[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.

[jnette]

Hey Moo !

This sounds just a tad much for them to expect of you... I've worked dialysis for the past 6 years, and none of our patients use this lidocaine cream. We do have one pt. now whose doc has ordered an anesthetic spray..(and all the other patients snicker at him.. even our little 92 yr. old woman).

If they want you to apply the cream, it is MHO that they should send someone over to you and explain a little bit about the graft or fistula, how they rotate sites and why, and bring along some pamphlets describing the cannulation process... BEFORE they expect you all to comply with their wishes.

Even better, see if they can't use the spray (can't think of the name of it right now, either) but it comes in a brown bottle and is sprayed on immediately before inserting the needle.. it has a "freeze/numbing effect". This would be more suitable and would not neccessitate anyone else's involvement.

That said.. (since you need this for Monday am) ... have WHOEVER will be doing this on Monday am attempt to see where he was last stuck...if it's a fistula, he will have a lower arterial stick and an upper venous stick. If it's a graft, he'll have an arterial USUALLY on the pinky side of the arm, and the venous access on the other side ( if it's a loop graft).. if it's a straight graft it would be arterial lower, venous higher.

This is really asking a lot, IMO, because the pt. is supposed to have his bandaids removed before bedtime on the night of his tx. day. So how are you to find his last stickmarks on Monday am .. unless they mark them or sth. ??? And that certainly is not advisable either. They are expecting you to rotate sites for cannulation sticks which is THEIR responsibility, and really cannot even be determined until the patient is ready to be cannulated... sometimes you have to go somewhere other than you intended with your stick due to all kinds of reasons....and then you'd be applying the cream for no reason if they need to stick higher or lower.. see what I'm saying?

Sorry, Nightowl, but this just does not smell right to me... I don't think it should be your responsibility to take on. If I were you, I'd have someone call the DON of the dialysis facilty ( or if acute/inpt. hospital, then have a dialysis nurse come and assess the sites first and tell you where to apply the cream)... and discuss this with the DON. It just does not make sense to me at all.

Yes, you can feel the "thrill".. a gushing, rushing, pulsating in the arm, and hear the bruit with your scope .. a rushing sound... but that still does not tell you where they want to stick him... in which exact location. Unless you just apply the cream over a large area, which is nonsense.

Hope this has helped a little, but I just don't agree with what they're asking of you... I've never heard of this being done before.

[jmtmom]

I just started working in dialysis last month, but I know a little about the subject. It's called Emla cream. We don't have any patients at my clinic who use it, but my preceptor did address the subject for possible future reference. I'm told that our patients don't use it because Medicare doesn't cover it, and it's very expensive. Most of our patients are low/fixed income.

When a patient receives dialysis, we poke their access site with two large bore needles. One needle pulls blood from the patient and sends it to the dialysis machine for cleansing and excess fluid removal. The other needle returns the cleansed blood to the patient. These needles range from 17g to 15g. If we numb the two areas that are to be poked with the Emla cream, it's more comfortable for the patient. Some of the patients at my clinic use sq Lidoaine for this purpose. Most patients don't use anything.

We "rotate" sites to avoid repeatedly poking the same spot in their access. It creates problems for the patient in the long run. I'll try to explain the basic kinds of accesses. If their access is more or less in a straight line, it is called a straight graft or fistula. In this case, one needle will be placed "higher" and one placed "lower". If the access has sort of a horse shoe shape, it is called a loop graft. In this case one needle is placed on the left, and one on the right. The thing to keep in mind in both cases, is we don't want to go into exactly the same spots we went in last time. So just go up a little, or down a little. And yes, make sure you apply the cream in a spot where there is a good pulse. I mean, a GOOD pulse, very pronounced. This where we would get the best blood flow.

It's my understanding that the Emla cream does not need to be smeared over the entire access. Just over the two places where we are going to stick the needles.

I hope this helps!

[jnette]

jmtmom is correct, Nightowl.

It still bothers me that they are asking you all to determine the appropriate cannulation sites, though. Like how are you supposed to know where he was last stuck since FRIDAY.. by Monday am? There's a lot of little stickmarks there. And even then, there's no assurance that they will want to use the 2 spots you've chosen for numerous reasons... then that expensive Emla cream (THANK YOU jmtmom!) will be wasted, the pt. won't have his anesthetic... and to simply applyit in a big swab would really be wasting it !

OK... I've grumbled enough here...

Going to bed now... if you have any further questions, though, I'll be around tomorrow and get back with you, ok?

[night owl]

Originally posted by jnette
Hey Moo !

Sorry, Nightowl, but this just does not smell right to me... I don't think it should be your responsibility to take on. If I were you, I'd have someone call the DON of the dialysis facilty ( or if acute/inpt. hospital, then have a dialysis nurse come and assess the sites first and tell you where to apply the cream)... and discuss this with the DON. It just does not make sense to me at all.
Hope this has helped a little, but I just don't agree with what they're asking of you... I've never heard of this being done before.

Well I've never either. Prolly the only reason why they want us to do the Elma cream application is to save them time.
I don't feel right about it either, and am thinking gut feelings are usually correct. I'm sure the renal guy will be calling our unit again on Monday. I tried to explain the application thing to the nurse who will be applying it tomorrow, but she acted like she didn't want to be bothered and knew all about it. Said, "Yeah I know the cream you smear on the graft site." Told her no smearing. Her reply, "Whatever." sheeesh!
Thank you for your replys ladies.

[jnette]

Originally posted by night owl
Well I've never either. Prolly the only reason why they want us to do the Elma cream application is to save them time.
Thank you for your replys ladies.

This is certainly their reason for requesting this, and I really can't argue with that. Surely, they don't want the patient to have to sit in the chair a whole hour there, waiting for the cream to take effect before even beginning his tx. That would hardly be fair to the patient OR the staff. So I can understand that now, in retrospect.

I would still ask them, however, if it would be possible to use the spray I mentioned... perhaps they could order it for him...have his doc write him a Rx. I'll look again this week and get the name.

[jackib]

Hi,
Sounds like you need some cooperation from the dialysis unit.
Could you suggest that they have a diagram of the access that travels with the patient to and fro and that they mark on the diagram where they want the cream for the next dialysis.
Our patients that use that cream just apply it at home and wrap their arm in cling wrap (that stuff you use to cover salad bowls etc to keep them fresh) - that's what we call it in OZ.

Hope that helps

[Browneyedgirl]

I used to work as a dialysis tech years ago. Lots of the patients used the lidocane spray. I've also worked in a nursing home and know how overworked the nurses can be there. Have you taken this up with your Director of Nurses?

I agree that this is something for the dialysis staff to attend to.

[TNcanNURSE]

Very weird to be reading this post now.....

I work in a subacute unit at a local nursing home. Last night one of my patients was asking for her "cream" because she had to go to dialysis this morning. This would be the emla cream. She keeps it with her personal stuff and we aren't required to apply it. I had never heard of it until 10pm last night. She takes it with her and they apply it at the dialysis clinic.

After reading your post, I am very glad we don't have this task included with our other duties. I don't think you should have to do it either.

[jnette]

OK... here's the name of the spray, NightOwl ...

Gebauer's Ethyl Chloride... a skin refridgerant. And it works beautifully ! The one patient that uses it swears he doesn't feel a thing ! So much quicker than the cream.. you spray and stick !...and every bit as effective. His daughter is a doctor, so I'm sure she gives him what works best.

TincanNurse.. the lady who applies hers at the dialysis unit... how long does she have to wait to be cannulated? Apparently the cream is supposed to be on the skin for an hour before? Makes me wonder if she sit there for an hour or what? Could you find out for us? Thanx !