Evaluating the Effect of the Valsalva Maneuver on Invasive Pain During Arteriovenous Fistula Cannulation in Hemodialysis Patients

Arteriovenous fistula (AVF) cannulation is a frequent and essential procedure for patients receiving maintenance hemodialysis, yet it often causes moderate to severe pain and anxiety, which can negatively affect patients' treatment adherence and quality of life. Although pharmacological methods are commonly used to manage cannulation-related pain, they can be costly and have potential side effects. Therefore, there is increasing interest in simple, low-cost, non-pharmacological techniques.

The Valsalva maneuver is a physiological technique that increases intrathoracic pressure through forced exhalation against a closed airway, stimulating the vagus nerve and providing an antinociceptive effect. Previous studies have shown that the Valsalva maneuver reduces pain in various invasive procedures such as intravenous cannulation and spinal puncture; however, evidence for its efficacy during AVF cannulation in hemodialysis patients is limited and methodologically weak.

This randomized controlled, single-blind trial aims to evaluate the effectiveness of the Valsalva maneuver in reducing pain intensity during AVF cannulation among adult hemodialysis patients. The study also investigates the feasibility, sustainability, and patient satisfaction associated with the use of this maneuver.

Patients in the intervention group will receive training on the Valsalva maneuver and perform it during each cannulation session over 12 hemodialysis sessions. Pain intensity will be measured using the Visual Analogue Scale (VAS) immediately after each session. At the end of the study, patient feedback regarding the acceptability and ease of use of the maneuver will be collected through a structured form.

This study is designed to provide high-level evidence supporting a cost-effective, easily applicable, and non-pharmacological approach to pain management during AVF cannulation, potentially contributing to improved patient comfort and adherence to hemodialysis treatment.

Inclusion criteria

• Age 18 years or older
• Receiving hemodialysis treatment via arteriovenous fistula for at least 3 months
• No analgesic medication use within the past 24 hours
• Systolic blood pressure between 90-160 mmHg and diastolic between 60-100 mmHg
• Pain score ≥ 1 on Visual Analogue Scale during AVF cannulation
• Able to perform the Valsalva maneuver (no contraindications)
• No communication barriers or severe psychiatric disorders
• Provided written informed consent

Exclusion criteria

• Unable to correctly perform the Valsalva maneuver
• Failed first cannulation attempt
• History of acute myocardial infarction or malignant arrhythmia
• Aneurysm, infection, edema, or scar tissue at AVF site
• Pregnancy
• Voluntary withdrawal from the study at any stage
• Switching dialysis centers or requiring hospitalization during the study