I posted this a couple years back but it’s a popular topic for dialysis patients, new and experienced, so I’ll post it again to refresh it.  It has some sage advice from other patients and how they deal with the needle stick.

Dealing with the pain of “the stick” is really difficult, especially for new patients.  But, it’s often tough for all of us.  Just when you think it’s not a problem anymore, you have a tech who’s not experienced with your access and it’s the “painful stick” cycle all over again.  Here are some things to consider:

When you start dialysis the prospect of a 15, 16 or 17 gauge needle being rammed into your arm is daunting… to say the least.  It was for me, too.  The techs referred to the sizes as “small, medium and large”.  That really doesn’t describe them well.   To my mind, they were all HUGE and, maybe, HUGER and HUGEST.  I described them to my friends as being about the size of the end of a ball-point pen.  The listener would squirm at the thought.  I knew at that point, they understood.

Injection

The typical solution to getting poked with that huge needle is to inject Lidocaine before the stick.  In this case, the tech injects a bit of Lidocaine just under the skin at the site where they’ll stick the dialysis needle.  It seems to help deaden the site and make the insertion of the needle less painful.

When I first began dialysis, it seemed a good solution and so I requested it and the tech did it.  However there are drawbacks to this method.  After a year or so of injecting Lido, my very special tech, Krystal, told me I shouldn’t use Lido as it causes scarring.  I struggled with this question for a while and then let her do one stick without it.  Given the sting of the Lido or the pain of the large gauge needle, it was actually less with the dialysis needle.  After a while, there is no pain at all as the area deadened to the poke.

A wise fellow patient had this to say in a posting about Lido Injection:

…lidocaine works great however the medical community is split some say it’s bad for the graft some say the benefits outweigh the risk. I personally never wanted to take that chance and when I had a graft I never used Lido. And also I have never used it with my fistula. I would say the best thing for you to do is take the pain now and get the area nice and dead. The area where you stick the needles will deaden and you will eventually have very little if any pain at all. I have seen patients ALWAYS use lido and their graft is fine, so it is up to you. Or you can just use lido for a little while, say the first few months and slowly wing yourself off of it.

The pain involved with needle sticks is determined by many factors one being how sharp the damn needle is, I have had some really dull needles another is the skill of the tech/nurse, another is your own tolerance of pain and of course how fast the needle insertion lasts. If you have a tech/nurses who is sticking the needle in slow then the pain will last longer. I have seen techs/nurses put a needle in in about 1 second. Yes that’s right about 1 second and usually those were the talented ones. The longer you are at your center you will know which techs are the best stickers and which techs to avoid. Unfortunately some centers are really small so you may not have a choice that is when I recommend you learn to stick yourself.

He has some very good advice and the scarring issue Krystal raised  is important.  Since I was on Lido injections for a while and didn’t immediately take Krystal’s advice, I had to deal with that.  I had a large area that was scarred from repeated Lido injections.  The result is that it doesn’t heal as easily after the poke and sometimes it won’t clot as quickly so I have to be careful to give it sufficient time to clot and heal before I remove the bandages.  Unfortunately, an “aneurysm” formed in that area.  If I hadn’t stopped using Lido, it would be much worse.  (I had the “aneurysm” repaired to avoid it bursting and being a real mess.  The area is still not a “stickable” area but the danger of the aneurysm is gone and the area is much smaller. )  So, the best advice if you need some help is to use the cream NOT the injection and preserve your fistula!

Cream

A patient in a dialysis discussion forum wrote about his experience with a cream that’s popular with dialysis patients.  You can apply it about 45-60 minutes before dialysis to numb the area where you’ll be stuck.  It’s called EMLA and it’s Lidocaine or Prilocaine at 2.5% concentration.  You can get it at a drug store and it requires a prescription.:

“I have the Lidocaine+Prilocaine cream, but it works the same as the EMLA cream. It soaks in over the hour or two that you have it on and covered. When you get to dialysis, you take off the plastic/dressing and wash off the cream. It stays numb for another hour after that. I feel no pain at all with the lower needle. The upper needle can hurt a bit as it goes further in.

I spread on the cream thick enough that I can’t see my skin, about twice as wide as my fistula (that is, covering my fistula, plus 50% that width on each side past my fistula), and an inch above and below the highest and lowest stick marks. I don’t know yet if that’s too much – I guess I’ll see if I run out before I can refill the prescription! Then I wrap plain kitchen plastic wrap around my arm, not tightly, and tape the ends. If there are things I need to do that morning before dialysis, I use a large Tegaderm instead because it stays on better and doesn’t get in the way.”

I tried the cream but it was difficult to do when I was rushing from work to dialysis.  I had to carry plastic wrap with me and try to wrap my arm with one hand.  I could do it pretty easily when I had someone to help me but it was too complicated otherwise and I often left it off.  My experience with the cream is that it really needed to be wrapped to make it most effective.  In the end, before I stopped, I would often apply the cream and use it’s anesthetic benefit to deaden the pain of the Lidocaine injection.  Kinda stupid but it worked for a while.

Spray

Another solution is a spray that “freezes” the area to be stuck.  Here, again, is what another patient had to say…

They use Lidocaine on me when I am in the hospital. In my clinic, they use Pain Ease. it is a spray which freezes the skin. I am not sure if it is harmful to my fistula, but, it sure makes the insertion of GIANT needles easier on me!!

I’m sure the spray doesn’t have the drawbacks of Lido injection. I found these warnings about it from the manufacturer.  It shouldn’t effect the fistula. But it could damage the skin and isn’t good if you have poor circulation. And, watch for infection.
Over spraying may cause frostbite
Freezing may alter skin pigmentation
Use caution when using product on diabetics or persons with poor circulation
Apply only to intact oral mucous membranes
The thawing process may be painful and freezing may lower resistance to infection and delay healing
If skin irritation develops, discontinue use
PRE-INJECTION ANESTHESIA: Prepare the syringe. Swab the treatment area with an antiseptic. Spray the treatment area with Pain Ease continuously for 4 to 10 seconds from a distance of 8 to 18 cm (3 to 7 inches) until the skin just turns white. Do not frost the skin/area. Avoid spraying of the target area beyond this state. With the skin taut, quickly introduce the needle. Reapply as needed. Follow these directions for other types of needle insertion procedures such as starting IV’s and venipuncture.
And I found this…
Pain Ease causes a transient freezing of the skin surface. The anesthetic effect begins immediately after application, but lasts less than one minute. It should only be applied to intact skin. 
Exclusions:
1.) patients with peripheral vascular conditions
2.) patients with history of hypersensitivity to the product

Advice

But, back to the issue of the needle stick.  Again, Epoman had some good advice:

Also in the future DO NOT let the tech dig around for too long if they don’t get it right away have them pull it out and try a new spot. By them digging around too much they may clog the needle with tissue and will have stick you in a new spot anyway. Believe it or not you are the boss, remember it is your arm not theirs. (Ibid)

I learned that lesson, too.  Previously, I would let the tech dig around and keep trying to find the artery or vein they so eagerly sought.  Now, I give them about 5 minutes and tell them, “Remove it!  Wait ten minutes and try again.”  I need that time to recover.  (Also, ask for Tylenol.  It helps.)  Rest up while they are getting the meds and a new needle.  In my case, there’s a spot where the vein narrows (or so we think) which makes that area particularly difficult to stick.  When a bad stick happens, I tell them to go back to proven ground and stick there.

The trick seems to be getting a tech that is really good at sticking you.  That’s not always easy.  I once asked another tech to let Krystal stick me and she got offended and walked off in a huff.  We didn’t speak for several weeks until I stopped her, apologized, and explained that I was going through a difficult sticking time and asked her not to take it personally.  We made up and were “friends” again.  But, it’s something I go through every time I have to break in a new tech.  For example, one week I was on a different shift. My regular tech wasn’t there so I had a new tech. The first time, no problem.  The next time, BIG problems.  Infiltration and bruising and tenderness.  The next time, digging and hunting and calling on the charge nurse to help.  OW!  I’m glad I went back on my regular shift the next week.  But, suffice to say, no Lido.  I endured.

So, long story short, no Lidocaine injection, no matter how much the needle stick hurts.  It’s still less than the sting of the alcohol suspension of Lidocaine and there’s never enough Lido to make all the pain go away.  If you’re using Lido injections, I encourage you to stop.  Discuss it with your doc or an experienced tech and see what they have to say.

If you have some sage advice, please leave a comment.  Dialysis is new to many people and sharing your experience helps!

© 2014 DevonTexas