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  • Button Holes

    Hello,
    My B/F is currently on short home hemo. He has a fistula is his left upper arm that is working pretty good far. He is currently using 15 gauge fistula needles and using the button hole technique. Just curious about if that is a good way to go ?..have heard some dont like the button hole technique...Also curious about anurisms in the fistula ..is there ways to prevent those or what there caused from or if there more common with the buttonholes..any info is appreciated...thanks

  • #2
    Re: Button Holes

    .

    BUTTONHOLE METHOD

    The constant-site method was used in another center in Poland on patients with either Cimino-Brescia fistulas or saphenous vein grafts with similar results.(9) Patients who were dialyzed more than thrice-weekly had two pairs of puncture sites which were used alternately because insertion at the same site on subsequent days was painful. Some of the patients who dialyzed only thrice-weekly also preferred two pairs of sites. Frequent dialyses (up to six times-per week) with the constant-site method not only led to no increased frequency of complications, but in some patients resulted in decreased complications due to improvement of uremic thrombopathy.(5) A few years later, Scribner reported his experience with the constant-site method in patients with Cimino-Brescia fistulas and confirmed all the conclusions of the previous study.(10,11)

    In 1984, Kronung presented an analysis of the consequences of single and repeated fistula punctures and the best technique to avoid fistula damage.(12) He found that each puncture causes elongation of the front wall of the fistula due to tissue displacement and the filling in of the hole with a thrombus following needle removal.

    According to Kronung, the consequences of repeated needle sticks depend directly upon the puncture technique that is used. If sticks are repeated in circumscribed areas (the "area puncture" technique), aneurysmatic dilatations develop in those areas, and stenoses develop in adjacent regions. Stenotic and aneurysmatic lesions tend to progress due to pressure and velocity distribution in accordance with Bernoulli's law of hydrodynamics. On the converse, if the punctures are equally distributed along the entire length of the fistula (the "rope-ladder puncture" technique), small dilatation occurs over the length of the fistula but without aneurysmatic dilatations.

    The best technique, however, proved to be the repeated puncture of the same site (the "constant-site" method) because it does not cause dilatation or stenosis. Kronung renamed the method the "buttonhole puncture" technique.

    GAINING WIDESPREAD ACCEPTANCE

    The buttonhole puncture technique enables long-term use of a fistula. In 1993, while visiting Poland, I saw the original patient on whom the method was first tried some 20 years earlier. The method was still being used on that patient and with the original fistula.

    There have been no publications refuting the superiority of the buttonhole technique; however, the method has never gained widespread acceptance in U.S. dialysis centers. The method is more frequently used by home hemoodialysis patients.(13) It is possible that the method has been tried in this country without success, but the results have not been published.

    Why has the method been successful in only a few centers and never gained widespread popularity? I believe that it is due to the type of fistulas currently used as well as the details of the technique.

    The Fistula

    All authors reporting results with the buttonhole method have used it exclusively in patients with primary fistulas or saphenous vein grafts. In recent years, however, primary fistulas are created only in a small proportion of patients. Most patients today have porous PTFE graft fistulas, and perhaps this type of fistula is not suitable for the buttonhole technique because of its thinner and weaker construction.

    Details of the Technique as Established in the Original Study

    Needle placement during the break-in period:

    In the original study,(9) following a period of several weeks of fistula maturation, the fistula was punctured by the same experienced sticker, using sharp needles, until the best site was determined. Only after good puncture sites were established were less-experienced stickers allowed to puncture the sites.

    Needle placement by the same experienced person during the initial period might be crucial for success. Each person has a distinct technique that uses the same direction and angle of needle insertion and the same depth of penetration. The good results demonstrated in home hemodialysis patients using the buttonhole method may be related to the "single sticker" practice.

    The Needles

    Following the break-in period during the original study, the needles used for the buttonhole method had a somewhat dull edge and surface. Needles with a dull edge tend to go through the established path, whereas sharp needles tend to cut adjacent tissues, enlarge the hole, and cause bleeding along the needle's path.

    It is very important that the needle goes through the established puncture tunnel and does not cut the adjacent tissue. The needles that have the best results did not have a siliconized outer coating and did not have a very smooth surface. Blood oozing alongside the needles was more likely to occur with the use of siliconized, smooth needles.(9)

    Puncture direction:

    In the original study, both needles were inserted in a centripetal direction that facilitated hemostasis after dialysis and decreased the chances of hematoma formation. Long dialyses with blood flows of 200 ml/min were then used.

    Centripetal direction of the arterial needle may not deliver the high blood flows currently used for short dialysis. Retrograde needle direction may deliver high blood flow but will require application of absorbable gelatin sponges and/or longer pressure on the puncture site after dialysis.

    CONCLUSION

    The buttonhole needle insertion method deserves revival and further clinical trials. With expanded use, I believe that it may become increasingly popular and successful among home hemodialysis patients because of the"single sticker" practice. Somewhat duller needles than those currently manufactured would be beneficial.

    The method may not enjoy comparable success or popularity in dialysis centers because of the "multiple-sticker" practice. It is also doubtful that the method can be used with conventional PTFE graft fistulas. It would be desirable to test the buttonhole method in the new thicker and stronger grafts such as Diastat'.
    Hope this helps, I tried to research quality of this technique,
    MdGuyS~
    http://slelupuskarenguy.com

    Comment


    • #3
      Re: Button Holes

      What can the patient do to monitor and maintain his/
      her access?
      Patients should be taught how to:
      �� Compress their access after needles are removed,
      or if spontaneous bleeding should occur after
      leaving facility.
      �� Wash skin over access with soap and water daily.
      �� Recognize signs and symptoms of infection.
      �� Select proper methods for exercising AV fistula arm
      with some resistance to venous flow.
      �� Palpate for thrill/pulse daily and after any episodes
      of hypotension, dizziness or lightheadedness.
      �� Listen for bruit with ear opposite access if they
      cannot palpate for any reason.
      All patients should know to:
      �� Avoid carrying heavy items draped over the access
      arm or wearing occlusive clothing.
      �� Avoid sleeping on the access arm.
      �� Insist the staff rotate cannulation sites daily.
      �� Ensure that the staff is using proper techniques in
      preparing skin prior to cannulation.
      �� Report any signs and symptoms of infection or
      absence of bruit/

      What size needle to use for first several cannulations?
      A 17 gauge one-inch needle should ALWAYS be used for
      initial cannulation of a fistula, for a minimum of two weeks
      after initial cannulation and for two weeks after any major
      cannulation complication. A fistula may appear and feel
      ready to cannulate, but still may be fragile. After a minimum
      of two weeks following the initial cannulation, increase to a
      16 gauge, and then 15-gauge needle based on the
      assessment of the fistula. Rotate sites every treatment,
      even when using one needle!! Fistulas that are cannulated
      throughout the entire fistula will mature more evenly and
      without aneurysm formation.
      http://slelupuskarenguy.com

      Comment


      • #4
        Re: Button Holes

        Wow that is great info! What info I used when I was planning on self cannulating was what I found at this site:

        http://www.homedialysis.org/learn/buttonhole/
        Angie
        Kidney Korner • Dialysis Ethics Forum • Kidney Pix • Awareness Shirts • KidneySpace • Donor Search
        I will be walking a Kidney Walk in Ontario Canada Sept 18th 2011
        • Peritoneal Dialysis = 4 yrs
        • Hemo Dialysis (in center) = 2 yrs
        • 2 kidney transplants = 1990 - 2001 & 2007 to present

        Comment


        • #5
          Re: Button Holes

          We love the buttonholes!

          As long as you use the heparin that is prescribed that keeps the clots away.

          The only issue with the buttonholes that I have experienced is the scab removal. It's a pain the tush, and tedious. You must be patient, and YOU MUST remove that scab, or you push it into the hole and can cause infection.

          Comment


          • #6
            Re: Button Holes

            Originally posted by Whatever View Post
            We love the buttonholes!

            As long as you use the heparin that is prescribed that keeps the clots away.

            The only issue with the buttonholes that I have experienced is the scab removal. It's a pain the tush, and tedious. You must be patient, and YOU MUST remove that scab, or you push it into the hole and can cause infection.
            I had found tweezers in a plastic container that were not the cheap kind and was red and I would only use them for my fistula to lessen the chance of any infection and I always used an alcohol swab. I heard though that some units don't like tweezers or is it using a needle tip to take off the scab that they said is a no no? I forget now as it has now been 2 years since I last had to take the scab off my button holes.. Always remember to wash the area before taking off the scab as the scab is the body's protective barrier to germs and you are removing that and since you want to protect the fistula and your blood stream from bacteria you need to do all you can. Afterwards I would then put Chlorhexidine swabs on it til it was time to cannulate.
            Angie
            Kidney Korner • Dialysis Ethics Forum • Kidney Pix • Awareness Shirts • KidneySpace • Donor Search
            I will be walking a Kidney Walk in Ontario Canada Sept 18th 2011
            • Peritoneal Dialysis = 4 yrs
            • Hemo Dialysis (in center) = 2 yrs
            • 2 kidney transplants = 1990 - 2001 & 2007 to present

            Comment


            • #7
              Re: Button Holes

              my hubby has to go back to the hospital to try and get the fistula to work better again........this will be his 7th surgery.....he has such a hard time with the sticks......and with clotting...........he hasn't gotton his blood back out of the machine for the last 3 txs........we found out about the button hole...he asked our local davita center about it and they don't do it..........bummer............hardly no one can stick him successfully

              Comment


              • #8
                Re: Button Holes

                Originally posted by taw View Post
                my hubby has to go back to the hospital to try and get the fistula to work better again........this will be his 7th surgery.....he has such a hard time with the sticks......and with clotting...........he hasn't gotton his blood back out of the machine for the last 3 txs........we found out about the button hole...he asked our local davita center about it and they don't do it..........bummer............hardly no one can stick him successfully
                Some units don't because staff has to be trained on how to initiate proper buttonholes or else they will only screw them up. In my unit only one nurse was trained and why mine failed (because properly done has to have the same person doing it for 6 times in a row to make sure the angle is perfect and all so that they don't mistakenly create false tracks) is because I only had the same person twice and ended up they had created a false track.

                This is why many people told me I should just do it on myself. But I was so scared because I had never even done rope ladder technique (the default way that people usually don't know has a name) on myself. But that is what people who have successful button holes were telling me.

                I had that a few times were I couldn't get my blood back and had to go in for a fistulagram to see what was going on there. I had narrowing but they stuck in a balloon (I guess? I didn't get to see it) and they made the path wider again so that the flow could improve after that. I thought my fistula was a goner which depressed me considering my first one failed after only 10 days but they were able to fix the 2nd one .. 3 times in fact (yes I had lots of trouble with mine).

                Hopefully they can fix your hubby's easily and get back into having dialysis with getting blood back before his hemoglobin and iron drops too low.
                Angie
                Kidney Korner • Dialysis Ethics Forum • Kidney Pix • Awareness Shirts • KidneySpace • Donor Search
                I will be walking a Kidney Walk in Ontario Canada Sept 18th 2011
                • Peritoneal Dialysis = 4 yrs
                • Hemo Dialysis (in center) = 2 yrs
                • 2 kidney transplants = 1990 - 2001 & 2007 to present

                Comment


                • #9
                  Re: Button Holes

                  Hello. I have a button hole. I'm fairly new to dialysis (a year now) and when I found out about button holes, opted to have one created as soon as I could. This was for several reasons: (i) less chance of developing large lumps on my arm after longtime use; (ii) no pain with blunt needles (eventually. At the beginning, it did hurt and I was not expecting that. Now, I feel nothing; (iii) self-cannulation. (This helps me tremendously as I used to get very nervous before treatment, wondering who would put the needles in. Some of the technicians are not very good. Now, I am my own technician....it gives a sense of independence, as much as one can be, on dialysis.)

                  The scabs: I have no problem with them. I try to take the scab off before treatments and if I can't, there are several ways to help make it easier taking them off....(i) ask the technician/nurse to soak your scab with a wet cloth (combo of water/alcohol I think?) This softens the scab quickly and effectively. (ii) There are blunt needles with pick on the end that you can easily use to pick off the scab before inserting needle. My clinic started to get these in because several more patients are doing button hole now. (iii) I find that if I leave the band-aid on my points right up until I go to my treatment, there is no scab. I do this for my venous button-hole, more than the upper one. Not sure why, but it works and I only have one scab to take off, as a result.

                  I hope this helps. The best advantage to button-holes is the ability to self-cannulate and then do home-hemo eventually.

                  I hope this helps you. Best of luck!

                  Comment


                  • #10
                    Re: Button Holes

                    Oh yes that reminded me, I used to leave my bandaids on as well as they seemed to keep the scabs from getting too crusty and was easier to take them off. My unit would soak but with alcohol swabs (not sure what you call those little white squares. Don't think swab is the right word) as they didn't want to use anything else for fear of infection.

                    I also think the fear of HOW you remove the scabs is that some people have harder to remove scabs than others and then dig. NEVER DIG.
                    Angie
                    Kidney Korner • Dialysis Ethics Forum • Kidney Pix • Awareness Shirts • KidneySpace • Donor Search
                    I will be walking a Kidney Walk in Ontario Canada Sept 18th 2011
                    • Peritoneal Dialysis = 4 yrs
                    • Hemo Dialysis (in center) = 2 yrs
                    • 2 kidney transplants = 1990 - 2001 & 2007 to present

                    Comment


                    • #11
                      Re: Button Holes

                      So my hubby has had 3 buttone holes. One created by the nurse, and two by me-the newbie.

                      The one from the nurse perfect.

                      The first one I did was perfect, for awhile, but then it started to hurt him and then it sort of closed up or got tighter. It was particular hard to get the needle out at end of treatment.

                      so we started a new one, again perfect for about 3 weeks, but it is now hard to get needle in and out. It's like the vein begins to close up around the path of the needle.

                      Any ideas?

                      Thanks!

                      Comment


                      • #12
                        Re: Button Holes

                        I have a pair of button holes and I stick my self. That way I know it is done right and there is no problem for the last 2-3 years. Not exactly sure when we started it.
                        My first button hole was doing great and my tech was sick and another tech decided he did not need to put sharps in a different site he could use the button holes. What he meant ws that he could screw it up. So I needed new button holes and my tech aid she could not do them as she was not going to be in for all the days that were needed, 6-8 consecutive I believe. So she said let me show you hoe to stick your self and the rest is history.
                        Not a big deal.
                        Cicero
                        May God have mercy on us all

                        CK

                        Idiopathic globular membranous nephritis 1999-2006
                        Feb 2006 Dx about 1-2 yrs before dialysis. Dialysis start 6-2006
                        Chest Cath 4 mos in center hemo dialysis
                        Fistula, button holes, self stick days 07-09 in center hemo
                        Graft nocturnal hemo 4Q09 to present

                        Comment


                        • #13
                          Re: Button Holes

                          New buttonhole establishment technique in research in the States headed by Satellite Health and involves only sticking once an I .V. like sharp needle that is left in for about 3 weeks then after 3 weeks you can start using blunt needles .... this method doesn't require same person all the time....
                          My Blog Site
                          Http://www.dailyhemo.org
                          sigpic

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