Important protocol for first-time fistula users

[rctraymanusa]

So it's your first day with your new fistula how you protect it. It's important to have your vascular surgeon outline the path of the fistula, whether it's organic or GoreTex.  The surgeon should mark a rectangle around the best place to access the fistula in hemodialysis.  This rectangle should have the depth the fistula has been placed at the time of surgery.  So what you will wind up with is in ink.  A 2 inch or 3 inch long rectangle about a quarter of an inch wide, and next to it would be written a number mine says 2 mm, which is the depth of the fistula from the surface of my skin.  It's important to know that if there's any infiltration or swelling from this procedure.  I suggest that you immediately go to your surgeon and have the arm, observed.  The reason for this is that most techs in dialysis centers are used in treating long-term dialysis patients and have little experience with first-time fistulas.  Those people are generally found in the hospitals due to the fact that people suddenly are in need of dialysis.  When the kidneys fail during an operation, unexpectedly.  The techs in dialysis centers generally have long-term patients ,as opposed to beginners ,who have a series of track marks that they can use as their guide from previous needles.  As a new patient, you will not have this guide.  They used no tools to see where you're fistula is.  It's also important to request that they listen to your arm with a stethoscope.  Especially before you have your second treatment, this is to protect you from additional unneeded needles, should your organic fistula or your Gore-Tex fistula become totally blocked by the infiltration.  Remember, these people can do you great harm, unwittingly.  There is an institutional mentality amongst the staff of these dialysis centers.  They tend to be very protective of one another, they're underpaid, and the corporations that they work for many meet federal standards that can easily fall into budget cutting that will affect your health in ways that are not necessarily visible to the newcomer.  It's also important to know that the first day you sit in one of those chairs, You're no longer for purposes of insurance, a person that simply has diabetes.  You're now considered an individual with end-stage renal failure.  This is determined by many other companies and insurance plans as being a pre-existing condition.  You may suddenly become exempt from joining other hospital programs or insurance programs because of this clause.  So don't sail down the river denial.  Really research, what ever your options are before you sit in a chair.  When managed correctly, a dialysis center to make $20,000 a month per chair, if you have private and Medicare insurance.  That's $140,000 a year.  This is why, at least in Southern California.  There's tremendous pressure to get you into one.  If you have a fistula and you haven't considered PD peritoneal dialysis carefully look into that program.  Many large dialysis units only have three to seven people in PD.  Even though they may have 30 chairs or 90 patients a day.  This is because Medicare thinks very kindly of PD, and they'll make less money off of it.  A lot less.  Many nephrologists consider the chair as guaranteed treatment and don't even discuss PD.  You have your responsibilities, make them and look into what I'm suggesting.  Let me make it clear that this is only one person's opinion.  And I am not a medical practitioner.  But I have experienced everything that I've just spoken about in the first person.  I have found on my own facilities to get PD through what is known as a presternal chest catheter. This is a catheter that is placed by the sternum.  High in your chest but ends where the normal abdominal catheter goes.  It has a much lower infection rate, allows women to wear two-piece bathing suits, because the catheter can be tucked into the top, and you can take a bath.  You're still not allowed to get it wet.  After an arduous search in four states.  I have located a facility with all of the capability to offer me these services.  My surgery is set for Wednesday this coming week, March 10.  At last Success. I will drop back in and let everyone know how it's going until then, I remain, RCtrayman USA@aol.com

[MooseMom]

What's an "organic" and "gore tex" fistula?  I'll be getting my fistula in the next few weeks, so I need to know asap!  Thanks!

[monrein]

I'm guessing here at the difference between the two terms but I think that the poster is making a distinction between a fistula, which is created from your own artery being attached to your own vein, but using nothing artificial in your body...and a "graft", which is made from synthetic material like gore tex and is done when a person's veins aren't able to be used for an "organic" fistula.  I call one a fistula and the other a graft to differentiate the two.   One important difference is that you can use buttonholes with a fistula but not with a graft.


http://www.scsp.net/lflynn_av.shtml   

[MooseMom]

Yes, monrien, that's what I assumed. 

[Des]

I am starting D in a week or two and when I visited the unit they told me they do not use buttonholes as the scar tissue creates big "bumps" over a long period of time and this shortens your fistula's lifespan. Please tell me if this is true.

[monrein]

http://ihatedialysis.com/forum/index.php?topic=965.0

Here is a long thread about buttonholes. 

I've used both the laddering technique and buttonholes.  Both are fine if done properly and there's the important bit...done properly.  The first time I was on D I had a forearm fistula, and I laddered my needles.  The key here is to consistently go up the fistula, each time in a DIFFERENT spot, right behind where the last stick was.  When you run out of space, you start again at the bottom of the ladder and slowly work your way up again.  This is to avoid aneurysms or weakening of the walls of the fistula by sticking in more or less the same spot each time.  Sometimes the nurses take the easy route and stick where it's obvious and you might in the moment think that's OK too but in the long run it's not good for the fistula.  It can also be tricky if your fistula is a bendy winding one with dips and such.  My first fistula was dead straight and very even because I cannulated myself and religiously laddered up and down.  Many times, when a new unit or nurse saw my fistula they were amazed at the eveness of it but I was also lucky because it started out straight and I kept it that way.  In five years, no troubles.

Second time around, the nurses laddered (I told them exactly where to stick but this is difficult if you're start for the first time) until the fistula was mature and stronger.  A lower pump speed in the beginning helps the fistula to tolerate the process of dialysis.   I took over the laddering as soon as I felt I knew the peculiarities of my fistula, where it went deeper etc and then we started talking about buttonholes.  There was only one nurse in my self care unit who did buttonholes....and it is very important that there be consistency with buttonholes.  She explained how we would establish them, same spot, same angle every single time, using sharps until the tunnel was established then we'd switch to blunts which are pointed but with no cutting edges.  She and I were the only two who ever did my needling of the buttonholes and she followed my lead as to angle and direction since I was going to be the one to do it eventually.  No point her doing it from her position on the other side of me if I can't get my hand into the exact same position as hers.  Once I got the hang of how she did it, I took over and it went fine. 


Des, I think that your unit might not do buttonholes because they don't understand exactly how they work.  You need a nurse who has experience with them and the same person each time is crucial...hard in a unit where the same nurse each time may be impossible.   So the bumps they speak about are aneurysms which develop from sticking in more or less the same place but not exactly the same and this weakens the walls of the vein.  A true buttonhole is more like a pierced ear hole, except that once you're through the established tunnel you have to punch into the vein and it is usually painless unless you've established the buttonhole right through a nerve.  I had one like that but I was used to the sensation and so no big deal.  I never used cream or numbing because I found it easier to "read" my vein when I could feel what I was doing but this is an individual thing. 
Buttonholes are supposed to be easier on the fistula and lengthen the lifespan of it BUT they must be done correctly and if your unit has no experience then they won't be.  So, next best thing is consistent laddering using as much of the length of the fistula as possible.  I prefer the term laddering to rotating the sites since to some nurse, rotating means using a couple or a few spots only, alternating between them but this can lead to big aneurysms too.