Dialysis needles, self-cannulation, and the Buttonhole technique

[okarol]

Dialysis needles, self-cannulation, and the Buttonhole technique

For many people on in-center hemodialysis (HD), getting the needles placed is the most high stress part of a treatment. Lack of control over who puts in your needles can be a black cloud over your treatment days. Fear of someone new putting in your needles may even keep you from traveling. But you can reduce your stress and feel less pain by putting in your own needles.

If you plan to do home HD, learning to place your needles (self-cannulation) will be part of your training. Learning that skill ahead of time can get you over a hurdle and help shorten your training time. You can learn to put in needles with your left hand if you are right handed, or vice versa. You do need to be able to see and to move your wrist, hand, and fingers.

When you learn to put in your own needles, you are literally taking control into your own hands—that's a great feeling. In this article, we'll cover why it's best to put in your own needles, getting past the fear, how to put in needles, and the Buttonhole Technique.
Keep your access longer

You've heard that your access is your lifeline, and it's true. Each person only has about 10 sites that can be used to make a fistula or graft for HD access. So, it's vital to keep each one as long as possible. The best way to do this is to have one, consistent person placing the needles. And the only person who goes to all of your HD treatments...is you.
Access defined

A fistula is a direct link from your own artery to your own vein—all your own tissue—so it's less likely to get infected or clotted. It is the best type of access and most likely to help you live longest.1 A graft is a piece of artificial tubing used to link your artery and vein together. It is more likely to need hospital "tune-ups" to remove clots, and more prone to infection.

When your access is infiltrated (the needle punctures both walls of the access), blood leaks into the tissues and causes swelling, and often a painful bruise. The escaped blood can compress your access. This may cause stenosis (narrowing of the blood vessel) and/or a blood clot that could damage your access—or even cause it to fail.

When someone else puts needles in, they can only feel the outside of your access. Since your access is in your arm or leg, you can feel the inside and the outside. Plus, each person may use a different angle to put the needles in—while you would use the same angle each time.

Both of these factors give you a built-in edge that no one else has, not even a professional. You are much more likely to do a good job. Your access may last years longer if you put your own needles in (and this helps reduce your stress level). Some fistulas have lasted 30 years or more.
Getting past the fear

There's no question that it can be hard to get up the nerve to put in your own needles. But people who do it say that they must focus so hard on getting the needle in that it distracts them from the pain. So, it hurts much less, which is a plus.

* If needle pain or fear of needles is an issue for you—as it is for many—please be sure to read our article called Dialysis Needle Fear: Easing the Sting.

You can take baby steps to get used to the idea of putting in your own needles:

    * Start by watching while someone else gets their needles put in.
    * Next, try watching while you get your own needles—even just a glance at first, if that's all you can do. Look for a bit longer at each treatment.
    * Hold your sites at the end of treatment if you haven't been doing that.
    * Ask the staff if you can hold a needle to get used to how it feels in your hand.
    * Think about using a topical cream or gel to numb the skin over your access.
    * Ask the staff to teach you how to put your needles in.*

* Note: Some centers worry that they will be sued if they let people self-cannulate. Others say they can't allow it if they are not certified by Medicare for self-care or home dialysis. Neither of these is true. No center has ever been sued for letting patients self-cannulate. (Putting in your own needles is safer than having someone else do it.) Plus, Medicare supports self-cannulation as part of the Fistula First program to raise the numbers of people who have fistulas. No self-care or home certification is needed.
How to put in needles

You can learn how to put in needles by having a professional show you, step-by-step, what to do. It's more of an art than a science. There are few studies to guide how things are done. Each center does the steps a bit differently; it's best if you follow the steps the way your center or home training nurse prefers. Here are the basic steps:

   1. Gather your supplies. You'll need needles, gauze pads, tape (you'll tear a number of pieces to length), a tourniquet, a cleanser for your access, clean gloves, alcohol wipes, Band-aids, a sharps container (to dispose of used needles or syringes), etc. Have it all in one place, with tape pieces torn and ready to use, so things go faster. You may want to write a checklist (or your center may give you one) of all the things you need.
   2. Assess your access. Feel for the thrill (buzzing vibration) and listen for the bruit (whooshing sound) with a stethoscope. Your bruit should sound the same from one day to the next, and your thrill should feel the same. A higher pitched bruit or thrill that becomes weaker can mean a problem that needs to be fixed. Look for signs of infection, like pus, warmth, swelling, or redness. Never place a needle into an area of infection—you could spread it into your bloodstream. If you see signs (or have a fever), call your training nurse. Don't place needles into spots that are flat or bulging. Choose your sites.
   3. Wash your hands & access. Your center will teach you how to wash your wrists, hands, fingernails, and between your fingers, and to clean off your access site. Use the soap or antibacterial product they suggest. Dry your hands well with paper towels, and use a paper towel to turn off the faucet. Put on gloves.
   4. If you have a fistula, apply a tourniquet or blood pressure cuff. A tourniquet just below your armpit helps you see your access, keeps the vessel from rolling, and tightens the skin so it is easier to put the needles in. The tourniquet should not be so tight that it causes pain or makes your fingers turn blue! Never use a tourniquet during dialysis. Tourniquets are not used for grafts.
   5. Insert the needles. Your training nurse will teach you how to hold the needle and what angle to hold it at to reach your fistula or graft. In most cases, both needles will point up, toward your shoulder.2 You'll grasp the wings of the needle and avoid touching it to anything except your cleansed skin. (If the needle touches something else, throw it out in a Sharps box and use a fresh one to avoid infection). Touch it to your skin and slowly press forward until it is in the vessel. You may feel a small "pop" when it is in place. Some centers will have you attach a syringe to the needle with saline in it. Others will not. A "flashback" of blood in the syringe or at the hub of the needle once you hook it up will help you to see that you are in the right spot.
   6. Tape down the needles. You'll learn how to place tape to hold the needles in place. For nocturnal home HD, you'll use extra tape, a Tegaderm® bandage, or a similar dressing to hold your needles and tubing safely in place all night.
   7. Troubleshooting. If the arterial or venous pressures on the machine are high, or the needle is uncomfortable, it may be pulling against the wall of your access. Your training nurse will teach you how to gently move it to a better spot. You may need to tape a small gauze pad under it to help hold it in place at the right angle.
   8. Removing the needles after treatment. When your HD is done, you'll take off the tape, and slowly remove one needle at a time, putting pressure on the site after the needle is all the way out. (Pressing on the needle while it is coming out can cut your access). When both needles are out, you'll hold your sites until the bleeding stops, then tape them or use a Band-Aid® as you were taught.

Using the buttonhole technique

When needles are removed from your access, they leave small holes. Over time, with many treatments, those holes must be carefully managed to avoid damage. Too many needles in the same small area can cause weak spots that can "balloon" out to form aneurysms (the "lumps and bumps" you may have seen on a long-term access). In a graft, there is only one way to prevent this: rotating needle sites. But in a fistula, there are two ways: rotating needle sites or using the buttonhole technique.

The buttonhole technique is also called "constant-site cannulation." It's not a device; it's a different way of putting in the needles. Instead of rotating sites, you choose two sites (one for each needle) and use them only. At each treatment, you put the needles in exactly the same spots at exactly the same angle. In 8-10 treatments or so, scar tissue will form around the needle into a tunnel—like a pierced earring hole—at each site to guide the needles into your fistula.3 The small holes, next to each other, look like the ones in a button.

When this happens, you use special, blunt needles that are much less likely to infiltrate or to change the track. People who use the Buttonhole Technique say that it is less painful than using a sharp needle at each HD treatment and when rotating needle sites. Once the tunnels are formed, it is usually quite easy to place the needles. Research shows that you are less likely to get aneurysms with the Buttonhole Technique.4

To use the Buttonhole Technique, you:

    * Gather your supplies.
    * Assess your access.
    * Wash your hands and access.
    * Apply a tourniquet or blood pressure cuff.
    * Remove the scabs from the last treatment. Scabs can be removed in several ways, but moistening them first is most helpful. You can use tweezers, a washcloth or gauze to remove the scabs.
    * Insert the blunt needles. There should be no resistance when the needle slides down the tunnel. A little pressure will be needed to push the needle through the blood vessel wall. Excessive force should never be used to insert your needle. Call your training nurse for help if you run into a problem. Sometimes, you might need to use a sharp needle for one treatment.
    * Tape down the needles.
    * Troubleshoot if necessary.
    * Remove the needles after treatment.

Medisystems, which makes the blunt needles that are used for the buttonhole technique, has a helpful brochure and a video so you can see this for yourself. You can download the brochure here, or call 800-369-MEDI to order the Constant-Site Cannulation with Buttonhole® Needles video.
Conclusion

Putting in your own needles is a vital self-care skill that will help preserve your access so you can feel your best and have more control over your treatment. When you can put in your own needles, you always know that you have an expert cannulator close at hand. This can free you up to travel or think about doing home HD.
References

   1. Dhingra RK, Young EW, Hulbert-Shearon TE, Leavey SF, Port FK: Type of vascular access and mortality in U.S. hemodialysis patients. Kidney Int 60:1443-1451, 2001.
   2. Lewis C. Let's empower patients with the choice of self-cannulation! Nephrol Nurs J 32(2):225, 2005.
   3. Twardowski Z, Kubara H. Different sites versus constant sites of needle insertion into arteriovenous fistula for treatment by repeated dialysis. Dial Transplant 8:978-80, 1979.
   4. Kronung G: Plastic deformation of Cimino fistula by repeated puncture. Dial Transplant 13(10): 635-638, October 1984.

Copyright © 2006 Medical Education Institute, Inc. All rights reserved.

[Riki]

One fellow who dialyzes with me who put in his own needles and does the buttonhole technique.  There are days where I just watch him, because I find it fascinating.  I can't put in my own needles because of my eyesight and where my fistula developed (in my upper arm), but the buttonhole technique has me totally fasinated

[cookie2008]

I have buttonholes, I dont put my needles in my husband does, I turn my head.

[Hemodoc]

Buttonholes are relatively easy to create and maintain once you become familiar with the technique.  It is the only proven method for reducing the risk of aneurysm formation and there is some evidence that it will increase the longevity of your fistula.  The only way to really do the buttonhole is to have only one person doing the access since even small changes in the angle of insertion makes the buttonhole fail.  It is fairly common for incenter attempts to fail when multiple techs are doing the procedure.  Because of this, the buttonhole has some bad press but it is really faulty application of an incredible technique.  It is much underutilized and getting over the fear of self cannulation comes fairly quickly once you simply do it a few times.  I believe all dialysis patients that can self cannulate should for simple preservation of the access.  I have been using the same buttonhole on my arterial access now for over 3 years and I rarely need to use a sharp.  Buttonhole is the way to go, plain and simple.

[Riki]

If I could put the needles in myself, I would probably consider the buttonhole technique, but since eyesight isn't that good, and will only get worse as I get older, I don't think it's an option

[caringpct]

I have a patient that prefers to self-cannulate but has bad eye sight. I basically get everything ready for her hand her the needle and show her where the hole is. It works great. Ever now and then I have to assist but for the most part she does it all on her own.

I also have another patient that programs her machine, sticks herself, takes herself off, resets the alarms. I told her she should be on payroll 
She tried home hemo but did not like it.

[Riki]

Home hemo scares me, to be totally honest, but it's not offered here so I don't need to worry about it.. *LOL*

I do miss PD, though.. stupid peritonitis

[monrein]

I also have another patient that programs her machine, sticks herself, takes herself off, resets the alarms. I told her she should be on payroll 
She tried home hemo but did not like it.

That was me too.  I only needed someone if a dropped a pen or something.  We used to joke that I could come in and take a shift for someone.  I needed that independence and control back and a couple of other patients started self-sticking too after watching and talking with me.  My favorite though was the guy who got ticked off because he'd been waiting a while for the nurse to get to him so I jokingly said that if he did it himself he'd have been on already...darned if he didn't pick up the needle, stick it in and to his shock get it in correctly.  Nurse had to really hurry over then and hook him up.  Mine was a self-care unit so we all had to prep our own machines but very few of us self cannulated.

[natnnnat]

My favorite though was the guy who got ticked off because he'd been waiting a while for the nurse to get to him so I jokingly said that if he did it himself he'd have been on already...

This is exactly why Gregory learnt to self cannulate.  He said it was either that or wait for hours.  Some nurse had also said to him that he wasn't taking control of his situation, and he decided to show them! 

[Riki]

ok.. another dumb question... why do you have to wait so long?  I mean, if the machine is set up, and you're in the chair, why isn't someone there to hook you up. Where I am, they don't take us into the treatment area until the machine is ready, and they stay with us till we're hooked up.  It takes all of 5 minutes, as long as nothing happens.

[natnnnat]

Gregory says, they were too busy helping other people, people who couldn't help themselves.  The nurses said to Gregory, if you want to wait for us to help, you can but if you want you can learn to do it yourself.    So that's what he did.  Otherwise he reckons he would be waiting for an hour and a half... "a lot of the time".  I felt like this didn't answer your question Riki, so I asked him for specifics, and this is the picture I got (bear in mind this was in 1986):    He started out dialysing at the hospital, and later was moved to a satellite unit.  There were 16 chairs at the hospital.  and about 6 or 7 nurses, he thinks.  There was a waiting area out the front, and you would be sitting there before you went in, waiting to be called, while they cleaned the machine up from the last person.  Then when you went in and sat in the chair, they would get called away to someone else, and you would be just sitting there, waiting.  That's when they said, you can learn to do it yourself.  So they showed him how to go and get his needles, and cannulate himself.  He had one lesson from Lucy.  The second time, he did it himself, and got it right.  He says he blew the vein sometimes, but not from cannulating, only from the needle moving towards the end of the session, they were doing 6 hour sessions.  So to avoid waiting, he learnt to get his own needles and do it himself.  Mind you, he comments now, sometimes they were helping other people, sometimes they were just drinking coffee.  They were pretty lazy.    Eventually he knew how to get the bloodlines, the artificical kidney, get the machines, set it all up, cannulate, then when you were finished, wipe the machine down, the lot... that's missing some steps he listed which I didn't catch because he went too fast. 

Once he got to be able to do all that, they sent him to the satellite unit where people were all able to do it themselves.

[Riki]

I still don't really understand. Even the fellow in my unit, which is a satellite unit (all the units in my province are satellite units) who has the buttonholes and puts in his own needles, there's always a nurse with him while he does it.  Now there are 12 nurses, but only 4 are on each day, the team lead would make 5, but she's usually doing administrative stuff, but lends a hand when she's needed, and 9 chairs in the unit.  There's also a girl with a line who hooks herself up and does her own dressings, but again, there's always a nurse with her when she does it.

What they would generally do with me is, they call me in and get my weight, then tell me which chair I'm going to.  They put the bp cuff on me and start it up, and I sit down.  While the bp cuff is doing it's thing, they will go get needles, tape, saline syringes, and anything else they'll need.  Then I'll stand, and they'll take another bp, and listen to my lungs.  When that's done, I'll sit down and take the tagaderm that's covering the emla cream on my arm off, and the nurse will clean it, first with a warm wash cloth, then a bit of alcohol gel.  They'll feel and listen to the fistula, then clean it with betadine, because I'm allergic to chlorhexidine.  Once that's done, they'll put the needles in, tape me up ond hook me up to the machine.  Sometimes they'll ask if I want the remote for the tv or a blanket.  I usually say no.  I have my ipod.  They don't leave me during hookup unless someone crashes or something like that.  It would have to be something big, where all 5 nurses are needed before they would leave someone.  Also, since I'm on the afternoon shift, and the sooner they get me on, the sooner they can get me off and get home themselves.

[monrein]

Riki, I did everything except tear down my machine at the end.  I'd arrive, they'd point to my machine (individualized for dialysate, but I'd always check personally to be sure it was correct) then I'd get my lines, saline, syringes, heparin, etc., set up the machine, get my weight and BP, chart stuff, heat up my food or tea (sometimes I'd ask someone to do this later if I didn't want it right away), get settled, do my needles, sometimes I'd draw blood if it was time for lab work, put in needles, hook up, get blood pump up to speed, check and chart BP and wait out my time.  The only other thing I didn't do was give myself an iron infusion when required from time to time.  At the end, I pulled my own needles, etc etc., charted everything and was on my way.  It was nice to know that if anything went wrong, the nurses were there to lend a hand or simply answer questions.  I'm in Toronto by the way and this was a self care clinic at Sheppard and Yonge.  I did five days a week, with buttonholes, no more than one day off in between sessions.

Some units are different in that patients can go in, sit down, get themselves organized while they wait for a free nurse to hook them up and a wait can happen if a patient presents with cannulation difficulties.

I think units vary greatly in the US also.

 

[Hemodoc]

Monrein, that is amazing that you can do 5 days a week incenter in Canada.  America is so far behind the rest of the developed world.  If we had self care incenter in America 5 days a week, the survival here would improve dramatically.  Truly amazing.

[Riki]

I don't hink we're allowed to draw our own bloods, because the nurse who took them has to sign the reqs and inital the vials.  The fellow who puts his own needles in doesn't take the blood.  One of the nurses has to do it for him.  I don't think I would like a self care centre.  I prefer that the nurses do everything

[Hemodoc]

Actually, once you learn how to do the fairly simple procedures, you might prefer to have the control over your treatments.  Anyone that has medical experience I am sure would feel better doing it themselves as I do.  I have done my own lab draws from the time that they allowed me to do self care incenter.  I do know that many people are uncomfortable and prefer the nurses to do everything, but for that that want to learn, it shouldn't take that long to learn how to do it correctly with a good teacher.

[Riki]

if my eyesight was better, I might consider it, but I know that the nurses will not let us set up machines and draw blood.  I prefer the nurses to do the needling simply because I don't think I would be able to feel or see my fistula well enough nor keep my arm straight while putting the needles in

[monrein]

There weren't too many of us doing 5 days a week Hemodoc, but I wasn't feeling great on 3 days so I asked the nurse supervisor if the clinic would have the room to give me two more slots, she said yes, I spoke to my neph and increased my frequency within a week or so.  Self care is a great idea IMO for several reasons.  I like the control and the independence, it's better for our bodies (nocturnal is best and that's what I'd do if I had to dialyze long term) and it's more cost-effective.  Win, win win and even if people can't do their own needles, almost everyone really ought to be able to set up their own machine...certainly not a big deal. 

[Hemodoc]

That's great Monrein that they allowed you to increase without a specific medical condition.  Even then, they only give one additional treatment for 4 a week.  I really haven't heard of incenter patient with 5 days a week here in the states.  Canada is still way ahead of the game.

[RenalSurvivorDotCA]

I've been putting my own needles in for about three years now. The nurse just stand over and watch and assist as needed; usually taping me up and hooking the lines. One time they were super busy at change-over time (noon) and I had scrubbed up and was ready in my chair. So I figured I was soon going to start training for home hemo and would do the taping and everything, so thought i would try to tape myself up after putting in my needles. I did everything and was sitting, flushing my lines every few mins to check if flow was still good and to prevent clotting. My nurse came over and said "Someone put you on already?" I said "Yep." She asked who and I said "You're lookin' at him."   

She said I did a good tape job for a one handed job.

[natnnnat]

I was thinking about this whole self cannulation thing last night, and I remembered some comments that I've seen on other threads as well as this one, that people with poor eyesight prefer not to self cannulate, and I think I've also seen comments where people just plain old said "brrrr, no way!"  But last night I realised, hang on, eyesight deteriorates with age.  In many people it does anyway.  And then I remembered my nana's hands before she died, how they shook.  In my slow, plodding way, it occured to me that eventually people might get too old to self cannulate.  You wouldn't have to be particularly old to start getting long sighted, my dad is only in his sixties.  I wonder when eyesight affects the ability to cannulate?  Regarding shaking hands, I asked Gregory, whose hands shake sometimes.  He his hands shook when he was cannulating but it was fine.  But he commented he thought older people would have problems, because their veins get smaller and harder to find.   

The thing that gets to me about this (and this reminds me of a comment BoutyHunter made recently  http://ihatedialysis.com/forum/index.php?topic=19602.msg332163#msg332163 about lack of attention to older people) is that segment of the population, if they did want the kind of control afforded by self cannulation, well maybe they can't have it.  I can't comment on people with poor eyesight, but older people, yes:  when we saw the standard of care in the homes and then the hospital she was in (cookie cutter, generic kind of care) Dad broke my Nana out of hospital and brought her home.

[okarol]

You might find this to be interesting.
It's a PDF file attached below and it's called "Cannulation Camp: Basic Needle Cannulation Training for Dialysis Staff."

[boswife]

dont know how i missed this one but very interesting..  Sort of makes me sad too though because hubbys buttonholes are established now, and they wont let me cannulate him at his clinnic and now since they're established, they're letting different techs cannulate each time.   It sickens me as this will go on for 3 weeks possibly before i can get trained at another unit and they'res nothing i can do about it till then.  Im trying my best to have faith (the nxStage nurses assure me it'll be ok that they are all trained over there to do button holes) but it's really bothering me..   Anyway, thanks so much for this article..  So helpful as always ;-)

[Bruno]

I'm fascinated by this thread so let me make a contribution. Firstly, age and eyesight don't matter (as long as you are not blind!) because for most of us as you get older there is some deterioration in your eyes...you end up with glasses for reading at least. So I'm 75 and need glasses to see my buttonhole...lucky me, I just happen to have the right pair for the distance required.
As for self cannulation, my centre uses a simple rule...they separate those who will from those who won't. If you won't (and there are plenty for many valid reasons...I'm not knocking anyone) the nurse will look after you.
But if you are prepared to try, a nurse will teach you how using the button hole technique. There are fewer of us in this section. We learn how to set up the machine, self cannulate, deal with problems, finish up and strip and clean the machine. After about 3 months we end up going home and dialysing in our own time.
But it is real hard being prepared to stick a needle in yourself so i deeply understand why people won't.

[Hemodoc]

I'm fascinated by this thread so let me make a contribution. Firstly, age and eyesight don't matter (as long as you are not blind!) because for most of us as you get older there is some deterioration in your eyes...you end up with glasses for reading at least. So I'm 75 and need glasses to see my buttonhole...lucky me, I just happen to have the right pair for the distance required.
As for self cannulation, my centre uses a simple rule...they separate those who will from those who won't. If you won't (and there are plenty for many valid reasons...I'm not knocking anyone) the nurse will look after you.
But if you are prepared to try, a nurse will teach you how using the button hole technique. There are fewer of us in this section. We learn how to set up the machine, self cannulate, deal with problems, finish up and strip and clean the machine. After about 3 months we end up going home and dialysing in our own time.
But it is real hard being prepared to stick a needle in yourself so i deeply understand why people won't.

Bruno, great post.  You are fortunate to have dialysis center the rightly promotes self care and home dialysis.