Cannulation during hemodialysis (HD) may not only be painful but is also associated with worse outcomes. Having a higher pain score during fistula cannulation is independently associated with missing HD sessions (1). It has been shown that missing just one session over a course of a few months is associated with a 68% higher rate of mortality (2). Moreover, untreated pain may increase the risk of developing needle phobia, tachycardia, and vasovagal syncope and contribute to future noncompliance. For all of these reasons, it is essential to consider managing pain with cannulation.
A number of strategies can help reduce pain associated with access cannulation, such as local anesthetic agents, topical heat, cryotherapy, and aromatherapy (3). Additionally, music interventions have been found to provide an effective complementary approach for the relief of acute, procedural, and cancer/chronic pain in the medical setting (4).
In a recent CJASN study, Inayama and colleagues (5) evaluated the role of music on decreasing pain during cannulation of HD access. The multicenter, single-blinded, crossover, randomized trial recruited 121 patients from five dialysis facilities in Japan who reported pain on cannulation. The treatment group listened to Mozart for 8 minutes before the cannulation procedure and underwent a cannulation while listening to music. To reduce the risk of bias, the authors set their control group as “white noise” rather than “no sound.” Using a visual analog scale score, they found that cannulation pain can be reduced by 12% when patients listen to music. Although there was no significant difference in anxiety, vital signs, or stress markers, the ability to reduce pain with minimal cost was substantial.
There were important limitations to the study, such as gender and culture. Needle fear and needle phobia have been found to be more prevalent in women than in men (6), and yet, in this study, 71% of the participants were male. Although Mozart is appreciated by many people around the world, the music may not be familiar to some. We must consider how a patient’s background may play a role in response to the type of music played. It is unclear if the therapeutic effect of Mozart’s sonata is generalizable or is directly related to the “enjoyment” the person may experience listening to this particular music. A study that examines combining various adjuncts listed above is lacking in the literature and would provide a better algorithm to reduce pain.
Overall, the outcomes of the study focused on patient satisfaction and could lead to improved, long-term use of access sites. Poor cannulation habits can lead to complications related to access. The 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines recommend rope ladder cannulation as the preferred cannulation technique for arteriovenous fistulas (7). However, patients who experience pain with cannulation may prefer the “area cannulation” technique in which the same site is repeatedly accessed, causing scarring, nerve damage, and then less pain in subsequent accesses. This technique leads to aneurysm formations, decreases the life span of the fistula, and should be avoided (7, 8). With pain reduction, the technique of area cannulation can finally be a thing of the past.
Music during dialysis access cannulation provides no added risk to the patient or facility and is simple to implement in dialysis centers. The CJASN study (5) did highlight the use of music as an adjunct to reduce pain.
Outcomes of various pain management techniques during HD access cannulation were analyzed in a recent systematic review of 35 studies (3). Cryotherapy was found to be the best adjunctive technique to reduce cannulation pain. Authors concluded that other interventions, such as aromatherapy, thermotherapy, and transcutaneous electrical stimulation, need further testing in a larger population to ascertain the effectiveness of pain reduction. None of the studies included in the analysis combined alternative therapies together to achieve an augmented effect. There is a clear need for further studies to determine which combinations of adjuncts can provide the most pain relief for our patients.
Tohme F, et al. Predictors and outcomes of non-adherence in patients receiving maintenance hemodialysis. Int Urol Nephrol 2017; 49:1471–1479. doi: 10.1007/s11255-017-1600-4
Al Salmi I, et al. Missed hemodialysis treatments: International variation, predictors, and outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2018; 72:634–643. doi: 10.1053/j.ajkd.2018.04.019
Alzaatreh MY, Abdalrahim MS. Management strategies for pain associated with arteriovenous fistula cannulation: An integrative literature review. Hemodial Int 2020; 24:3–11. doi: 10.1111/hdi.12803
Inayama E, et al. Effect of music in reducing pain during hemodialysis access cannulation. Clin J Am Soc Nephrol 2022; 17:1337–1345. doi: 10.2215/CJN.00360122
McLenon J, Rogers MAM. The fear of needles: A systematic review and meta-analysis. J Adv Nurs 2019; 75:30–42. doi: 10.1111/jan.13818
Lok CE, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 update. Am J Kidney Dis 2020; 75(4 Suppl 2):S1–S164. doi: 10.1053/j.ajkd.2019.12.001
Parisotto MT, et al. Cannulation technique influences arteriovenous fistula and graft survival. Kidney Int 2014; 86:790–797. doi: 10.1038/ki.2014.96