= BUTTONHOLE TECHNIQUE - The definitive quide =

[Epoman]

BUTTONHOLE TECHNIQUE


I have always known about the buttonhole technique since starting dialysis about 13 years ago, but I never used it because at the time I was kinda hesitant, then as the years went on I became more and more interested in it by reading more and more good things about it. I have heard many people say they love it.  Davita would however not order me the required needles to try it (you need "blunt" needles), I guess I really never pushed the issue hard enough. So just started sticking myself in very small areas, I never rotated sites, I always choose a spot very close to the spot of my last session. I did that for many years and have never had any problems. The Buttonhole technique has been around for over 30 years and is widely used in countries other than the U.S.A., for example the Kaiser where I was trained on the NxStage is just now starting to use the buttonhole technique on their patients according to the nurses. I myself started using the buttonhole when I started training for nxstage, and let me tell you I absolutely LOVE IT! I have ZERO pain when I insert the needles and all of my anxiety is gone, when I say anxiety I am talking about worrying about finding a "good" spot to stick that day. I started my buttonhole by sticking the spot in the exact same place 5 times with a "sharp" needle doing that creates the "tunnel" then I tried with a "blunt" needle on my 6th time and let me tell you if you don't line it up just right that "blunt" needle WILL NOT go through the fistula unless you add a lot of pressure. I never knew how strong the fistula becomes, it's amazing. Here is a picture of the "blunt" needle in comparison to a "sharp". I tell you a couple of times I have pushed very hard and the needle just slides right off or pushes the fistula inward and it just won't go in. Which is why many people develope a second set of buttonhole sites. If you do not have a second set of buttonholes then you can just use a "sharp" which I had to do a few times so far. I have also read that one buttonhole may develope faster than the other, for example my venous buttohole never gives me problem, but I have had to use a "sharp" a few times on my arterial. I think it is because I tried the blunts too soon, I should have waited and used the sharp a few more times.

It's really hard to believe, but it is very hard to pierce the fistula if you don't line it up correctly in the track. But when you do get it right it just slides right in. I have gotten it the last 4 treatments in a row, my buttonhole is developing great. I am so pleased, I really wish I had done this sooner. Here is a picture from medisystems the maker of the "blunt" needle. I always had wondered how people could sleep on nocturnal dialysis with a couple of sharp needles in their fistula, well with the blunt needles, it would take a lot to have the needles infiltrate your arm if you move while you sleep.

If you want to read the best literature with the most information I have found about the buttonhole technique, please open the .PDF file I have attached to this thread. See picture below to find out where to click to download the .PDF file of a very comprehensive article on the buttonhole technique.

It's a .PDF just under 400Kb but it is worth the wait. So please if you are interested please click the link for the .PDF

Here are some very small thumbs of the .PDF (this are just to show you an example of the contents of the .PDF file).

Again I can't speak highly enough of the buttonhole technique, It's to bad for years, nurses and techs in the U.S.A. were taught to rotate fistula sites, and NOW they see the benefit AND errors of their ways. I have spoke to many nurses and they all say they were taught to never stick in the same spot. And still to this day many nurses and techs are still very hesitant to use buttonholes, because for years all they heard was how bad it was to stick in the same spot. I remember just last month asking the techs and nurses at my old center (Davita) why didn't they use buttonholes on patients and they had no idea what I was talking about, all I got was puzzled looks from everybody. But I am glad to see that the buttonhole is getting more and more common.

[Mom3]

Thanks for the pictures of those needles! Seriously, since I'm not a  dialysis pt yet, I found it helpful,

Mom 3

[angieskidney]

Wow thank you Epoman!! I really wanted to see all this Now I will feel better prepared for when I learn this  as it is available in my city I have not been set up to learn it as my fistula still is maturing but I already was able to talk to the head nurse finally so hopefully it will be soon if my fistula doesn't blow anymore! When I watched the one guy doing the buttonhole technique I saw one time he had to go back to the sharp because one hole wasn't working. But I watched as he picked off the scab. Doesn't it bleed like crazy when you do that? Well, I will read the PDF Thank you Epoman!

[Epoman]

Wow thank you Epoman!! I really wanted to see all this Now I will feel better prepared for when I learn this  as it is available in my city I have not been set up to learn it as my fistula still is maturing but I already was able to talk to the head nurse finally so hopefully it will be soon if my fistula doesn't blow anymore! When I watched the one guy doing the buttonhole technique I saw one time he had to go back to the sharp because one hole wasn't working. But I watched as he picked off the scab. Doesn't it bleed like crazy when you do that? Well, I will read the PDF Thank you Epoman!

Does not bleed at all, not one drop. Sometimes you will just have to use a sharp, it happens. But the next day you should be fine. Yeah the PDF file is great, lots of history of the technique. You're welcome.

[Panda_9]

If you are using local with the buttonholes it can bleed. Just apply a bit of pressure with some gauze until it stops. If you cannulate without stopping the bleeding, it continues to bleed and creates a very nice moist blood clot, which encourages bacterial growth. I am only saying this because this does happen, but not to everyone. Not everyone continues with local once buttonholes are developed. I still do, as I still get some pain, and it makes it much easier to cannulate.

[Epoman]

If you are using local with the buttonholes it can bleed. Just apply a bit of pressure with some gauze until it stops. If you cannulate without stopping the bleeding, it continues to bleed and creates a very nice moist blood clot, which encourages bacterial growth. I am only saying this because this does happen, but not to everyone. Not everyone continues with local once buttonholes are developed. I still do, as I still get some pain, and it makes it much easier to cannulate.

I just can't imagine anyone having pain with buttonholes  I mean you are NOT piercing the skin, it's a HOLE. I believe you however, I use NO local and it is pain free. You are using "blunts" right?

[angieskidney]

When I do the buttonhole they don't offer the local through a needle here. I just will be using the Emla cream. But I have already given it some thought and I want to have it NOT 100% numb because I find it important to feel even with me still using the sharps now. The nurse asks me, "How does it feel?" So I figure it is probably better to feel it then not right? Or does it matter as much with the buttonhole and blunts? Sorry if this is a dumb question but I am just learning about this and my unit still hasn't talked about this with me.

[Panda_9]

I am using blunts yes. I dont get much pain with the venous but the arterial is very tender and becoming difficult to cannulate. I find with a bit of local it is easier for me to cannulate, as when I feel pain I resist, and it makes it harder to push through that pain. It also is painful to take off the arterial scab. It is the only arterial site I have ever used, apart from a handful of times having to use a sharp in another spot above it. I have tried the arterial without local before, because I forgot to use it, and it did hurt a bit more than my liking, so its just my choice to use it.

[BigSky]

Myself I use no local nor use buttonholes.  Never had a problem sticking myself.  Of course it doesnt bother me to let nurses stick me either.  Never has been an issue.

It is not uncommon though for some to still use local with buttonholes.  Everyones level of pain acceptence is different.  Do not know if its true or not, maybe its the urban legends of dialysis units , but that some units do not give numbing agents at all.

[Panda_9]

Theres no way I would use a sharp without local, they hurt enough as it is when the local wears off. I normally do have a high pain tolerance, but when Im doing it to myself its different.

[angieskidney]

I can't wait til they start doing buttonhole on me because they seem to make my fistula blow with the sharps

[BigSky]

I can't wait til they start doing buttonhole on me because they seem to make my fistula blow with the sharps

How long are they able to run before "blowing"?

[Panda_9]

OMG I am at least a bit happier now!! I toughed it out and didnt use local on either buttonholes. Arterial hurt a bit, but Im prepared to put up with it. WOOOHOOOO no more local!!!

[angieskidney]

I can't wait til they start doing buttonhole on me because they seem to make my fistula blow with the sharps

How long are they able to run before "blowing"?

Oh I never blow while running. It was always upon cannulation.

OMG I am at least a bit happier now!! I toughed it out and didnt use local on either buttonholes. Arterial hurt a bit, but Im prepared to put up with it. WOOOHOOOO no more local!!!

Congrats How long did it take to learn Buttonhole anyway? They still are not teaching me

[Epoman]

OMG I am at least a bit happier now!! I toughed it out and didnt use local on either buttonholes. Arterial hurt a bit, but Im prepared to put up with it. WOOOHOOOO no more local!!!

Congratulations! Now if you just learn to stick yourself, you will eventually have no pain. 

[Panda_9]

OMG I am at least a bit happier now!! I toughed it out and didnt use local on either buttonholes. Arterial hurt a bit, but Im prepared to put up with it. WOOOHOOOO no more local!!!

Congratulations! Now if you just learn to stick yourself, you will eventually have no pain. 

Stick myself? What?

Angie, I started doing buttonholes from the very beginning, about 18 months ago. So it only took as long as it takes to get the courage up to cannulate yourself. The nurses guide you all the way, and once youve found a good spot, you are pretty much set. Then its just a matter of practice makes perfect.

[angieskidney]

Angie, I started doing buttonholes from the very beginning, about 18 months ago. So it only took as long as it takes to get the courage up to cannulate yourself. The nurses guide you all the way, and once you've found a good spot, you are pretty much set. Then its just a matter of practice makes perfect.

Well they are slower moving in Canada (or is it just my city?). I have no clue when they will start me on Buttonhole but I have heard from one of the nurses that I would have to go on mornings instead of evenings like I am.

[Panda_9]

What? They are full of crap angie, why does it have to be on a certain shift? Your arms arent going to be any different from morning to night lol Unless there is only the same people on the morning shift everyday, that would be the only excuse I can think of. If you can do it yourself, you should be able to start straight away. I didnt have the same person training me every time, and my buttonholes are fine. I think I did start off with laddering until I was confident in cannulating, then I started buttonholes.

[angieskidney]

it is because the head nurse that does it is only on the morning shift. I have only seen her once or twice on my shift but only because someone called in sick and she had to pull a 12-hr day.

[Epoman]

OMG I am at least a bit happier now!! I toughed it out and didnt use local on either buttonholes. Arterial hurt a bit, but Im prepared to put up with it. WOOOHOOOO no more local!!!

Congratulations! Now if you just learn to stick yourself, you will eventually have no pain. 

Stick myself? What?

Angie, I started doing buttonholes from the very beginning, about 18 months ago. So it only took as long as it takes to get the courage up to cannulate yourself. The nurses guide you all the way, and once youve found a good spot, you are pretty much set. Then its just a matter of practice makes perfect.

Oops, sorry I forgot that you already stick yourself. 

[Panda_9]

it is because the head nurse that does it is only on the morning shift. I have only seen her once or twice on my shift but only because someone called in sick and she had to pull a 12-hr day.

Well that just sux!!! Theres no reason why she couldnt train the other nurses to do it. Its not hard!

[angieskidney]

it is because the head nurse that does it is only on the morning shift. I have only seen her once or twice on my shift but only because someone called in sick and she had to pull a 12-hr day.

Well that just sux!!! Theres no reason why she couldnt train the other nurses to do it. Its not hard!

Ya but with all the trouble they've already been having with my fistula I don't think I really trust them to start something new on me they just learned from the head n :-[urse

[slothluvchunk]

Great guide Epo!

Amber, Angie et al,

It is important to let only have one person develop buttonhole sites.  It does sometimes pose some scheduling concerns, because that means the same person always needs to be available to stick you, at least for a few weeks.

This is why you should begin sticking yourself with sharps, and be the only one to stick yourself while developing the buttonholes.
You are the only person who will consistently be there.
What happens when you travel down state-side and dialyze at a clinic who's never heard of it?  They typically associate buttonhole with "lifesites" and will sometimes not let you dialyze there.  I've run into this multiple times in California.

The trick I found was to simply tell them I stick myself, and that I bring my own supplies (don't even mention buttonhole).  Then take your own needles with you (ship them ahead of time or put in checked baggage obviously) and stick yourself.
Otherwise your buttonholes won't get used, and you'll have someone with God knows how much experience sticking your fistula with a sharp.

Not a good place to be in my not-so-humble opinion.

My $.02  (worth much less when adjusted for inflation)  <G>

[angieskidney]

Wow! I am getting more and more scared of travelling but now that my fistula finally has stopped blowing (they fixed it with the last fistulogram) I am getting ready to go to mornings to have the buttonhole taught to me. I am still scared to stick myself but as soon as the catheter comes out I can finally learn (I hope!)

[Panda_9]

Yes I know that sloth