= BUTTONHOLE TECHNIQUE - The definitive quide =

[jedimaster]

I have been on hemo for 6 months and my fistula looks like a "snake"....the holes are not bad, but I care....I'm not ashamed of my fistula and I don't care what people think or might think the way it looks....keeps me alive so I can enjoy my son everyday and try to do some good in between...agree with Epoman...vanity not a good thing....these are our battle wounds!

[angieskidney]

Epoman may be harsh but he speaks the truth. Not one for tact but he also won't scare us. I had posted a horrible fistula pic (just a reality shot of the worst I have seen in my dialysis unit) and he took it down. Why? Because Epoman doesn't want to scare us. But it is true that you also can't be vain. If you want to live you have to choose an option. PD = you have a catheter sticking out of your abdomin, HD = you have a snake under your skin. Well not a snake but a fistula. If you do the ladder technique or buttonhole, either way it won't be pretty. The constant cannulations leave scarring which make people notice and assume you are a druggie and as it grows it becomes easier to use in dialysis but may creep other people out who have never known anyone without kidneys before.

I too didn't want mine to be big and so far it is not. But I am going for buttonhole because I am already developing scar tissue and I want to keep my fistula working instead of getting blocked by tissue and having to make yet another one. I figure the lease fistulas I have the better right?

Here is mine:

[kitkatz]

OKay so, the graft I have has some hematomas and sometimes looks obnoxious. Black and blue colored. So what!  My battle scars are proof I still am alive and kicking!

[MattyBoy100]

I thought the pic was small, have changed it now.

I can't help being a bit vain guys.  I still care about how I look and have some pride in my appearance regardless of dialysis.

[Epoman]

I thought the pic was small, have changed it now.

I can't help being a bit vain guys.  I still care about how I look and have some pride in my appearance regardless of dialysis.

And you don't think, we have pride and dignity? Of course I understand where you are coming from. I am just getting you ready for the inevitable. Try sitting in a wheelchair for 5 years like me and having everyone stare, like I am some freak. I really used to care, and the only time I try to cover my arm up is when I am at my sons school because the kids can get really curious and it's hard to explain to young kids about dialysis, and why I have this weird ass looking arm.

Tell you what, we'll bump this thread 10 years from now and we will see how important your arm looks to you is. 

[renal30yrs]

I personaly find buttonhole technique the best thing happened since slice of bread.

[brenda]

I'll agree with that. I have just started getting a buttonhole established. I think about 5 times now I have used it. I never even heard of such a thing before IHD. I asked at my unit and apparently they have been doing it for about 2 years she said. One of the disadvantages of being a home patient. I would have quite torturing myself long ago had somebody told me about buttonholes. It's just way too easy.

[Gram2Twinz]

My husband began HD in center with Davita in July '07. The Home Hemo NxStage system was new to this area, so we decided to begin classes. the in center nurse began establishing his first set of buttonholes (BH) in late August.
Here's a few tips we have learned-
Make sure when they begin the BH- the placement is very important.
If you intend to self-cannulate you need to have the BH placed in such a way that it is easy for you to reach comfortably and it is is an area of your fistula that has great flow space. 
Make sure that the staff that is beginning your BH will be the same one each time. This is very important because each needle placement should be done with the same angle and pressure. (Our nurse had a difficult time and had another staffer come and do the stick. Not a good idea, but they were eager to begin treatment and not very experienced with the procedure.)
Insist that you get the same person. It is your "lifeline", your decision not theirs. If you must, talk to the center director and let them know you understand the procedure and the process required to establish a "good" BH.
Also, it is important to know if your center offers home hemo. If they do, will they require you to have 2 sets of buttonholes? If that is the case, our experience is to have both sets of buttonholes well established before beginning the training for home hemo. If you have to try to get BH established while training, you may experience delays due to problems with your BH.
All centers have different protocol for this relatively new procedure- BH, so ask questions, you'll be glad you did!

[karen547]

I don't understand why people would stick their needles in the same place each time- My techs always rotate to help with the bumps plus to prevent an aneurysm.

[glitter]

I don't understand why people would stick their needles in the same place each time- My techs always rotate to help with the bumps plus to prevent an aneurysm.

maybe you should read this thread from the begining..it explains why this technique is used, its almost painless for starters, and the trauma on your fistula is alot less..

[KR Cincy]

Karen, it's all part of the continuing advancement in what we know about this stuff. The experts thought for years that the rope ladder was the best way to go...move the sticks around so the vein has time to heal itself. Now, the buttonhole is gaining popularity here, though it's been used in Europe for awhile. You build the little tunnel to your fistula, saving on the pain of a sharp going through your skin, and stick the same place. If you are on home hemo, they want you to have at least 2 buttonhole sites for arterial and venous to give a bit of time for the vein to heal since we go 6 days a week. I'm having less problems with my rope ladder than I thought, I don't use any creams or sprays, but I have a great fistula and my wife hits it first time almost every time, so I'm not rushing to buttonhole...but that's just personal preference.

[karen547]

I dpn't use cream or spray and find it doesn't hurt that much less/more if I use cream or not...

[Black]

... If you are on home hemo, they want you to have at least 2 buttonhole sites for arterial and venous to give a bit of time for the vein to heal since we go 6 days a week. ...

My husband Mike does 6 days and is still using the same holes that were made in his initial sticks on his first day of dialysis 2/5/07.  His buttonholes heal so fast there is no way he could keep two sets functionally useable.

[kidney4traci]

In center for almost 3 years and they did the ladder, and I did have an anurism (sp?) and my arm looks worse because of that and the resulting scars than from the buttonhole.  Have had the bh now since May, and have had no problems.  And it does heal faster, my bleed time is leterally less than 30 seconds. 

[jollor]

I was curious about when you can start buttonhole. I've been on dialysis for a little over a year now and I was wondering if it's still possible to start buttonholes if you already have scars from a years worth of sticks. They've never offered buttonhole before but one of the patients has been asking about so now there goint to try it on him. He'll be first one at my center and if I can I would love to be the second. Thanks for all the help guys.

[kruep]

You can start button holes at any time better late than never.  I always started my new fistulas with them.  Any time that I got a new patient in the unit I started button holes no matter how long they have had their fistula.
kruep

[jollor]

Cool thanks for the info. Well I guess I'll see how they do with this guy at my center since he'll be the first one. One interesting thing I found out is that even after the buttonholes are started it will always be one of the staff that does the sticking.

[dialysisguy]

Coming from the East Coast, I never heard of buttonholes. When I started working in Oregon I was introduced to buttonholes. It is now 2 years later and I'm still not 100% sold on this technique. The reasons are 1) Many of my people find it more painful than a sharp. 2)To many RN's or techs use different angles creating a track which is hard to follow 3) It does not always eliminate the formation of psudo-aneurysm.
  Some of the suggestiions I have are everyone should be able to discribe the parculularities of their buttonhole and use a hand lotion on the sites before coming for a tx. Cover it with plastic wrap. It is much easier to remove the scab, I also find that the scab will often rub off when washed before we start.
    Our unit has started to create a second set of buttonholes. The recommendation being that we should rotate sites.

[Black]

Cool thanks for the info. Well I guess I'll see how they do with this guy at my center since he'll be the first one. One interesting thing I found out is that even after the buttonholes are started it will always be one of the staff that does the sticking.

If you want to do your own, which Epoman highly recommended, then get your neph to write the prescription, requiring them to teach you to do it yourself.

[petey]

My husband has been on hemo for 13 years, and we never heard of buttonholes until we started training for home hemo (last summer).  We were always told that he had to have the alternating "rope" sticks to make his graft and/or fistula last longer.  The trend now seems to show that a BH will make the fistula last longer -- my, how things change.  Of course, a lot of other things have changed in protocol since he first started.  I don't think they can do the BH with a graft because the site wouldn't close up in a graft like it does with a fistula (not sure about this -- Marvin has a fistula).

Marvin had his current fistula for two years before we started the home training and the BH.  The same nurse stuck him every time to establish his BH.  She made me "fake" stick him the first day to see the size of my hand when closed on a needle, the angle that I stood in front of him, etc. and then established it according to what she thought would work best for me (and, ultimately, for him).  She stuck him for the first week of home training, and then I took over.  It was really easy for me to learn, and I'm not a medical person (a high school teacher, thank you very much); in fact, that was the first time I ever put a needle in.  (BTW, I'm now giving him his EPO shots, too!)

Marvin swears that the BH is the way to go.  He still uses cream for numbing (he's a little bit of a baby when it comes to pain -- but, the poor fella has been stuck so many, many times, I don't blame him).  We have found that his bleed time after tx is shorter with the BH.  Marvin had to be hospitalized at Duke Hospital (Durham, NC) in December, and his neph wrote in his chart that I was to be allowed in the hospital's dialysis unit (a first for them) and I was to stick him and pull his needles (another first for the hospital).  I felt really special -- and only one nurse gave me a nasty look because I was the one sticking and pulling.  But, I didn't care -- it's my husband and now, damnit, it's my BH.

I didn't tell Marvin until it was all over, but the only thing that made me nervous during the home hemo training was sticking him.  Of course, that first day, I took the needles and winked at him, and he thought I was totally comfortable with it.  On the inside, I was scared to death.  I was scared I'd infiltrate his fistula (and he hated when a nurse/tech infiltrated!! ).  After a couple of times, it didn't scare me any more.  Now, I'm a pro at it.  I haven't infiltrated a single time .  (Watch me now -- I've probably jinxed myself and will screw it up tomorrow.)

[cherpep]

Hello!  I am a new home hemodialysis patient after being in clinic for almost a year.  I began training for home hemo on 2/4/2008.  On that day, we started sites for the buttonholes.  It has now been 5 weeks using the sharps.  I attempted on a couple of occasions to use the blunt needles, but each time they could not pierce through the fistula, no matter how hard I push it.  I am going to try again with the blunts tonight, here's hoping for success! 

I do have a couple of questions - has anyone else ever experienced this difficulty?  Also, are there problems in using the cutting needles on the same insertion sight for a long period of time? 

Thanks in advance for your help.

[petey]

Hello! I am a new home hemodialysis patient after being in clinic for almost a year. I began training for home hemo on 2/4/2008. On that day, we started sites for the buttonholes. It has now been 5 weeks using the sharps. I attempted on a couple of occasions to use the blunt needles, but each time they could not pierce through the fistula, no matter how hard I push it. I am going to try again with the blunts tonight, here's hoping for success!

I do have a couple of questions - has anyone else ever experienced this difficulty? Also, are there problems in using the cutting needles on the same insertion sight for a long period of time?

Thanks in advance for your help.

cherpep -- For Marvin's buttonholes, the nurse established it with sharps for five days.  Then, I took over with blunts.  We didn't have any problems with blunts (used them almost six months) until he had to go back in-center for six weeks (antibiotics on the machine).  Then, the in-center nurses allowed me to cannulate, but I had some trouble.  I think it was switching from six days a week to only three.  It was like his track wanted to close up between treatments (the Tuesday treatments were the worst -- having to go since the Sat. before without a stick).  I found myself putting a little more pressure as I was sticking, and, usually, I could get it to go in.  However, I did have to revert to sharps a couple of times.  We were told that you had to be very, very careful with the sharps because they could damage the track (going in or coming out).  When I stick him with a sharp, I "thread" the needle (after I get a blood flash and I'm inserting it all the way in) very, very, very carefully and very, very, very slowly.  Hope this helps.

[kidney4traci]

I have used the buttonhole needles for 9 months now.  I have also had a few problems that my needle wouldn't go in, so I would revert to a sharp.  As Petey said, I would usually find this happend after a day off, as the skin does close up fast.  But when I would push in I would try to find the same track and it seems to help as I can go right back to the buttonhole the next day.  Since I do it myself, I can tell where the vein is and can feel not to infiltrate with the sharp.  This does not happen much, maybe once a month.  The problem as Petey mentioned is that you can mess up the track that the duller needle follows.  Keep up the practice, sometimes there needs to be a bit more pressure than you would think.  No pain though if you are in the right track.  Just more like pressure.  The protective flap inside the opening needs help to open up.  As it matures I bet it will be easier.  5 weeks sounds like there may be a problem, mine was established in aout 5 days too.  You really have to make sure you get the right angle, right everything everytime.  Again, it may seem hard at first, but it is really so easy once you get used to it.  Good luck, hope it gets going!

[petey]

Yes, kidney4traci is right -- you have to use the same angle and same direction every single time.  I stand exactly in the same spot as I'm cannulating Marvin.  I try to get him to position his arm in exactly the same place every time, too.  I hold my hand exactly like I did the time before (or, I try -- you know I'm not exactly, exactly on every single time -- but I'm dog gone close!).  It does get easier each time you do it.  I can "feel" if I'm in the track (if not, I back out just a little -- not all the way out -- and try again).  Marvin says I'm the slowest sticker in the world (nurses in-center would just pop -- needles are in! -- but, they weren't working with a buttonhole).  Also, I haven't infiltrated a single time (thank goodness -- Marvin HATES infiltrations!).  Once you get it down pat, it's a piece of cake!  We love Marvin's buttonholes!

[cherpep]

I tried using the blunts again last night, no success.  I sit in my chair in the same position each night.  I use the same hole for entry.  I actually look at a freckle on my arm as a direction indicator for inserting the needle.  When I use the sharps, I have no pain, and it goes in easily, good flashback, great pressures.  However, when I try the blunts, I push and I push and I push.  The blunt enters the hole, moves along pretty easily, but just doesn't pierce through the blood vessel.  I never get a flashback.  When I'm pushing, I'm really pushing.  My nurse has never seen this before.  I don't mind using the sharp needles, as they really don't hurt.  I'm just wondering if there is any danger in using a sharp repeatedly in the same place for a long period of time.  I know at the clinic, they always moved it around.