HELP with buttonholes

[TaylorMN]

My husband began dialysis (hemo in clinic) in May of this year.  We tried PD over the summer and failed.  They began establishing buttonholes at the clinic a couple months ago, and we are now in our second week of home hemo training (yes it is overwhelming).  He has been a real trooper and has been putting the needles in (even the sharpies) even since the first day they started on the buttonholes.  He hasn't been able to get the blunts in recently so I think they may send him back to the clinic until he can either get the needles in or they can establish new buttonholes.  The sites that were chosen for the buttonholes may be part of the problem, and it seems that his veins like to move and roll.  Anyway, I just feel so sad and disheartened that we will again not accomplish what we wanted.  I really hate the thought of sending him back to the clinic.  I'm wondering from all of you . . . what suggestions can you give us on buttonholes and establishing and/or using them.  Do you have any tricks in your bag that might help us?

Thanks for any thoughts you have.  You all are such a wonderful support network. 

[Desert Dancer]

When I established my buttonholes, I spent an inordinate amount of time palpating to make sure I was dead center on top of the fistula. That worked for a long time but then my fistula went on the move again and does like to roll. What I do is get it into the right position, then I clench my fist to keep the fistula from rolling, unclenching once I'm in. Sometimes I think my arm is right where it needs to be but I can't find the door into the fistula. Then I just have to roll my arm back and forth in tiny, tiny increments, pulling the blunt almost all the way out and back in until I find it.

It took me a whole month of sharp sticks to get mine established. That might have been overkill but once I did switch to blunts I had no problems at all. On rare occasions my buttonholes will close up - I think it has to do with diet - and then I just sharp stick to open them, pull the sharps and insert the blunts.

You might think that once you had them established, that would be that, but it hasn't quite seemed to work out that way. You are, after all, dealing with an organic body with umpteen variables. It can be frustrating at times and calls for a lot of patience!

I wish you all the luck in the world; I am sure you will be successful in the end if you can persist. Keep us posted!

[MooseMom]

You might like to have a look at the forum at Home Dialysis Central; there is a cannulation expert there named Stuart Mott who is quite famous in dialysis circles.

www.homedialysis.org

But Desert Dancer is right...it does take patience, but by what I have been told, it is soooo worth it to be able to self-cannulate using buttonholes.

[mcclane]

You might like to have a look at the forum at Home Dialysis Central; there is a cannulation expert there named Stuart Mott who is quite famous in dialysis circles.

www.homedialysis.org

But Desert Dancer is right...it does take patience, but by what I have been told, it is soooo worth it to be able to self-cannulate using buttonholes.

What is the favourite mantra of jedi knights ?  Patience !!  I will x 3 on the patience.  You will need an inordinate amount of it.

I started button hole development in late june of this year, and to this date, I am still having issues with needles (I am getting better at the top hole, the bottom hole I feel like biting down on something hard while i jam a needle in it hard - that is how frustrated i am with the bottom hole).

I don't have any tricks with buttonholes, or else I would be writing good things about it.  What I do find helps somewhat is the amount of fluid that is in the body.  If I drain myself dry, I find it is much harder to poke thru, on the other hand if I am more on the puffy side with fluid overload is it abit easier.  Other than that, button hole is all about getting the angles right, and even though it is not 100%.

[ESRD Survivor]

When is the blunts not suppose to hurt in the buttonhole?  I still need Elma cream.  I tried once without it and nearly fainted! I've been establishing them since June.

[Hemodoc]

My husband began dialysis (hemo in clinic) in May of this year.  We tried PD over the summer and failed.  They began establishing buttonholes at the clinic a couple months ago, and we are now in our second week of home hemo training (yes it is overwhelming).  He has been a real trooper and has been putting the needles in (even the sharpies) even since the first day they started on the buttonholes.  He hasn't been able to get the blunts in recently so I think they may send him back to the clinic until he can either get the needles in or they can establish new buttonholes.  The sites that were chosen for the buttonholes may be part of the problem, and it seems that his veins like to move and roll.  Anyway, I just feel so sad and disheartened that we will again not accomplish what we wanted.  I really hate the thought of sending him back to the clinic.  I'm wondering from all of you . . . what suggestions can you give us on buttonholes and establishing and/or using them.  Do you have any tricks in your bag that might help us?

Thanks for any thoughts you have.  You all are such a wonderful support network.

It is quite common to need to use sharps periodically to keep a buttonhole going. I have both sharps and dull needles and at times will need the sharp. You should become familiar with using both to be able to stay at home. I have had to start new buttonholes with sharps at homes on a couple of occasions. Not a lot of fun, but not a big deal either once you are used to sticking your own fistula and know the angles and positions to use.

As far as the vein rolling, you need to develop a technique to secure the skin and fistula. At one point, my wife would hold the fistula above and below my needle insertion to stretch the skin and keep it from moving. I now insert my needles one handed by pulling down on the skin with my  3rd to 4th fingers and inserting the needle with my thumb and index finger. By pulling down, I secure the skin and the vein and it works well so far.

Some folks have different techniques to secure the skin, but it usually is a must do every time. Some folks have tight skin, but I guess I am just too fat for that. LOL

As far as position of the buttonhole, that can be an issue that you will need to discuss with your medical team. Please understand that the buttonhole technique was developed for people that had limited access sites so that they had to use a single "constant" site.  In such, just about any part of the fistula that is able to accommodate a needle will work.

In all things, time and training brings about the experience you will need to gain confidence. We all go through those scary moments when we ar elearning to do self care. Over time, it gets a lot easier once you know your own arm and how to access the fistula well.

Keep at it and work with your team. Hopefully things will improve for you soon.

God bless,

Peter

[Zog]

If they started the buttonholes in center they may have been inserting them at an angle that was easier for the nurse and not for your husband.  It isn't uncommon to start new buttonholes every few months.  Make sure he starts the next set of buttonholes or at least guides the needle while someone else pushes it in.  My wife makes new buttonholes about every 8 months.  I have to hold her arm the same way when she puts them in.  For one needle I have to press down on the fistula to make it bigger.  For the other needle I have to push it a little to the side so everything lines up.  It took a few tries to figure out exactly how to manipulate the fistula at first and there are some days when we have to use sharps.

This may be discouraging, but her last fistula never worked with buttonholes.  She had to use sharps everyday.

Keep working at it.  There is no one size fits all solution for fistulas.   Everyone's different.

[JohnJ]

I stopped using button holes after 18 months. They just wouldn't go through any more. I use the regular fistula needles with no problem. I am very careful and I have the advantage of being an Army medic years ago so sticking was easy for me. I was told by my vascular surgeon who used to be part of a kidney transplant team to not worry about using sharps. Some people's venous anatomy is just not conducive to long term use of button holes. As long as you are careful sharps will work fine. I've been on home hemo for just about 2 years now.

[Hemodoc]

I stopped using button holes after 18 months. They just wouldn't go through any more. I use the regular fistula needles with no problem. I am very careful and I have the advantage of being an Army medic years ago so sticking was easy for me. I was told by my vascular surgeon who used to be part of a kidney transplant team to not worry about using sharps. Some people's venous anatomy is just not conducive to long term use of button holes. As long as you are careful sharps will work fine. I've been on home hemo for just about 2 years now.

There are risks of using sharps long term to include more risk of aneurysm and developing an enlarged buttonhole which leaks while on dialysis. My fistula take a bit of sticking before I can use the buttonhole needles, but I always switch as soon as the fistula will accommodate a dull needle.  Yes, it is possible to use sharp needles on buttonholes long term, but most should be able to use the dull buttonhole needles with a bit of patience.

[JohnJ]

I guess I'll take a Vascular Surgeon and former renal transplant doctor's advice over yours.

[Hemodoc]

I guess I'll take a Vascular Surgeon and former renal transplant doctor's advice over yours.

Dear JohnJ, sorry, but I wasn't advocating at all that you change your technique or not take your own docs advice. Far from it.

However, when looking at the issue of sharps and buttonholes, there are several known complications of this when looking at a population of patients utilizing this technique. In addition, there are several reasons why a person will not be able to use buttonholes effectively, but in most cases, with problem solving that can be overcome. However, the buttonhole with dull needles is not a technique for every single patient as your own case demonstrates. If sharps works for you, by all means follow your own docs advice.

As I noted in my prior posts, I have used sharps for extended periods on my buttonholes since my fistula is thick walled and I ran into the problem of "trampolining" where the needle easily cannulated through the skin but just bounced off of the vein. That took quit a bit of time and attention to proper technique to finally overcome with time. However, I stand by the data that there are long term complications of using sharps. I myself have a small aneurysm on my venous buttonhole from this long term use of sharps. For this reason and due to the medical literature on this issue, for the majority of patients they should avoid sharps long term in a buttonhole. Here is an excellent review of the issues of complications with buttonholes. I hope that this helps.

http://www.esrdnetwork.org/assets/pdf/annual_meeting/2010_annual_meeting/complications_of_the_buttonhole_technique.pdf

God bless,

Peter

[tyefly]

I used the same buttonholes for two years.... and times I did have some problems getting the needles in....that is the blunt needles..... I never  once used a sharp in the two years that I did dialysis at home....  I found that because I had a upper arm fistula I had to tape my arm so I would stretch the skin to make it tight.....  some people have helpers who will spread the area to make the skin tight.....but I always did everything myself so I would tape my arm the same way  in the same spots each time.....  I used three tapes usually per buttonhole and would use a star type of formation so that the tape would pull the skin tight.... I do have some pictures if this doesnt make since....  After I would flash I would then light tape my needle down and take those tapes off.... I would then competely tape everything down..... I did nocturnal dialysis so I did alot of taping since I usually slept for 7 to 8 hours.....   a few times I had problems because I didnt get my skin tight.... to me it made a big big difference...... anyway....buttonholes in my opinion are the best way to go..... no pain but practice good clean cannulations..... 

[tony2911]

i,ve been developing my button holes for 13 weeks, we decided to leave the pegs out for one dialysis and to our amazement they healed up in just a day and a half, i,ve had to start over again with new buttonholes. can anyone give any advice why that happened, i get blunts in sometimes sharpes the others. i wondered if it was sharp needles causing damage on the way in and starting the healing process. HELP PLEASE 

[bevvy5]

Very timely topic. Hubby has been using the same buttonholes since March, never used a sharp although we have had a few sessions where we just couldn't get the needles in. 

We've been having a bit of trouble the last week or so and his nurse said she could either establish a new arterial buttonhole or teach us how to use sharps.  We're not quite ready to take either step but if we keep having problems, it will force a decision.

I cannulate him and frankly, the thought of using a sharp terrifies me.  Is there anybody here who does NOT cannulate themselves that has a home hemo helper cannulate with sharps?

[katieking1981]

We've been doing home hemo since April and I do the needles for my boyfriend.  We had trouble with the initial button holes early on and his nurse suggested that I create button holes. She said that they would be better, because they would be positioned perfect for how I put in the needles and how he sits at home. The 1st attempt didn't work,  I think that i over thought it instead of doing whet comes naturally to me. Since then they have been great.

In full disclosure,  I'm very comfortable with needles. I'm a vet tech and put catheters in dogs and cats. I know not the same,  but the experience does help.  I say that if you can get over the nervousness,  you'll be better off creating the button holes yourself.

Katie