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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2017  |  Volume : 28  |  Issue : 5  |  Page : 1050-1056
Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia

1 Department of Physical Therapy, University of Tabuk, Tabuk, Saudi Arabia
2 Post Graduate and Scientific Research Unit, College of Nursing, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
3 Graduate Program, School of Nursing, Saint Louis University, Baguio City, Philippines
4 Department of Nursing, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia

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Date of Web Publication21-Sep-2017


Pain during arteriovenous fistula (AVF) cannulation remains a common problem in hemodialysis (HD) patients that leads to noncompliance to lifetime maintenance HD. This study was performed to determine the effect of cryotherapy on reducing pain during AVF cannulation among HD patients in the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. This is an experimental study which included 62 patients undergoing HD through an AVF. Randomization was used to assign the patients into the experimental (received cryotherapy) and control (no cryotherapy) groups. The Arabic version of Wong-Baker pain rating scale was used to determine the pain score. There was a significant difference in the pre-and post-intervention pain scores among the experimental group, while there was no such difference in the control group. The null hypothesis was rejected based on a P <0.05. Our study suggests that cryotherapy intervention to relieve AVF cannulation-related pain among adult patients undergoing HD is effective. Therefore, it is recommended that cryotherapy should be considered as a complementary intervention to reduce pain related to AVF cannulation.

How to cite this article:
Al Amer HS, Dator WL, Abunab HY, Mari M. Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 2017;28:1050-6

How to cite this URL:
Al Amer HS, Dator WL, Abunab HY, Mari M. Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2022 Jun 27];28:1050-6. Available from: https://www.sjkdt.org/text.asp?2017/28/5/1050/215141

   Introduction Top

The prevalence and incidence of end-stage renal disease (ESRD) in the Kingdom of Saudi Arabia (KSA) have increased over the last three decades which is higher than many other countries.[1],[2] The prevalence of chronic kidney disease (CKD) in the Saudi population is around 5.7%[3] as against 1.9% in the United States.[4] The Saudi Center for Organ Transplantation reported in 2015 that there were 17,000 diagnosed CKD cases in KSA of which 15,600 undergo regular hemodialysis (HD).[5] In 2008, HD costed around US$ 224 million (840 million Saudi Riyals) for 9000 patients.[6]

HD needs a well-functioning angioaccess that permits drawing up the blood from the body by a needle, circulating in the artificial kidney machine and returned to the patient after removal of excess water, electrolytes, and waste products. Each dialysis session takes 3–4 h and is conducted three times per week.[7] The majority of angioaccess used in Saudi Arabia is arteriovenous fistula (AVF) which is created by surgical anastomosis of artery and vein.[8],[9]

Pain is an inevitable experience during AVF cannulation in HD patients.[9],[10] Local anesthesia is one of the options to ease pain during AVF cannulation and may be ineffective due to vasoconstriction, burning sensation, scarring, and infection. The patient on maintenance HD is left to endure the pain as he/she undergoes 10 AVF punctures a month and would continue until a successful renal transplant. It is important, therefore, to consider his or her comfort with the procedure to encourage long-term compliance with the treatment.[9] Relief from pain during cannulation influences the acceptance of the procedure and will impact on the quality of life for the HD patients.[11]

Studies to alleviate pain during AVF cannulation include the application of cryotherapy as an adjunct therapy in HD patients. From a review conducted,[12] cryotherapy is the application of any material that removes heat from the body resulting in decreased tissue temperature. It decreases tissue blood flow by causing vasoconstriction and reduces tissue metabolism and muscle spasm. These result in a local anesthetic effect called cold-induced neuropraxia. Barnard,[13] stated that the mechanism of cryotherapy is conditional on the ability of extreme cold (<-20°C) to cause a short-term degeneration of nerve axons and destruction of the sheath architecture. The axons will regenerate gradually in a few months.

Several studies have found cryotherapy to be effective in alleviating pain caused by veni-punctures in various occasions. They have reported a significant reduction in the objective and subjective pain scores of patients with application of cryotherapy.[9],[14],[15],[16]

Melzack et al[15] reported in their study that majority of the patients experienced a significant decrease in the intensity of dental pain when ice massage was applied on the web between the thumb and index finger on the same side of the painful region. Findings of Waters and Raisler[16] also concurred in their study that applying ice massage generated a significant reduction in labor pain.

In an experimental study conducted by Hassan et al,[17] the researchers used cryotherapy as an intervention to assess the differences in pain during AVF cannulation in children; their findings showed a significant reduction in pain perception among children who received cryotherapy when compared with the control group.

HD patients undergo AVF punctures about two to three times per week. Thus, these patients experience pain related to AVF cannulation about 10 times monthly. Hence, this study was conducted to look into the possibility of providing an affordable, noninvasive, nonpharmacologic alternative to relieve pain inflicted by AVF cannulation, thereby increasing compliance to the therapy and improving the quality of life among the patients.[9],[11],[18]

This study was performed to review the baseline demographic and HD utilization data for CKD particularly in King Khalid Hospital (KKH), Tabuk, KSA, and to determine the effectiveness of cryotherapy on the reduction of pain due to AVF cannulation in these patients.

   Patients and Methods Top

Study design

Experimental, descriptive, and retrospective methods were used in this study. An experimental design was used to assess the impact of cryotherapy on reducing the severity of pain. Descriptive and retrospective methods were used to assess the demographic data, annual AVF creation rate, the incidence of acute and chronic renal failure, and renal transplantation rate.

Setting and sample

A total of 62 patients undergoing HD through AVF were selected. The sample size was computed based on the Slovin’s formula.[19] Randomization was used in the distribution of the participants into two groups; 31 patients in the experimental group received cryotherapy, and 31 other patients did not receive cryotherapy.

The inclusion criteria included patients with ages from 16 and above, able to report pain adequately and not having any other cause of pain. Patients with conditions such as advanced diabetes, cardiovascular insufficiency, cold allergy, Reynaud’s phenomenon, and nerve and tissue damage were excluded from the study.

Ethical consideration

The benefits and risks considered in this study were reviewed by the Ethical Review Board (HAP-07-TU001) at the University of Tabuk with research number 12 for the year 2015. The study presented no risks since the intervention was noninvasive and participants were carefully screened based on the inclusion criteria, excluding any patient who did not qualify. Informed consent was obtained from all the participants. Confidentiality of information gathered from the AKU and anonymity of the patients was observed throughout the study.


The Wong-Baker faces pain rating scale was used in this study to report the pain resulting from AVF cannulation among the patients. This scale has been used widely around the world and translated into many languages. The Arabic version was retrieved from Wong-Baker Faces foundation and used in this study after obtained the necessary permission.[20] This scale was utilized since it is used regularly by the staff at KKH as the primary way of assessing pain. The scale is divided into six faces range from no hurt to worst hurt. Scoring system used in this study were as the follows: Scores 0–1, no hurt; 2–3, hurts little bit; 4–5, hurts little more; 6–7, hurts even more; 8–9, hurts a lot; and 10, hurts worst. The reliability of this instrument has been checked in various settings and different age groups.[20]

Procedure/data collection

The first part of the study which is descriptive retrospective involved summarizing and analyzing all entries of the patients admitted at KKH for kidney diseases in a span of six years from 2010 to 2015. It covered the demographic variables such as age, gender, and dialysis utilization. The data from entry to exit of these patients on regular maintenance HD were used to calculate various other indicators such as transplantation rate, new AVF creation rate, new cases of acute renal failure (ARF), and CKD. Simple descriptive statistics were used for analysis of data gathered in this part of the study.

An experimental design was used to determine the effect of cryotherapy on the pain experienced during AVF cannulation of HD patients. There were 62 patients who were randomly assigned into two groups: 31 patients constituted the experimental group and received cryotherapy, and 31 others were the control group who did not receive cryotherapy. All these patients were undergoing regular HD treatment sessions, three times per week. Randomization was done to control for any confounding factors. Both groups had a similar distribution in terms of gender, and no other adjustments were made for any other potential confounding factors. It was ensured that the same staff nurses performed the AVF cannulation to the patients throughout the study to control interactions.

Pain scoring was done on all three HD sessions per week for two weeks. During the 1st week, baseline scores of subjective pain (pretest scores) for both experimental and control groups were observed. Both groups did not receive cryotherapy during this week. In the 2nd week, cryotherapy was applied in the experimental group during the three HD sessions while the control group did not receive cryotherapy. Subjective pain scores (posttest scores) for both groups were recorded during this week.

Intervention (cryotherapy)

The cold application was made with ice packs on the web between the thumb and index finger of the contralateral arm (the hand not having the AVF). The procedure was started ten minutes before venipuncture and was continued throughout the puncturing procedure (approximately two minutes). The staff nurses of the AKU performed the ice massage while another staff nurse did the AVF cannulation. The same staff nurses performed the cannulation for the patients in all the sessions. Arabic version of Wong-Baker faces pain rating scale assessment was used to measure the subjective pain scores of patients during cannulation.

   Data Analysis Top

The collected data were coded and computerized. The IBM Statistical Package for the Social Sciences for Windows version 21.0 (SPSS Inc., Chicago, IL, USA) was used in data analysis. Frequency and percentage were utilized to analyze the demographic data gathered from the AKU records. T-test was used to assess the differences in the subjective pain scores between and among the groups.

   Results Top

More than half of the respondents (n = 36, 59%) were male. Their ages ranged between 16 and 65 years, with majority (n = 30, 48%) in the age-range 45–64 years, followed by 36%, n =22 in the age–range 26–44 years, 11%, n = 7 >65 years and above; and 5%, n = 3 in the age-range 16–25 years [Figure 1].
Figure 1: Percentage of patients according to gender and age groups (n = 66).

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[Figure 2] shows the number of AVF created each year from 2010 to 2015. An average of 38.33 AVFs were created per year during six years. The figure shows a decreasing trend in the number of AVF created except for a slight surge in the year 2014. Hospital records between 2010 and 2015 showed that there was an increasing number of newly diagnosed cases of ARF, CKD, and postkidney transplantation.
Figure 2: Number of arteriovenous fistulas created in 2010–2014.

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[Table 1] shows the level of pain related to cannulation experienced by the control group during the three sessions pretest, and the three session posttest, both without cryotherapy in a two-week observation period with grand mean scores of 3.11 and 2.82 out of ten, respectively, which indicate that the patients’ experience during cannulation “hurts little bit.”
Table 1: Mean score of the control group per observation.

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[Table 2] shows the level of pain related to cannulation experienced by the experimental group during the six sessions in a two-week observation period. The experimental group during the 1st week without cryotherapy had a pain level grand mean score of 2.80 which indicates that cannulation “hurts a little bit.” The table also shows the level of pain related to cannulation experienced by the experimental group when cryotherapy was used before the cannulation. A grand mean score of 1.00 which indicates that “no hurt” was felt during the cannulation.
Table 2: Mean score of the experimental group per observation.

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The pain induced by AVF cannulation among the control group in three different sessions over two weeks, showed no difference. The t-test result revealed no significant difference with the P = 0.476, 0.202, and 0.103, respectively at 0.05 level of confidence. This demonstrates that the control group who did not receive cryotherapy intervention sustained the same range of pain scores experienced for each AVF cannulation. However, in the experimental group, the result showed that there was a significant difference in the level of pain before and postcryotherapy. T-test results showed a significant difference in the three-paired observations with the P = 0.001, <0.001, and <0.001, respectively at 0.05 level of confidence. The result implies that cryotherapy administered before the procedure is effective in reducing the level of pain experienced during AVF cannulation among the patients undergoing HD.

   Discussion Top

The average number of AVF created in KKH between 2010 and 2015 was 38.33, which is consistent with literature showing that the vast majority of angioaccess was AVF in accordance with the United States National Kidney Foundation guidelines.[21] AVF is associated with lesser cost, superior patency rate, and fewer complications compared with venous catheters or artificial grafts.[22],[23] However, it is asso-ciational with various complications such as pain, which influences the patients’ compliance with the procedure and impacts on the quality of life.

The majority of renal patients in KKH were male. This is consistent with previous findings in KSA reporting males as dominant than females,[22],[24] except one study which reported the opposite.[25] The mean age of the respondents was 48 years, which is similar to the average age of renal patients reported by two other studies.[22],[26] Majority of the patients undergoing HD belong to the productive workforce in terms of age and gender, thereby implying a significant effect on the human resource workforce of the KSA. According to Al-Sayyari and Shaheen,[27] there has been a marked rise in the prevalence and incidence of ESRD in KSA over the past three decades, which exceeded those of other countries. This rise has been attributed to rapid changes in lifestyle, high population growth and rapid increase in life expectancy, and massive urbanization. The two major factors that influenced the ESRD status are the very high rate of diabetic nephropathy and shift in age demographics. The consistently high number of new cases yearly revealed in this study is reflective of the national statistics disclosed.[27] Moreover, it is noted that there is a small number of patients with ESRD who opt for kidney transplantation. Kidney transplantation is the last resort when all options have been exhausted and remained unresponsive. All the respondents of this study underwent HD three times every week which means that they are punctured with a large needle at least 144 times per year throughout their lifetime. The pain of AVF puncture is undeniably a problem for patients undergoing HD. Its high prevalence has been shown in findings of various studies from different countries. Vergne et al,[28] Çelik et al,[29] and Noto-Kadou-Kaza et al[30] had reported a prevalence of pain related to AVF cannulation of 57.5%, 56.1%, 60.9%, respectively. HD is a lifetime treatment borne by patients with CKD. It implies that patients have to experience the same pain related to AVF cannulation during their lifetime. Pain is a kind of stress that affects the compliance of the patients to their regular HD treatment.

In this study, the pain score among the experimental group was found to be significantly reduced after using cryotherapy (P <0.001). The introduction of cryotherapy as a non-pharmacological alternative is connected to many benefits including cost and accessibility to its use. The efficiency of cryotherapy in reducing pain has been proven in various studies.[9],[17] Furthermore, cryotherapy has clinical implications as it is easily implemented by nurses to manage the pain caused by the AVF puncture within a relatively short time.

   Limitations Top

The potential limitation for this study was the small sample size due to the limitation of health-care facilities that provides HD in Tabuk city. Furthermore, this study did not include HD patients <18-year-old or patients with advanced complications because of limited number of those patients in Tabuk city.

   Conclusions and Recommendations Top

Cryotherapy as an independent intervention is effective in the reduction of AVF cannulation-related pain among patients with chronic renal failure on HD and thereby rejects thenull hypothesis. It is highly recommended that cryotherapy is considered as a complementary therapy to relieve pain for patients undergoing AVF cannulation for HD. It is noninvasive and inexpensive; hence, it is affordable for the patients and their families.

Health programs emphasizing on prevention of kidney diseases should be intensified and comprehensively implemented.

   Acknowledgment Top

The authors would like to acknowledge the financial support for this work, from the Deanship of Scientific research (DSR), University of Tabuk, Tabuk, Saudi Arabia, under grant no. S-1436 -0060.

Conflict of interest: None declared.

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King Faisal Specialist Hospital & Research Centre. Saudi Arabia: Chronic Kidney Disease; 2016. Available from: https://www.kfshrc.edu. sa/en/Home/HealthEncyclopedia/DiseasesCond itions/1384 .[Last accessed on 25 August 2016].  Back to cited text no. 3
Centers for Disease Control and Prevention (CDC). National Chronic Kidney Disease Fact Sheet; 2014. Available from: https://www.cdc. gov/diabetes/pubs/pdf/kidney_factsheet.pdf. [Last accessed on 25 August 2016].  Back to cited text no. 4
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Çelik G, Özbek 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;8:623-7.  Back to cited text no. 29
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Correspondence Address:
Mohammad Mari
Department of Nursing, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 28937062

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