applications per week. On the other hand, its analgesic effect can persist up to 1 h, which makes its advantageous use compared to other techniques.[15]

In our study, no side effects were reported after application of Emla™.

Nowadays, more and more patients use non-pharmacological therapeutic called natural medicine, on the one hand for their low financial cost, but also for their accessibility. Cutaneous application of cold, known as “cryotherapy”, is a natural method used in several medical disciplines (rheumatology, traumatology, neurology, dermatology, oncology, …), for its analgesic and anti-inflammatory effects. As described by Melzack and Wall in 1965, cold indirectly reduces the sensation of pain (reduction of edema, inflammatory reaction, and muscular contracture), and directly by increasing the pain threshold by the anesthesia it provides by activation of gate control (gate Control Theory), and decreasing conduction in the afferent fibers, and inhibition of the axon reflex.[16]

In our study, the use of cryotherapy with ice cubes induced a significant reduction in pain at AVF puncture, and thus confirms the results of other studies. Indeed, Deepika et al experienced cryotherapy (using ice cubes) in 60 HD patients (30 each in experimental and control groups), which resulted in a significant decrease in pain experienced by patients with the application of cryotherapy.[11] In a recent study published in 2017 by Fin et al and that included 19 patients, a frozen cushion (-20°C) isolated by a sterile field was directly applied on the puncture sites, for 3–5 min, immediately before the puncture, for six consecutive sessions. The efficiency of the technique was evaluated by a self-questionnaire, with a pain score of study start at 4.1, and 1.6 at the end of the study.[12]

Another cryotherapy technique has been tested by several teams using cryogenic spray which is widely used for its analgesic and soothing properties, and the results are controversial. Dalvandi et al used cryogenic spray and Emla™ in 40 non-HD patients, before intravenous punctures, and the results showed a less efficiency of cryogenic spray compared to Emla™.[17]

A recent study used cryotherapy before AVF puncture in a pediatric population (40 children) undergoing HD. The assessment of pain intensity was based on the Wong-Baker faces pain rating scale, in addition to other physical signs: respiratory rate, oxygen saturation, cries and tears, anxiety. The results of the study reveal a statistically significant pain attenuation after cryotherapy.[18]

In addition to being effective against pain, cryotherapy is an inexpensive technique that can be easy to reproduce. There are few contraindications: allergy to cold, Raynaud’s syndrome, sensitivity disorder and the presence of cryoglobulinemia. However, some side effects can be observed: feeling of discomfort, urticaria, burning (if not respecting the time limit of contact). In our study, a small proportion of patients (6 patients) reported a feeling of discomfort during the application, which was instantaneous.

The results of our study demonstrated analgesic efficiency for both techniques tested, with greater efficiency in favor of cryotherapy. In addition, 79% of patients who participated in our study have chosen cryotherapy after the survey conducted at the end of our study.

Our study is the first to compare the efficiency of the two techniques (Lidocaine and Prilocaine in the form of anesthetic cream/ cryotherapy in the form of ice cubes) in the management of pain at AVF puncture in HD patients. On the other hand, our study presents certain limits. It is a single-center study, with a small sample of patients. In addition, the use of VAS as a way of evaluating pain also has certain limitations, since its validity is based on comprehension and language, hence its contraindication in patients who are visually impaired, in alterate general state, with impaired cognitive functions, or low socio-cultural level. Multicenter studies with larger samples are therefore needed.

   Conclusion Top

Pain at AVF puncture in HD patients is a recurrent and challenging problem, especially since it’s felt by a large proportion of patients. Several techniques have been experimented for the management of pain at AVF puncture, and their efficiency remains highly controversial. Both techniques used in our study have shown their efficiency in reduction of pain. However, each technique have several advantages and inconvenient. Concerning the anesthetic cream Emla™, its main advantage is its duration of action that is relatively long. On the other hand, it is a technique that may be difficult to apply in our context (high financial cost, availability, and time constraint). Concerning cryotherapy, it’s a natural, easy for daily use, and inexpensive technique for pain management, with some few contraindications. Based on the results of our study that is the first to compare the efficiency of the two techniques within HD patients, cryotherapy can be proposed in the long term to overcome the pain felt at AVF puncture, for better management of HD patients.

Conflict of interest: None declared.

   References Top

National Kidney Foundation. Clinical Practice Guidelines for Vascular Access. National Kidney Foundation; 2006.  Back to cited text no. 1
Brkovic T, Burilovic E, Puljak L. Prevalence and severity of pain in adult end-stage renal disease patients on chronic intermittent hemodialysis: A systematic review. Patient Prefer Adherence 2016;10:1131-50.  Back to cited text no. 2
Çelik G, Özbek O, Yılmaz M, Duman I, Özbek S, Apiliogullari S. 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;8:623-7.  Back to cited text no. 3
Kaza BN, Sabi KA, Amekoudi EY, et al. Pain during arterio-venous fistula (AVF) cannulation. Am J Internal Med 2014;2:87-9.  Back to cited text no. 4
Crespo Montero R, Rivero Arellano F, Contreras Abad MD, Martínez Gómez A, Fuentes Galán MI. Pain degree and skin damage during arterio-venous fistula puncture. EDTNA ERCA J 2004;30:208-12.  Back to cited text no. 5
Marticorena RM, Hunter J, Macleod S, et al. The salvage of aneurysmal fistulae utilizing a modified buttonhole cannulation technique and multiple cannulators. Hemodial Int 2006;10:193-200.  Back to cited text no. 6
McPhail S. Hemodialysis needles can be pain free: Use of a topical anaesthetic cream. J CANNT 1992;2:19-20.  Back to cited text no. 7
Watson AR, Szymkiw P, Morgan AG. Topical anaesthesia for fistula cannulation in haemodialysis patients. Nephrol Dial Transplant 1988;3:800-2.  Back to cited text no. 8
Wong Fat M. Hypnose aux Premières Ponctions de Fistule Artério-Veineuse: Que Pensent Nos Infirmières D’hémodialyse? 22e cours congrèsdela Société Francophone de l’Abord Vasculairel; June, 2017. Available from: http://sfav.org/Publication/SFAV2017/ S03-IN07.pdf.  Back to cited text no. 9
Aghajanloo A, Ghafourifard M, Haririan H, Gheydari PS. Comparison of the effects of cryotherapy and placebo on reducing the pain of arteriovenous fistula cannulation among hemodialysis patients : A randomized control trial. J Nurs Midwifery Sci 2016;3:59-65.  Back to cited text no. 10
  [Full text]  
Deepika K, Dandeep M, Somesh G, Meenakshi A, Yadav SL. Effect of cryotherapy on arteriovenous fistula puncture-related pain in hemodialysis patients. Indian J Nephrol 2008;18:155-8.  Back to cited text no. 11
Fin L, Rubenstrunk A, Nakhla M, et al. Cryoantalgie de la ponction de l’accès vasculaire du patient dialysé. Néphrol Thérapeutique 2017;13:274-5.  Back to cited text no. 12
Murtagh FE, Addington-Hall JM, Edmonds PM, et al. Symptoms in advanced renal disease: A cross-sectional survey of symptom prevalence in stage 5 chronic kidney disease managed without dialysis. J Palliat Med 2007;10:1266-76.  Back to cited text no. 13
Vergne H, Darnis MC, Ostertag A, Poux JM. Douleur A la ponction de la fistule artério-Veineuse en hémodialyse. Centre National de Ressources de Lutte Contre la Douleur; May, 2008. Available from: http://cnrd.fr/IMG/pdf/ VERGNE.pdf.  Back to cited text no. 14
Kitamoto Y, Kano T, Mishima M, et al. Dermal patch anesthesia: Pain-free puncture of blood access in hemodialysis patients. Am J Kidney Dis 1992;20:489-91.  Back to cited text no. 15
Melzack R, Wall PD. Pain mechanisms: A new theory. Science 1965;150:971-9.  Back to cited text no. 16
Dalvandi A, Ranjbar H, Hatamizadeh M, Rahgoi A, Bernstein C. Comparing the effectiveness of vapocoolant spray and lidocaine/ procaine cream in reducing pain of intravenous cannulation: A randomized clinical trial. Am J Emerg Med 2017;35:1064-8.  Back to cited text no. 17
18. Attia AA, Hassan AM. Effect of cryotherapy on pain management at the puncture site of arteriovenous fistula among children undergoing hemodialysis. Int J Nurs Sci 2017;4:46- 51.  Back to cited text no. 18

Correspondence Address:
Loubna Kortobi
Department of Nephrology, Dialysis and Renal Transplantation, Ibn Rochd University Hospital, Casablanca
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.289446

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  [Table 1], [Table 2], [Table 3]


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