Comparative analysis of the effectiveness of pharmacological and non-pharmacological interventions on arteriovenous fistula cannulation-related pain in patients receiving hemodialysis: A systematic review and network meta-analysis

BACKGROUND: Managing arteriovenous fistula cannulation pain in patients receiving hemodialysis is essential for ensuring patient comfort and promoting adherence to treatment. Various interventions have been proposed to alleviate this pain. OBJECTIVE: To evaluate the comparative effects of non-pharmacological and pharmacological interventions and to rank the best intervention options for cannulation-related pain. METHODS: A Systematic review and network meta-analysis were conducted. Five electronic English databases (Medline, CINAHL, EMBASE, Cochrane Trials, and Clinical trials.gov) were searched from inception until November 2023 to identify eligible randomized controlled trials. Screening, data abstraction, and quality assessment were performed by two independent reviewers. The Cochrane Collaboration risk of bias tool 2.0 was used to determine the risk of bias. Data were analyzed using RStudio with the netmeta package, employing a frequentist framework and random effects model. RESULTS: Twenty-four randomized controlled trials published between 2014 and 2023, involving 1704 participants, were included. The studies comprised 25 interventions, categorized into alternative/complementary therapies and local anesthetics. Compared to usual care, 11 interventions statistically significantly improved AVF cannulation pain: cryotherapy combine with visual distraction (SMD = 4.32, 95 % CI: 1.87, 6.77), visual distraction (SMD = 3.95, 95 % CI: 2.12, 5.77), lavender inhalation aromatherapy (SMD = 3.68, 95 % CI 2.63, 4.73), arnica ointment (SMD = 2.83, 95 % CI: 0.81, 4.85), auricular acupressure combine with compound lidocaine cream (SMD = 2.70, 95 % CI: 0.90, 4.51), lavender topical aromatherapy (SMD = 2.51, 95 % CI: 0.88, 4.14), lidocaine tape (SMD = 2.36, 95 % CI: 0.15, 4.57), cooling spray (SMD = 2.17, 95 % CI: 0.59, 3.76), EMLA cream 5 % (SMD = 1.80, 95 % CI: 0.48, 3.12), auditory distraction (SMD = 1.78, 95 % CI: 0.01, 3.55), and Hegu point acupressure (SMD = 1.52, 95 % CI: 0.04, 3.01). The P-scores and SUCRA rankings indicated that cryotherapy combined with visual distraction, visual distraction alone, and lavender inhalation aromatherapy were the top three effective interventions, respectively. CONCLUSIONS: Non-pharmacological interventions, particularly cryotherapy combined with visual distraction, visual distraction alone, and lavender inhalation aromatherapy, were determined to be effective in reducing arteriovenous fistula cannulation-related pain in hemodialysis patients. Integrating these interventions into clinical practice can enhance patient comfort during hemodialysis procedures. Further research is needed to explore individualized approaches and assess the long-term efficacy of these interventions. REGISTRATION: The review protocol was registered at PROSPERO (CRD42023475975).