Application of Lidocaine cream before dialysis

[night owl]

As long as I've been in nursing, when the dinosaur roamed the earth, I've never had any dealings with dialysis until recently. I have a few questions. They're probably dumb, but please bear with me.

OK. We have a resident who goes to dialysis M-W-F at 0600. We have instructions to put this Lidocaine cream to the graft site which is on his Left forearm an hour before the dialysis. OK, easy nuff.... huh? The cream is called E..... something. Darn, I used it once and already I forgot the name. I'm not sure of the application, so I asked this other nurse I work with to apply it. The instructions say not to smear it around, but to place half of the 5gm tube the site to be used, then apply the tega derm over it. It didn't say apply it to two spots. Well he put the cream on and smeared it over the entire site then applied the tega derm which really didn't stick too well because he smeared it beyond where the tega derm was supposed to stick to. I'm thinking, hmmm, this doesn't seem right, but I guess he knows what he's doing.(?) Got a call from renal while the resident was there and the renal guy, a nurse, said to "rotate sites" when applying the cream the next time which will be Monday. Also said to place it anywhere you feel a "pulse" at the site and apply it in two places...Entry and exit portals. Could someone please explain to me what exactly I'm to do here? It's kind of difficult getting an inservice over the phone. Actually another nurse will be doing it because I'm off on Monday, and that's another thing. The same nurse won't be applying this cream all the time, so I'd like to get it right for all of us. Therefore, I'll need an answer say like tonight and before 0800 tomorrow morning because I won't be back tomorrow night for Monday. You gals/guys are the greatest. Thank you so very much in advance. :kiss

[Northern nephron]

Hi, wanted to know what the final outcome was...I am reading this long after the original posting. I am a hemo nurse and the emla is a lifesaver for the patient. We can always use a local lidocaine needle but the rationale is why poke twice - poor patient. The patients in most hemo units are considered outpatients and therefore it is their responsibility to apply the cream if they want to use it. It does come in handy patch form with a peel and stick backing that covers a large area allowing the hemo nurse to then have options on where to place the needles. Ask the patient where it should be placed - they should be able to tell you where the last needles were. Also, in defense of the poor hemo unit - if the patient comes and requires the staff to apply the topical freezing and then wait for an hour for it to take effect - they may not get a full dialysis treatment because this will take one hour out of an already full treatment block of time. By this I mean that most units run 3 shifts/day so patients have a block of time (8-1230 for example) and if they need 4 - 41/2 hours for a full treatment there is not enough time for them to wait for the cream to work. The cream is really simple and effective and is a patient saver....

[cruss]

Night owl,

I read all of the postings concerning the Elma Cream and there is something that everyone seems to be leaving out. The patient! The reason for the Elma Cream could be that the patient has allergies or a sensitivity lidocaine, fear of needles or many other reasons. I am a registered nurse and have worked in Dialysis for 20 years and I can assure you that saving time is not the reason they are asking you to do this. It takes less than one minute to inject lidocaine in both sites. We have one patient that uses it because his fistula is so close to the surface it is difficult to inject the lidocaine without penitrating the fistula. He could do without any thing but he is afraid of needles.

The reason for rotating the sites is so that they do not wear the fistula out by sticking the fistula in the same spot all the time. It would be good for you to move the sites of application up or down about 1 inch each time, and if you would use Saran Wrap to wrap around the arm it would work better than the tega derm. They ask you to do this instead of doing it themselves is that it takes about an hour before the cream is effective. I would suggest that if you have time, stop by the dialysis unit sometime and discuss this with the nurse and you would have better understanding of what is happening to your patient when they go there, and I bet they would be happy to inservice you on the dialysis access. If you would like more information on the dialysis patient the National Kidney Foundation has a great web site @ www.kidney.org.

I hope this clears up any confusion that you have.

Experienced:nurse:

[GeauxNursing]

Our people apply the cream, rub it in, rub it in, rub it in, cover in cling wrap about an hour before, then come to dialysis. (probably not the correct way to do it, but that's how it's done.) we had one lady who it just wouldn't work for. she tried all different ways of apllications, varying the times and amounts she used, still had really painful sticks. we could never figure it out.

Oh! The people who use it just smear it all along they area that they know could possibly be cannulated. none of this "2 spots" nonsense. lol. they want to be sure they are covered.

we have one who uses the spray, she still screams.

some ppl just get lidocaine injections.

[annfaith, DNP, NP]

I currently work in a dialysis unit and we have two patient's who use the Emla cream. They are responsible for putting it on themselves. When they arrive to the unit, and prior to cannulation we remove the saran wrap or whatever they have choosen to cover the site and wipe the cream off and clean the site with betadine ( yes we still use betadine) prior to inserting our needles. This is the practice that we have used. Any in-patient's have the option of lidocaine (another shot) prior to treatment. Most patient's just go cold turkey and resume whatever practice they had prior to admission. Keep in mind I am a dialysis nurse. It is our responsibility to take care of these issues. Maybe management or the doc needs to be made aware of this.

[mmurphy]

This "pulse" is called a thrill. It is basic nursing 101. A patent graft or fistula will have a strong "thrill" when palpated. The thrill is from the anastomosed artery and vein, if you do not feel this thrill likely the graft/fistula is clotted. When ausculatated the graft or fistula has a stong swoosh sound known as the bruit.

Secondly Emla cream is widely used. 90 year old patients apply it themselves a hour before dialysis, it is not a huge deal. It should be applied over the entire access, as you do not know where the dialysis staff is going to cannulate the access. Apply liberally and cover with any type of dressing or simple saran wrap.

[angieskidney]

I know this is a bit old but such an important topic that I felt it would be appreciated what I am about to add. I have been thanked a few times for making this video on Proper Application of Emla Cream prior to Dialysis Cannulation of the AV Fistula. Here is the video:

I hope this helps! If you have any questions my email is on the site listed on the YouTube video page.

- Angie

Kidney Patient Advocate

[madwife2002, BSN, RN]

I know this is a bit old but such an important topic that I felt it would be appreciated what I am about to add. I have been thanked a few times for making this video on Proper Application of Emla Cream prior to Dialysis Cannulation of the AV Fistula. Here is the video:

I hope this helps! If you have any questions my email is on the site listed on the YouTube video page.

- Angie

Kidney Patient Advocate

Thank you so much for this link

[littlefoot1115]

EMLA should be applied an hour pre-tx... then wrapped with saran wrap to maintain its potency pre-tx... i've even seen a pt come in with their arm wrapped in tin foil because they had nothing else!

its the vascular surgeon's job to determine if the AVG/AVF is usuable; we don't initiate cannulation without a rx from the surgeon with noted locations for "best stick sites," which they have diagrams of in the pt's chart, so just request a fax of that.

we've had a lot of instances of "one site-itis" / sticking too close to the anastamosis thus creating aneurysm that are dangerous, risky, and not to mention, disgusting looking.

[Agnes RN]

Just can't help but remind us all as nurses that we are here ti make pt lives healthier and better and mote comfortable. I am not a dialysis nurse, however, I am more than willing to learn to use Emla cream for the sake of decreasing the pain of someone who has most definitely suffered enough. My experience is oncology/ hospice and if I ever forget the patients abd what is best for th I need to get out of caregiving professions!:nurse:Agnes