Music during cannulation cuts patient pain, study indicates

Eight minutes of Mozart have been found to reduce the pain of cannulation for haemodialysis patients, though not their level of anxiety, in a recent study published in the Clinical Journal of the American Society of Nephrology (CJASN). The Japanese randomised controlled trial suggests the use of music can, at the very least, make for an effective and affordable adjunct to existing analgesic measures during what is often a painful procedure for patients.

High levels of pain during cannulation are associated with patients skipping dialysis sessions, while missing just one over several months has been associated with a 68% higher rate of mortality. This risk, as well as the cost associated with existing treatments for cannulation pain, prompted the study authors, including lead author Emi Inayama (Mihama Narita Clinic, Chiba, Japan) and corresponding author Yosuke Yamada (Shinshu University School of Medicine, Nagano, Japan), to investigate methods for its management.

Building on a study by Jin Hyung Lee (Ewha Womans University, Seoul, South Korea) that has suggested music is an effective reliever of pain in other medical settings, Inayama et al designed their own that explored its capacity for doing the same in a haemodialysis setting. It was a prospective, multicentre, single-blind, crossover, randomised controlled trial taking place across five dialysis facilities in Japan. There, 121 patients were selected who were over the age of 20 and who had been undergoing dialysis for more than six months at the beginning of the trial. Of these, 86 were men and 35 were women, while

Plastic cannulas “vital” for patients at risk of needle infiltration

Dori Schatell (Medical Education Institute, Madison, USA) has spoken at VEITHsymposium (15–19 November 2022, New York City, USA) extolling the advantages of plastic cannulas and their flexibility. Though not yet approved by the US Food and Drug Administration (FDA), Schatell argued that they present several opportunities for clinicians.

PLASTIC CANNULAS HAVE BEEN USED for 30 years or more in Japan, and 15 years in Europe, Australia, and New Zealand, but are not yet FDA-approved in the USA. That may be changing, Schatell said. She argued that plastic cannulas should be considered for patients requiring more flexible access. Needle infiltration, which occurs more frequently with metal cannulas, can disrupt treatment and create a requirement for new procedures. A flexible cannula may reduce the risk of infiltration, she said, while also drawing attention to other scenarios in which plastic cannulas may be useful, such as for nocturnal haemodialysis during sleep, in restless patients and children, as well as those with endovascular arteriovenous fistulas (endoAVFs) or metal allergies.

A direct statistical comparison was drawn by Schatell between plastic and steel. Referring to a study in the Journal of Vascular Access led by Sun Ryoung Choi (Hallym University Medical Center, Seoul, South Korea), she noted that there was “no optimal flow, angle, depth or needle eye” to prevent wall their median age was 64 years. Those with impaired hearing were excluded. sheer stress with steel cannulas, while plastic cannulas were associated with more stable arterial and venous pressures. Cannulation success generally was higher with a plastic rather than metal needle, and plastic use resulted in “less AVF injury, failure [and] haemostasis time.”

Enrolled patients were randomly allocated to two groups, both of which experienced haemodialysis twice with no sound, once with white noise played as a control and once with Mozart’s “Sonata for Two Pianos in D Major, K.448”, which has been selected for other studies exploring music’s analgesic properties including James Stephen Jenkins’ (Ochsner Medical Center, New Orleans, USA) into the “Mozart effect”. The patients also experienced the white noise and music for eight minutes before cannulation. The primary endpoint was visual analogue scale (VAS) pain score reported by patients immediately after cannulation, while their VAS anxiety score was among the secondary endpoints.

The VAS pain score for patients who heard Mozart was 12% lower than for those who heard the control of white noise, which the authors describe as “significantly lower”. The 8% reduction on the VAS anxiety scale, meanwhile, they call “not significant”, while “the per-protocol set results were similar”. The study design had its limitations, including its gender imbalance, notable given that female gender has been associated with fear of needles by other studies. It was also not considered whether the analgesic effect of Mozart in particular is dependent on a patient’s cultural background and personal enjoyment of the genre or composer. Inayama et al call their study “well-designed” while demonstrating an analgesic effect. Their final remark states that “the effect size of music alone might not be clinically sufficient to control pain”, but that as a “safe and inexpensive adjunct pain relief method” alongside others it shows promise.

There was, however, a “learning curve” associated with plastic, Schatell suggested. Cannulation pain was generally found to be higher than with metal cannulas, but can be addressed with topical anaesthetics. Nurses also found cannulation more difficult at first [p=0.084]. Despite these drawbacks, she said, plastic cannulas “save lives” by allowing earlier cannulation.

Though plastic cannulas initially cost more, Schatell said, their advantages resulted ultimately in savings for healthcare providers. She concluded by stating that they were “cheaper per patient” in part because they were both “less likely to harm the access” and “able to be used faster,” reducing the need to start haemodialysis with a risky central venous catheter.

“Blood vessels are flexible—but metal needles are rigid,” noted Schatell. “Getting plastic cannulas FDA-approved and in regular use is vital to reduce the fear, pain, and potential damage from metal needles and to help make home haemodialysis more possible for many.”