Indian Journal of Clinical Anatomy and Physiology


Analogy and collation of Valsalva manoeuvre and Ball compression on pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis


Full Text PDF



Author Details: Meenu S,Satheesh Balakrishnan*

Volume : 6

Issue : 1

Online ISSN : 2394-2126

Print ISSN : 2394-2118

Article First Page : 65

Article End Page : 67


Abstract

Introduction: Valsalva manoeuvre and Ball compression will be effective in reducing pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis.

Objective: To assess the pre-test level of pain during arteriovenous fistula cannulation among haemodialysis patients, to assess the post-test level of pain during arteriovenous fistula cannulation after practicing Valsalva maneuver among haemodialysis patients, to assess the post-test level of pain during arteriovenous fistula cannulation after practicing ball compression among haemodialysis patients and to compare the pre-test and post-test level of pain after practicing Valsalva maneuver during arteriovenous fistula cannulation among haemodialysis patients. To compare between pre-test and post-test analysis of Valsalva manoeuvre and Ball compression in reducing pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis.

Materials and Methods: About 50 patients were selected and their pain during cannulation was assessed on a verbal pain scale of 0-10. Two sessions of dialysis were selected and the average calculated. Afterwards the same set of patients were asked to do the Valsalva manoeuvre during cannulation and pain severity recorded for next two sessions and the average calculated. Then the patients were explained about the ball compression method and they were cannulated along with ball compression for next two sessions and the average calculated.

Statistics: ANNOVA followed by Dunnets’ Multiple Comparison test. p value <0>

Results: We found that both Valsalva manoeuvre and Ball compression on pain during arteriovenous with fistula cannulation in patient with chronic renal failure on haemodialysis with a p value of < 0>

Conclusion: Both Valsalva manoeuvre and Ball compression was equally effective in reducing pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis.

Keywords: Arteriovenous fistula cannulation, Ball compression, Chronic renal failure, Haemodialysis, Valsalva manoeuvre.

Introduction

Damage to kidneys or decrease in glomerular filtration rate with <60>[1] Worldwide, more number of patients are suffering from end stage renal disease and among the number of patients, about 20-30 patients will have renal dysfunction of some degree who needs renal transplant.[2] Dialysis is a process to remove excess of waste and water.[3] Even though, dialysis has not completely replaced kidney function, but may manage kidney function activities as result of diffusion and ultrafiltration.[4] The criteria for dialysis are extracellular volume expansion, uremic syndrome, hyperkalaemia, failure to medical treatment, creatinine clearance of 10 ml/min/1.73 m2 or less etc.[5][6][7] An unpleasant feeling along with emotional experience that is associated with actual or potential tissue damage including physiological and psychological response for which a patient visits the health-care centres is due to pain.[8]

A non-pharmacological treatment to reduce pain is Valsalva maneuver which act by increasing the intrathoracic pressure that activate baroreceptors followed by vagal stimulation that reduces the pain.[9] Valsalva maneuver is so unique method as it does not require any equipment. It can be easily learned by the patients that reduces the pain intensity related to peripheral venous cannulation and also has helps to increase the success rate of venous cannulation.[10] Valsalva maneuver also decreases the pain due to skin puncture in spinal injection.[11]

To reduce painful needle insertion, many techniques like infiltration analgesia and eutectic mixture of local anaesthetics (EMLA) patch have been used, but local anaesthetics produce pain during the procedure and there exists doubt regarding infiltration analgesia advantages over puncture without analgesia.[12][13][14]

Both somatic and psychological components are involved in pain and more over local anaesthetics reduces somatic pain and attention-diverting measures (pressing ball) diverts the pain of psychological component.[15][16][17]

Based on the above fact the following study was undertaken to accesses analogy and collation of Valsalva manoeuvre and Ball compression on pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis.

The objectives of this study was to do analogy and collation of Valsalva manoeuvre and Ball compression on pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis.

Materials and Methods

Institution Ethics consent was obtained and informed consent was taken from study participants. Study was conducted in the Department of Nephrology, Pushpagiri Medical College. Time period was from 01-01-18 to 31-01-18.

Study Design

About 50 patients were selected and their pain during cannulation was assessed on a verbal pain scale of 0-10. Two sessions of dialysis were selected and the average calculated. Afterwards the same set of patients were asked to do the Valsalva manoeuvre during cannulation and pain severity recorded for next two sessions and the average calculated. Then the patients were explained about the ball compression method and they were cannulated along with ball compression for next two sessions and the average calculated.

Inclusion Criteria

  1. Patients undergoing haemodialysis and with a patent AV fistula. A mature AV fistula which is in use for at least a month

Exclusion Criteria

  1. Patients with diabetic neuropathy or other neurological disorders altering the pain perception
  2. Patients with aneurysmal dilation of fistula
  3. Patients with cellulitis of the fistula arm.

Statistics

ANNOVA followed by Dunnets’ Multiple Comparison test. p value <0>

Results

Table 1: Comparison of Valsalva manoeuvre and Ball compression in chronic renal failure on haemodialysis

Pre-test

Post Valsalva manoeuvre

Post Ball compression

Q value

p value

7.64±0.12*

4.32±0.17**

5.06±0.12**

>2.235

< 0>

ANNOVA followed by Dunnets’ Multiple comparison test. *p = >0.05, ** <0>

Discussion

As per American pain society in considered as important part of care and a “fifth vital sign” to be emphasized for effective pain management. Dialysis is a painful procedure and the patient will be already on the psychological stress of their condition and physical pain adds on to it making the life miserable, hence non pharmacological pain management is the best method of pain management and hence this study was selected.

Activation of the sinoaortic baroreceptor reflex arc is the main factor that is involved in Valsalva maneuver.[18]

Valsalva maneuver is known to reduce pain by a variety of complex mechanism as is proved by the data of related to haemodynamics linked to modulators of pain perception by a baroreceptor reflex the triggers an antinociception. Valsalva maneuver is known to act by dual mechanism that is by distraction component and sinoaortic baroreceptor reflex arc mediated antinociceptive mechanism which was maintaining circulatory homeostasis utilizing peripheral receptors and central nervous system through reflex adjustment of parasympathetic and sympathetic efferent to the cardiovascular system. Release of Substance-P into circulation, secretion of noradrenaline which increase blood pressure and distribution of blood flow towards heart are the three main mechanisms by which sinoaortic baroreceptor reflex works.[19][20][21]

During Valsalva maneuver contraction of thoracic cage compresses lungs and cause increase in intrathoracic pressure resulting in compression of vessels within the chest and in turn baroreceptor activation. The activation of the cardionpulmonary baroreceptor reflux induces antinociception.

Cardiopulmonary (CP) baroreceptors have thought to modulate baroreflex control of sympathetic nerve activity. Due to loading of CP baroreceptors due to increase intrathoracic pressure causes modulation of baroreflex

control sympathetic nerve activity and it causes antinociception.
[22]

The efficacy of Valsalva maneuver on needle projection pain has been reported in various studies.[23][24][25]

The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon. Ball compression is done by guiding the patient to compress a rubber ball during the procedure and the values were recorded on a pain scale and graded between 0 to 10 by both pre-test and post Valsalva manoeuvre and Post Ball compression.

We found that both Valsalva manoeuvre and Ball compression was equally effective in reducing pain during arteriovenous fistula cannulation in patient with chronic renal failure on haemodialysis with a p value of < 0>

Conclusion

Patient undergoing dialysis will be already on many medications and analgesic to reduce pain during the procedure of dialysis will be an extra burden both clinically and economically, hence non-pharmacological treatment like Valsalva manoeuvre and Post Ball compression can offer alternative approach in pain reduction.

Conflict of Interest: None.

References

  1. ^ National Kidney Foundation—K/DOQI. Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 2002;39(suppl 1):S1–266.
  2. ^ Jones CA, McQuillan GM, Kusek JW, Eberhardt MS, Herman WH, Coresh J, Salive M, Jones CP, Agodoa LY. Serum creatinine levels in the US population: third National Health and Nutrition Examination Survey. Am J Kidney Dis 1998;32(6):992-999.
  3. ^ Hakim RM, Lazarus JM. Review Initiation of dialysis. J Am Soc Nephrol 1995;6(5):1319-1328.
  4. ^ Lee KY. A unified pathogenesis for kidney diseases, including genetic diseases and cancers, by the protein-homeostasis-system hypothesis. Kidney Res Clin Pract 2017;36(2):132-144.
  5. ^ Dialysis procedures alter metabolic conditions. Stegmayr B. Nutrients 2017;9:548.
  6. ^ Ifudu O. Care of patients undergoing hemodialysis. N Engl J Med 1998;339:1054–1062.
  7. ^ Daily hemodialysis and the outcome of acute renal failure. Schiffl H, Lang SM, Fischer R. N Engl J Med 2002;346:305–310.
  8. ^ Smeltz S, Ber B, Hinkle JL, Chyioer KH. Surgical-Internal Nursing, Brunner and Sudart, Shock Pain and Electrolytes, Cancer and Cares of End of Life. Parsa Yekta Z, Tazakorri Z, Salemi S, Abed Saeedi J, Barahimi N, Farahani M, translators. Tehran: Salemi Press; 2007. p. 320
  9. ^ Mashhadi SA, Loh CY. Valsalva manoeuvre and the wrist block. Eur J Plast Surg 2011; 34:421-422.translators. Tehran: Salemi Press; 2007. p. 320
  10. ^ Suren M, Kaya Z, Ozkan F, Erkorkmaz U, Arlcl S, Karaman S. Comparison of the use of the Valsalva maneuver and the eutectic mixture of local anesthetics (EMLA) to relieve venipuncture pain: A randomized controlled trial. Jpn Soc Anesthesiol 2013;27:407-411.
  11. ^ Mohammadi SS, Pajand AG, Shoeibi G. Efficacy of the valsalva maneuver on needle projection pain and hemodynamic responses during spinal puncture. Int J Med Sci 2011;8:156-160.
  12. ^ Morris RW, Whish DK. A controlled trial of pain on skin infiltration with local anaesthetics. Anaesth Intensive Care 1984;12(2):113-114.
  13. ^ Morris R, McKay W, Mushlin P. Comparison of pain associated with intradermal and subcutaneous infiltration with various local anesthetic solutions. Anesth Analg 1987;66(11):1180-1182.
  14. ^ Koscielniak-Nielsen Z, Hesselbjerg L, Brushøj J, Jensen MB, Pedersen HS. EMLA patch for spinal puncture. A comparison of EMLA patch with lignocaine infiltration and placebo patch. Anaesth 1998;53(12):1218-1222.
  15. ^ Koscielniak-Nielsen Z, Hesselbjerg L, Brushøj J, Jensen MB, Pedersen HS. EMLA patch for spinal puncture. A comparison of EMLA patch with lignocaine infiltration and placebo patch. Anaesth 1998;53(12):1218-1222.
  16. ^ Patterson P, Hussa AA, Fedele KA, Vegh GL, Hackman CM. Comparison of 4 analgesic agents for venipuncture. AANA J 2000;68(1):43-51.
  17. ^ Usichenko TI, Pavlovic D, Foellner S, Wendt M. Reducing venipuncture pain by a cough trick: a randomized crossover volunteer study. Anesth Analg 2004;98(2):343-345.
  18. ^ Sanjay Kumar, Sujeet Kumar Singh Gautam, Devendra Gupta, Anil Agarwal, Sanjay Dhirraj, Sandeep Khuba. The effect of Valsalva maneuver in attenuating skin puncture pain during spinal anesthesia: a randomized controlled trial. Korean J Anesthesiol 2016;69(1):27–31.
  19. ^ Agarwal A, Sinha PK, Tandon M, Dhiraaj S, Singh U. Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study. Anesth Analg 2005;101:1230–1232.
  20. ^ Englstrom JW, Martin JB. Disorders of the autonomic nervous system. In: Braunwald E, Fauci AS, editors. Principals of internal medicine. New York: McGraw-Hill; 2001. pp. 2416–2421.
  21. ^ Randich A, Maixner W. Interaction between cardiovascular and pain regulatory systems. Neurosci Biobehav Rev 1984;8:343–367.
  22. ^ Merrian Webster, An Encyclopaedia Britannica Company. Baroreflex. (Internet) Available from http://www.merriamwebster.com/medical/baroreflex (retrieved on 23 April 2014)
  23. ^ G Basaranoglu, M Basaranoglu, V Erden, H Delatioglu, AF Pekel, L Saitoglu. The effects of Valsalva maneuvers on venipuncture pain. Eur J Anaesthesiol 2006;23(7):591-593.
  24. ^ Akdas, G Basaranoglu, H Ozdemir, M Comlekci, K Erkalp, L Saidoglu. The effects of Valsalva Maneuver on venipuncture pain in children: comparison to EMLA (lidocaineprilocaine cream). Ir J Med Sci 2014;183(4):517-520.
  25. ^ Mohammadi Soltani Sussan, Pjand Ghasemi Amin, Shoeibi Gita. Efficacy of Valsalva Maneuver on Needle Projection Pain and Hemodynamic Responses During Spinal Puncture. Int J Med Sci 2011;8(2):156-160.