why does established buttonhole cannulation suddenly not work

[NCspinner]

I have been cannulating my partner for home hemo (using blunt needles and buttonholes)  for almost two years now, and after the usual learning curve I've felt for the past months that those crucial buttonholes were working as they're supposed to and we finally had it figured out. Treatment went pretty much by the book with very few alarms, cannulation was predictable ... it's funny what constitutes a good day now vs. before dialysis started.
However, yesterday, out of the blue, although I used the same technique and everything else was as usual, I absolutely could not get the venous access cannulated. I made several tries with a rest in between, changed to a new needle in case a clot was clogging the tip ... nothing worked. Finally, afraid I was messing up the buttonhole with all the fruitless prodding, I gave up, turned off the cycler, and took everything down. No treatment yesterday.
I contacted our wonderful home hemo nurse. This morning (it's Christmas Eve, folks!) she came and stood by while I once again tried and failed to cannulate the venous with the blunt needle. We keep sharps on hand for times like this but I'm not trained to use them. She cannulated the venous (not through the buttonhole of course) in one try and got everything carefully taped up and connected to the cycler. Now treatment is almost done but she advised we "rest" the venous buttonhole and soothe it with cold compresses for a few days before trying to cannulate it again. Meanwhile she will come by as this morning to help get treatment started.
Of course I appreciate her help but I'm also so frustrated, angry and confused. She couldn't explain why a buttonhole that has functioned just fine for months should suddenly be impossible to cannulate (she had tried as well). Nor could she explain why or how it would recover after a few days and be useable again. This is part of the "black box" of home hemo that makes it--IMHO--very stressful, even as we're glad to be able to do it. I wake up every treatment day thinking, "Will it work this time?" The past couple of days just make that uncertainty worse.
THanks for any input. And oh yeah, almost forgot--Merry Christmas.

[cassandra]

Hi NCspinner, I have the same buttonholes for over 6 years now, and I still have times when I can't get the venous in? I usually 'soak' the buttonhole than for the whole day, and try again the next. If that doesn't work, I'll use a sharp. I really, really don't know why it happens. Sometimes after 'soaking' I'll 'find' a big lump of skin/meat in the BH. Sometimes not.
I now set a limit to stop trying befóre I get frustrated. Try again next day, then use sharp.


So learn to use sharps please.


No need than to get frustrated etc (very normal I would think, especially in the first years or so)


Good luck, strength, love, and merry Xmas to you too, Cas

[NCspinner]

Cassandra, thanks for your very helpful response. It's not exactly encouraging to hear that you still have issues with buttonholes after six years, but it helps to know that yours start working again after "soaking" (not sure exactly what that means; we were told to ice it).
I have asked the home hemo nurse to train me to use sharps as a fall-back for this situation. She is very busy right now and it hasn't happened yet, but I'll persist. I watched her cannulate the venous with a sharp on Monday and it was pretty intimidating--the procedure, her extreme care in placing the needle and in taping it up, then her strict instructions to my husband to stay in one position with his cannulated arm cradled on a pillow, all to avoid infiltration. (He hasn't had to do dialysis in center since we started this so he had kind of forgotten all that.) The treatment went fine and we got disconnected without mishap but I hope we're able to use blunt needles on both buttonholes again soon. The nurse is coming again today to cannulate the venous with a sharp because she thinks the venous buttonhole needs to "rest" after the two unsuccessful attempts.
Thanks again for getting back to me. It sounds as if you cannulate yourself, which is pretty impressive. My husband can't do that because he has familial tremor, and it has gotten much more pronounced in recent years.
All best,
NCspinner

[KatieV]

It may look intimidating, but using sharps isn't a big deal.  You just need to learn where the fistula runs.  I cannulate myself with sharps 5x a week!

[NCspinner]

Thanks! I understand this is the logical next step so we won't get stuck if (when) a  buttonhole SNAFU happens again. My husband says he's confident I can do it ... I'm the one who's not sure. THanks for your support, and best wishes for the New Year.
NCspinner

[PrimeTimer]

Keep trying. If you are not getting a "flash" it almost sounds like you are completely missing the buttonhole tunnel. And why would that happen? Because sometimes weight gain/loss or fluid gain/loss changes the angle and depth of where the buttonhole track lies inside. Makes me think of a little worm bobbing up and down in water. You might need to go in deeper or a little more left or a little more to the right, etc...you have to keep trying. Venous buttonholes can be pesky but don't despair. It happens. And then it gets easier. Sometimes a balloon job (angioplasty) is needed to open things back up. Might need a visit to the vascular surgeon for a looksy. 

[NCspinner]

WHen the blunt needle goes in, it feels as if the tunnel is there just as usual ... but there's nothing at the end. The needle slides in past the point where I usually get a flash. I've tried slight changes in the angle left or right as well as slightly deeper or shallower. Have been icing the access, will try again tomorrow  but nurse will be on hand to use a sharp if the blunt needle doesn't work on the first try.

[PrimeTimer]

That trap door to the tunnel can be a pesky thing. We once discovered that our whole approach had to be changed. Immediately after going in at our usual angle of depth and opening the trap door, we discovered that we had to quickly "flatten" out the needle before pushing forward. In other words, the whole track was very very shallow inside his fistula. It happens. Another time it changed where instead of having to push the needle towards his torso it had to be pushed more away towards the outside of his arm. Also make sure that you are holding the fistula in place by gently pressing your thumb and index fingers along the sides. Gotta keep it from wriggling away on ya.

[cassandra]

I happen to just read this article. Also read the comment from Dr.John Agar.


 https://homedialysis.org/news-and-research/blog/289-cannulation-for-solo-home-hemodialysis-my-technique


I personally would never cut the wings of, as I use them as stabelizors, and to stick the tape on.

[NCspinner]

This has all been so helpful. Last Friday, with the home hemo nurse (thank you, Janet!) standing by, I was able to cannulate both buttonholes with zero difficulty. Same thing Saturday and again today. All the comments are so true ... we're dealing with moving parts, not a foam arm with a plastic tubing vein like the one I practiced on during training. Another possible factor: I had been cranking the tourniquet  (we use it just above the elbow) as tight as possible to make the fistula really pop up. Janet said I was making it too tight. Easing off the tourniquet makes the flash smaller but it's still definitely there, and I wondered whether I was distorting the track somehow with all the extra pressure.

Thanks to everyone who offered input, and best wishes for 2019.

[justagirl2325]

My husband's button holes were like that.  I would be able to cannulate for weeks, then boom, nothing I tried worked.  The hemo nurses always got them, it makes you feel useless, stupid, inadequate and so frustrated.  They caved and gave us sharps (we were not allowed to order them.)  I'd get about 15 at a time and keep them at home.  Our rule of thumb at the end was try one blunt and if it didn't work, use a sharp.  They were scarier; I did infiltrate badly once, his arm ballooned and we stopped right away- within seconds.  Luckily he was fine the next day, just a bit sore.

[NCspinner]

Well, it happened again this week after almost a month of successful, uneventful cannulation since the debacle around Christmas. On Monday the venous simply wouldn't cannulate and my husband ended up driving to the center for a partial treatment using sharps. Yesterday the nurse came for the beginning of treatment and when neither of us could cannulate the venous with the blunt needle she gave me the sharp and coached me through the cannulation. It was really scarey, not helped by my husband's dismay and discomfort. Today is a day off but I already dread tomorrow. I'm losing sleep over this and, in some part of me, getting angry.

[cassandra]

Well, it happened again this week after almost a month of successful, uneventful cannulation since the debacle around Christmas. On Monday the venous simply wouldn't cannulate and my husband ended up driving to the center for a partial treatment using sharps. Yesterday the nurse came for the beginning of treatment and when neither of us could cannulate the venous with the blunt needle she gave me the sharp and coached me through the cannulation. It was really scarey, not helped by my husband's dismay and discomfort. Today is a day off but I already dread tomorrow. I'm losing sleep over this and, in some part of me, getting angry.

Do you use Emla cream or spray on the needle sites/buttonholes?


Makes a huge difference with the pain.


Love, luck and strength, Cas

[NCspinner]

He typically uses Lidocaine cream on the sites ... but because of some problem with WellDyne, the new meds provider since DaVita Rx went belly-up, he ran out of Lidocaine and used Aspercream instead.I believe the pain is as much mental as physical and Lidocaine doesn't do much for that. Because of the way his fistula is configured and the location of the buttonholes, the sharps need to be inserted at awkward locations. He needs to keep his arm straightened and immobile for the whole treatment. . Fingers crossed that I can get both buttonholes to work today, but I am not optimistic. A great thing to wake up and think about at 3 AM.

[PrimeTimer]

Hang in there, NC! My husband self-cannulated but needed my hands to guide...he has Tourette's and diabetic neuropathy. Stress? What stress?? hahahaha....uh....

[Cowdog]

Do some research on Stuart Mott and his methods. I use a variant of his touch cannulation with my buttonholes. I occasionally have to use a sharp when tracks and gates get out of alignment. My fistula is very deep (about 3/4") and sometimes the gate moves away from the end of the track.

[justagirl2325]

I feel for you. I've been there numerous times.  The sharps are scary as hell at first.  Try to relax before you do it.  I know it's hard but if I can do it (just an accountant) you can too.  After I got more comfortable with them I was better with them over blunts, my husband said they hurt less.  And understand there were times he'd let me try with blunts every five minutes for a hour or more - it was always his venous too.  Maybe he liked sharps better cause they were faster (most times the sharp worked right away or maybe two).

[justagirl2325]

I happen to just read this article. Also read the comment from Dr.John Agar.


 https://homedialysis.org/news-and-research/blog/289-cannulation-for-solo-home-hemodialysis-my-technique


I personally would never cut the wings of, as I use them as stabelizors, and to stick the tape on.

Ooh, I never thought of doing that, I hated those things.  I always held the needle past the wings. 

[NCspinner]

I really appreciate all the feedback on this topic. Today, after lying awake half the night imagining the worst, I was able to cannulate both buttonholes with the dull needles. I had a sharp handy but was SO HOPING I wouldn't need to use it because the brief walk-through with the nurse on Tuesday left me with so much to remember. She's very competent but she was also watchful and nervous as I made my attempt. There were lots of "don't do this, be careful about that" and warnings of how different this was from using blunts. The taping-up is different, the cautions against "any movement" once the sharp is in are intimidating. I notified her that we had managed okay today and told her that I really want more training if I am going to use sharps as a backup. She is seriously overextended (IMHOP) with the number of home hemo patients she has either in training or out there dialyzing at home, so we were lucky she was able to come by this week and bail us out.

Cowdog, thanks for your suggestion--I will certainly check out Stuart Mott.  Unlike your fistula, my husband's is very shallow, the contours quite perceptible under the skin. Somehow that makes it even more frustrating when the gate just isn't there.

Thinking positive about tomorrow. Thanks so much, everyone.

[NCspinner]

Haven't had to resort to sharps again (yet)  but the blunts simply aren't sliding in as slick as they used to. SOmetimes it's several tries before I find the gate. Not sure what's going on -- once he's connected the pressures are just fine. Icing the access seems to help but unless I remind him (AKA nagging) somehow he just doesn't get around to it. This seems illogical ... he's the one getting poked and it seems he would like to minimize the chance it will take me more than one try. I get really tired of being the grownup.
(This is supposed to be a place where it's safe to rant, right? AAAARRRGGGHH!)

[PrimeTimer]

If it ever gets to the point where you start saying things to each other that you'll regret, might be time for him to go to a center for his diaylysis. Save your sanity and marriage.

[PrimeTimer]

Haven't had to resort to sharps again (yet)  but the blunts simply aren't sliding in as slick as they used to. SOmetimes it's several tries before I find the gate. Not sure what's going on -- once he's connected the pressures are just fine. Icing the access seems to help but unless I remind him (AKA nagging) somehow he just doesn't get around to it. This seems illogical ... he's the one getting poked and it seems he would like to minimize the chance it will take me more than one try. I get really tired of being the grownup.
(This is supposed to be a place where it's safe to rant, right? AAAARRRGGGHH!)

Is it going any better now?

[NCspinner]

Hi--

I haven't posted for a while. It's been a long haul, months, to get back to fairly reliable cannulation using blunts and buttonholes. The original buttonholes simply stopped working after a period of off-and-on. (Here's another NOW THEY TELL US moment: Apparently this is common.) I never was comfortable trying to use sharps, had one  scarey, painful episode when the venous slipped out of place and the arm swelled up as soon as the cycler started.
It took weeks then as the home hemo nurse came for the beginning of every treatment and established new buttonholes, which meant 9 same-site cannulations with sharps before she could try the same site with a blunt.  Now we have three new established buttonholes, although one is always a little dodgy, and can plan our own schedule after months of working with the nurse's schedule. Don't misunderstand...she was and is wonderful.
It literally is one day at a time. As of this fall it will be three years on dialysis, as of the winter three years doing it at home.  If I feel resentful, all it takes to set me straight is the monthly visit to DaVita for the home hemo clinic to be reminded of what in-center treatment is like.