Sharp vs blunt needles for buttonholes

[HubbysPartner]

My husband and I are finishing up NxStage training.  He is establishing buttonholes in his fistula.  After 4 weeks should his buttonholes be established well enough to use the blunt needles?  He is still using sharps and doesn't seem to be in a hurry to move to the blunts.  He says they don't hurt much at all now.  Is there any problem if he wants to continue using the sharp needles?  I guess I'm a worrywart concerning his fistula.  It has matured nicely and I really don't want him to have any problems with it.  Any advice would be appreciated, thanks.

[Hanify]

I talked to fistula users on the weekend who had been doing D for some time themselves.  They both said they continued to use sharps with their buttonholes and found it easier.  I think your husband should do what he feels best with.  Good on you both.

[del]

Hubbyspartner, I am hubby's partner too!!  He has had buttonholes for the past 3 years and uses blunts.  He does nocturnal so blunts are recommended because they is very little chance of infiltration if you bend your arm. If the sharps are going in easy without hurting then the blunts will work just as well.  We sometimes have to use a sharp to open up the tunnel but very rarely.  With blunts there is no tearing if you are not right in the tunnel because the blunt will not pierce the skin.  After 4 weeks using sharps the buttonholes are ready for blunts.  Hubbyspartner feel free to pm me if you have any questions!! 

[Pam]

I've had buttonholes for 3 mos. They used sharps for 1 month before changing to blunts. My venous has never been a problem but every once in awhile they have to use a sharp on the arterial. Don't know why but the arterial does move around a lot sometimes. Just make sure that no matter how small, if there is a scab to remove it first.

Pam

[Stacy Without An E]

I gave blunts a chance, I really did.  But an hour into treatment, they would start hurting to the point where I asked to return to the sharps.

They'll say, "Oh, after a while, the blunts will be painless.  You won't even need to use lidocaine!"

That's a load of uninfiltrated bunk.

Once, just once I let them place a blunt in without lidocaine.  Worst pain I've had in years.

Go by what's most comfortable and NOT by what your clinic says is "standard operating procedure" (my God I hate that phrase so much)

[HubbysPartner]

Thanks everybody!  We are going to stay with the sharps for now.  My husband feels more comfortable using them.  He sticks himself, so he knows when they go in.

[Bub]

The change from sharps to blunts happened very quickly for me, but the blunts still hurts a lot on the arterial stick.  On the venal (is that the right word?) no pain at all.  Don't knowl what the difference is.

[del]

Hubby has no pain at all with the blunts!! You do have to make sure the scab is completely off first or there is a very high risk of infection.  Do whatever you feel comfortable with.

[Wallyz]

The level of pain has to do with the proximity of nerve tissue to the entry site, so the issue is, do the blunts irritate the nerve more, or do the sharps?  If you are doing nocturnal, I would encourage you to use blunts just for safety.

[Hemodoc]

I have been using buttonholes for over 2 years.  I have an upper arm, brachiocephalic fistula, which has an S curve in it limiting the length of usable areas that are straight enough for .  My arterial is a poster child for perfect buttonholes.  It paradoxically hurts worse cannulating than my venous with a blunt needle than my venous which I must still use a sharp.  However, the blunt needle in an established buttonhole will reduce the risk of aneurysm formation which could limit the length of time that a fistula will last.

On the other hand, I have not been able to establish a stable buttonhole on the top, venous access site and just a week ago I had to change to a different location, probably my 5th or 6th since starting buttonholes with my venous.  I have also developed a small aneurysm at the venous site that is not present at all with my well established arterial site.

The literature reports 0% aneurysm formation with the buttonhole technique with blunt needles which is quite visible with my arterial vs venous access sites.  I have no doubt that the arterial will hold up for a very long time, but I do worry about my venous site.  The take home message is that if you are able to establish an excellent buttonhole with a blunt needle, it will likely result in less complications despite the fact that the blunt needle may be a little more uncomfortable to insert.  I simply grin and bear it while I am inserting the needle.  What choice do we have in the end analysis.  Enduring a few seconds of mild burning is a small price to pay.  In my mind, the mild, short limited discomfort is not fun, but if I can keep a healthy fistula for a longer period of time, then I wish I could likewise establish a blunt access with my venous as well.

Speak with your medical team and review all of the literature that you can find on buttonholes and make the best determination of what will give you the longest lasting and most effective access that you can get.  I have found the key to keeping my arterial buttonhole going is finding reproducible landmarks to guide my insertion at the same precise angle and entrance each time.  Just being a little off will render an established buttonhole unusable making a sharp entrance needed. 

The other issue with using sharps for buttonholes is that of "one-sititis" where the hole is enlarged by a millimeter here and there which can weaken the fistula wall leading to aneurysm formation.  In some cases like mine, you have no choice but to use sharps, but you will need to be very careful in entering the same exact hole each time.  It sounds easy, but in fact, without landmarks, you will find that you march in one direction or another away from the original hole.  In my case, that is what has resulted in the small aneurysm formation with my venous access and the need to change the buttonhole from time to time.  Once again, my wish is that the venous would have worked as well as the arterial despite increased discomfort with cannulating with blunts.  Its a small price to pay for a longer lasting fistula in my opinion.

Another issue is to pull the needles out the same precise angle as it is inserted. You should not feel the needle coming out at the end of the session.  I found that was the single biggest error that techs made when I was incenter.  I haven't seen any data on this issue, but it is easy to see how a sharp needle pulled out against the lining of the fistula could cause quite a bit of damage to the fistula over time.  I had only one tech that pulled the needle out the same angle every time.  She placed a band aide over the needle pulled half way out directly over the exit hole, then she taped a gauze pad firmly but not too tight at the site.  She didn't push down at all until the needle was completely out, thus keeping any exit damage to the minimum.  With the taped down gauze, there is very limited bleeding doing it this way without any pain as well.

What I see most techs do is to pull the needle out the wrong angle and press down on the needle before it is out of the hole, thus cutting on its way out.  It is actually quite simple to avoid this problem by pulling it out the same exact angle it goes in and not pushing down before the needle is out.  You should not feel the needle going out at all.  If you do, is cutting you on the way out.  My personal opinion is that this is an unstudied source of complications with fistulas.