Buttonholes

[hillary]

I've had my buttonholes for 5 months.  I am in horrific pain every time my partner cannulates me.  This can't be normal. It's not pressure, it's stabbing pain.  I hate these buttonholes!!!  But my partner is afraid of using sharps on me. I can't cannulate myself due to my fistula being on my dominant hand and I can't do it with my left hand.

I thought the point of the buttonholes was that it was supposed to take away pain, not cause it.

[hillary]

BTW, I have had them looked at by my vascular guy and by my nurse and they both say they are not infected.

[Maggie and Jeff]

Maggie and I have used the button hole technique for over 8 years.

I think the main benefit of the button hole is fistula longevity.

Not so much pain reduction.

5 months is about the longest time we keep a button hole due to the pain of sticking.

I'm the sticker Maggie is the stickee.

I understand the fear of sharps.

When the pain get to be to much as you have indicated it's time to make new holes.

I like using a sharpe marker to mark the vain where I want the needle tip to go (don't push the needle through the ink thats how tattooing works)

I keep the marks fresh for about 12 days because it helps me hit the mark (vein)

after 8 to 12 good sharp sticks I start trying the dull.

If I miss no big deal just use a sharp and follow the hole made with the dull.

Maggie has track marks all up and down her fistula.

Some spots hurt to bad to use even with a sharp.

I have cried a lot over the years it is not easy to hurt the one you love.

But it is life saving and necessary.

Starting a new hole should start on Monday as we take Sunday off.

I like to take some time and pick the new BH location.

usually by sticking a new spot 8 or 9 times using sharps I will try a dull but not force the dull I just want to make sure I'm opening a straight track to the vein then use a sharp.

usually takes 2 or 3 days of this before the dull works.

even if I got a dull in yesterday it may not go in today don't force it.  Back away from the vein a mm wait 3-5 seconds gently try again and then use a sharp if it don't just go in.

I have less trouble these days than years ago but it is still nerve racking.

When the sharp goes in and you see blood don't stop pushing but gently raise the tip of the needle (to avoid infiltrating) as you slide the rest of the tip into the vein.

you can feel the upper ridge of the bevel clear the vein go about 2mm past that point and tape down.


I hope this helps I'll check back here as I would love to help  PM me and I'll give you my phone # if you'd like some moral support or what have you.

do keep gauze handy while using sharps.

We get up around 4-5 am central time and have to see the heart DR tomorrow.

We don't use or have a cell and will be gone from about 1:30 until 4ish

Hang in there

Maggie uses lidocaine and prilocaine cream and she says it helps alot.


One more tip ok 2 more

we use 15 gauge dulls we have found using 15 gauge sharps to start the BH helps the pain to be less once the BH is established.  of course when her fistula was less mature this was not so easy.

make the next set further up the fistula.

you have a red and blue clamp blue being up red being down regardless of the direction of the needle.

I have always put both facing up arterial (RED) first tape down then the venous (BLUE) tape down.

The fistula will last longer the more you use the upper part  to avoid a sonoanurisum (however you spell it)

[obsidianom]

WE don't use buttonholes . I use sharps on my wife. She rarely has pain. By the way the studies show there is no difference in fistula longevity with buttonholes. Sharps don't damage the fistula. For some buttonholes are ok , but they are not for everyone. Sharps with rotating sites are actually easier to do.

[Simon Dog]

sonoanurisum

pseudoanuerysm

[Maggie and Jeff]

obsidianom I'm not disagreeing with you.  I have meet a few people over the years with there original unrevised fistula.  One guy had his for over 20 years.  Both people were using the ladder technique with sharps of course.  One of them had always been in center the other was at home.  But I only meet them each briefly.

After 8+ years of cannulating Maggie 6 days a week (around 5000 cannulations if you count both needles) I have no trouble using a sharp.  I find the BH bleeds a shorter time upon removing the needles and is not likely it infiltrate.  As for longevity the vascular surgeon told us not to expect the fistula to last more than 3 years but now believes it may last a lot longer than that.

Would you mind citing a study or 2? For my own education and maybe others.
 

By the way the studies show there is no difference in fistula longevity with buttonholes.

Simon Dog thank you I'm not a great speller.

hillary Please post and let us know how things are going.  I think we all know this is not an easy road but it sure is a blessing.

[PrimeTimer]

My husband has been doing home-hemo for a year and self-cannulates and uses Buttonholes. His fistula is on his upper arm. He uses 15 gauge 1 inch blunts. He's in his 50's, has Diabetes, wears reading glasses and his hands aren't always so steady anymore but...he is able to do it and I'm his helper. Most days are painful but some days the needles seem to slide in almost effortlessly with little-to-no pain. We don't use any pain killer cream. We have both paid strict attention to the angles and depth he must use on each buttonhole so he can aim the needle in the right direction. In fact, I note the angles/depth in a journal because every time he has gone for a fistula revision or angioplasty, the angles seems to change. To help, he uses a bright floor lamp and I use a mini flashlight so that we can really illuminate his buttonholes (I always make sure the flashlight is swabbed with disinfectant wipes before each use and we BOTH glove up during the whole process). We always feel for his fistula, for the thrill and flow. After awhile, you start remembering angles and depth. We've been doing this for a year and still question ourselves..and still have anxiety but it eases up the more you do it. Took us several months before we stopped feeling so anxious and scared over it. But there is still a fair amount of anxiety, I think because of the fear of pain and blood. You want neither..

We have learned to make sure the buttonholes are dry from being swabbed with alcohol before needle sticks, otherwise the alcohol stings. Also, I help to guide his hand to the entry of the buttonhole (kind of a tandem stick) only without actually sticking the needle in but merely "pointing" it into the hole, then I hold the skin around the buttonholes "taut" to help keep his artery and/or vein from moving/sliding from side to side like a worm as the needle goes in and pushes against them. We also make sure that I put the tourniquet on before he cannulates. We've also learned that when his blood pressure is up or if he has more fluid on-board than usual, the needles hurt more and even the angles/depths of the buttonhole tracks can change but on the days that his BP is lower and he's carrying less fluid, the needle sticks seem to be a little easier and less painful for him. Either way, there always seems to be a fair amount of pain but there are actually days where the needles "go in like butter". We are methodical about the process, we never rush it and just take our time because the important thing is getting him on the machine so, once the needles are in, we know the hard part is over and the good part can begin (dialysis and removing fluid and toxins). Needle sticks suck, it is truly awful what dialysis patients must go through but once the needles are in, there is always a sigh of relief for the patient and their care partner Takes a while but we get use to it.

[obsidianom]

Am J Kidney Dis. 2014 Dec;64(6):918-36. doi: 10.1053/j.ajkd.2014.06.018. Epub 2014 Aug 8.

Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review.

Wong B1, Muneer M2, Wiebe N2, Storie D2, Shurraw S3, Pannu N3, Klarenbach S3, Grudzinski A4, Nesrallah G4, Pauly RP3.

Author information

Abstract

BACKGROUND:

The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain.

STUDY DESIGN:

A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded).

SETTING & POPULATION:

HD patients (both in-center conventional HD and home HD) using an AVF for vascular access.

SELECTION CRITERIA FOR STUDIES:

We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique.

INTERVENTION:

Buttonhole versus rope-ladder cannulation technique.

OUTCOMES:

The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality.

RESULTS:

Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, -0.76 [95%CI, -1.38 to -0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI, -0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections.

LIMITATIONS:

Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes.

CONCLUSIONS:

Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.

Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.


KEYWORDS:

Buttonhole; access-related infection; arteriovenous fistula (AVF); cannulation technique; chronic kidney disease (CKD); end-stage renal disease (ESRD); hemodialysis (HD); needling pain; rope-ladder; systematic review; vascular access


PMID: 25110302  [PubMed - in process] 

[obsidianom]

Clin J Am Soc Nephrol. 2014 Jan;9(1):110-9. doi: 10.2215/CJN.03930413. Epub 2013 Dec 26.

Buttonhole cannulation and clinical outcomes in a home hemodialysis cohort and systematic review.

Muir CA1, Kotwal SS, Hawley CM, Polkinghorne K, Gallagher MP, Snelling P, Jardine MJ.

Author information

Abstract

BACKGROUND AND OBJECTIVES:

The relative merits of buttonhole (or blunt needle) versus rope ladder (or sharp needle) cannulation for hemodialysis vascular access are unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:

Clinical outcomes by cannulation method were reviewed in 90 consecutive home hemodialysis patients. Initially, patients were trained in rope ladder cannulation. From 2004 on, all incident patients were started on buttonhole cannulation, and prevalent patients were converted to this cannulation method. Coprimary outcomes were arteriovenous fistula-attributable systemic infections and a composite of arteriovenous fistula loss or requirement for surgical intervention. Secondary outcomes were total arteriovenous fistula-related infections and staff time requirements. Additionally, a systematic review evaluating infections by cannulation method was performed.

RESULTS:

Seventeen systemic arteriovenous fistula-attributable infections were documented in 90 patients who were followed for 3765 arteriovenous fistula-months. Compared with rope ladder, buttonhole was not associated with a significantly higher rate of systemic arteriovenous fistula-attributable infections (incidence rate ratio, 2.71; 95% confidence interval, 0.66 to 11.09; P=0.17). However, use of buttonhole was associated with a significantly higher rate of total arteriovenous fistula infections (incidence rate ratio, 3.85; 95% confidence interval, 1.66 to 12.77; P=0.03). Initial and ongoing staff time requirements were significantly higher with buttonhole cannulation. Arteriovenous fistula loss or requirement for surgical intervention was not different between cannulation methods. A systematic review found increased arteriovenous fistula-related infections with buttonhole compared with rope ladder in four randomized trials (relative risk, 3.34; 95% confidence interval, 0.91 to 12.20), seven observational studies comparing before with after changes (relative risk, 3.15; 95% confidence interval, 1.90 to 5.21), and three observational studies comparing units with different cannulation methods (relative risk, 3.27; 95% confidence interval, 1.44 to 7.43).

CONCLUSION:

Buttonhole cannulation was associated with higher rates of infectious events, increased staff support requirements, and no reduction in surgical arteriovenous fistula interventions compared with rope ladder in home hemodialysis patients. A systematic review of the published literature found that buttonhole is associated with higher risk of arteriovenous fistula-related infections.


Comment in
Should buttonhole cannulation be discontinued? [Clin J Am Soc Nephrol. 2014]

[Maggie and Jeff]

Thanks obsidianom

So far Maggie has not had an infection in her fistula but one time we had a button begin to look like it had some puss in it so we abandoned it that day and rope laddered a few days before I picked a new BH.  I did express the puss that day and checked it the next day (pulled the scab) it seemed dry but we still let it heal over.


I do know having learned BH first sharps seemed scary a lot longer than if we had used the ladder from the start.

[Hemodoc]

I have used buttonholes for over 7.5 of my nearly 8 years on dialysis without a single  complication by God's grace.

It is in vogue right now to denegrate BH cannulation but I find it the best way to cannulate. Are there issues with infections? Yes, but many feel that is technique related. Stuart Mott has over 50,000 cannulations recorded with only one infection using his "scrubber" method for scab removal. I believe this will be the key to BH cannulation infections.

Should you use sharps continuously with BH? No, there are many potential complications that can occur with continuous sharps includiing increased risk of aneurysm formation. Local blood clots at the site of the BH are more common with sharps as well as enlargement of the BH.

I am not impressed with the recent BH studies. I have found that most nurses have no clue how to do BH correctly and if that is what is taught to the patients, it is no wonder that outcomes with infection are worse. BH cannulation is an issue that needs improved technique and I believe we know where to take this. I am looking forward to seeing Stuart Mott publilsh his work and hopefully soon.

BH cannulation takes time to remove the scab completely and you cannot force it. That is counter to the usual in-center experience where the nurses and techs are under great pressure and time restraints. In addition, I have seen videos on the internet where patients are VERY cavalier about technique, not using mask or gloves and paying very little attention to proper "surgical" technique with poor skin cleansing before inserting the needles. I am convinced that with proper technique, BH cannulation is a superior method to rope-ladder. Hopefully, we will be able to get those studies published to show statistically that is true.

[fuzzyL]

using button holes for two years now--we got to the point that the needle would almost drop in for a while,that is-then for some reason, it started getting hard to hit the artery one--it would take numerous tries which got very uncomfortable-so we started a new one with sharps and now back to blunts and that solved the problem for a while-but now its getting difficult and uncomfortable again-we are wondering if different physical conditions affect this

[Simon Dog]

I have been using button holes for 1.5 years with no problems.

When I started, I was told not to use a mask.   A month or so in, I got an email from the RN - "new policy, use a mask, do you need a supply?" and have been using them ever since.

[fuzzyL]

I too after over 2 years am disappointed by the lack of pain I heard about was supposed to happen with time--my main thought process is that it is unpleasant but not unbearable  so I know I can handle it

[Hazmat35]

I have been doing in-center treatment for almost 5 years now; and they have been using the button hole method on me for about 3 1/2 years.  I had two sets; but they had to put in two different sets; they just weren't working well.  But the two that I have now; have been working GREAT for over a year now! 

Occasionally, a scab will develop inside, and they have to use a sharp needle to get passed it, but generally, they slide in like 'butter'!. 

I still use the Lidocane cream prior to treatment; but when I forget to use it; I still get pain from the blunt needles.