Buttonhole Advice Needed

Very interesting Bill, I don’t occlude at all to stick or on removal, I just remove the venous, hold for 2 minutes, tape off and then remove the arterial and hold for 2-3 minutes then tape. I have the machine already acid washing (something you don’t have to do) while removing the needles so am not wasting time.

Why do you need to occlude? Is your fistula deep so it is hard to find?? Mine is a transposition upper arm fistula and very easy to see and right at the surface.

Interesting Cathy. I’ve never tried to cannulate without ocluding. I have a shallow fistula in my right forearm. I’m not sure I could do a sharp stick without ocluding - a buttonhole stick might work.

I have NEVER occluded, even for the very first stick in the fistula with the sharp needles.

I’m curious why you feel the occlusion is necessary, for blood draws on regular veins they do it so that you vein will fill with blood and get big enough to find and get a needle in.

Even 30 years ago with my father I don’t believe I remember ever using anything to occlude his fistula prior to cannulation.

Curious about other dialysis people, is your fistula/graft occluded prior to cannulation??

I found this sample P&P regarding fistula care and cannulation:

Fistula Management Model Sample Policy
http://www.therenalnetwork.org/images/VAAPFistulaPolicy.pdf
It suggests: “…Have patient apply light manual pressure or apply tourniquet lightly …” to make cannulaiton easier. The reason given is: “May increase firmness and dilation of fistula facilitating cannulation.” This has been my experience - that I need the added firmness to successfully pierce the built up scar tissue.

I did check out the Cannulation Camp resource I posted on this board via another thread and it does not mention occluding at all. With the scar tissue that is along most of my fistula I don’t think I’d want to try without the added firmness created by occluding.

How long does it take to get trained for bh? How do those of you who do your own sticking get the needles out and hold pressure?

My husband Michael does NOT use buttonhole technique, so maybe this isn’t relevant to your thread, but regarding your question regarding occluding during cannulation, I have to say that I do Michael’s sticks, and I not only dn’t occlude, I think it is harder to stick his fistula with occlusion.

Basically, when we trained, they told us to use a tourniquet which made the fistula huge and hard. The sticks felt like they were going through lead pipe! So, after a few sticks, I decided to try cannulating without the tourniquet. I could feel the fistula very well, and I discovered that without occlusion, the fistula was just as easy to locate, and when I did the stick there was less resistance and the “pop” was much less “violent.” I haven’t used occlusion since.

Perhaps because we are not using buttonhole, we do hold Michael’s sites much longer than the rest of you–about 10 minutes. The bleeding appears to stop within 2-3 minutes, but if we don’t hold longer, he bleeds “internally” and develops severe bruising in his lower arm beneath the level of the fistula.

Deb

Are you referring to internal bleeding related to the arterial site? I’ve had this happen. Its not a lot of bleeding , but looks like blood leaked out underneath the skin. I had wondered what causes this. I hold each site for 5 min, but his happens usually only when I am rotating my sites and am sticking the art site closest to the anastimosis.

I may be unusual, but I started dialysis in a home training program, so I have done every stick on my fistula except for the first arterial stick (they didn’t think I’d be brave enough but I asked to do the second one and they let me). It took around 6 sticks prior to using the dull needles and in the beginning every few days I still needed a sharp to get it to work right, and as you can see from the beginning of this thread I still need to use a sharp every so often, although ever since that horrible day they have gone in extremely easily (please don’t jinx me).

So I would have to say learning to do both the sticks and buttonholes were very easy for me. I too wondered how you remove the needles and hold at the same time, but the needles have tubing that is long and can be held in your fistula hand to remove the needles so you use the other hand to hold the gauze in place and pull the needle with the fistula hand, hold that one, tape off, then remove the other. Alternatively, some people use a cloth type clamp to hold the one and then remove the other and hold it, and some people are coordinated enough to hold both at the same time. I haven’t tried that, and since the machine is rinsing anyway, I don’t lose any time.

As I’ve said earlier, my buttonholes stop bleeding exceedingly easily, generally 1-3 minutes, and except for the first few weeks I’ve had no bruising and only re-bled once, just held another couple of minutes and was fine. I think we all just need to figure out what works for us.

Cathy I think your fistula will set longevity records. I think you’ve “done it right”.

Deb wrote:
Perhaps because we are not using buttonhole, we do hold Michael’s sites much longer than the rest of you–about 10 minutes. The bleeding appears to stop within 2-3 minutes, but if we don’t hold longer, he bleeds “internally” and develops severe bruising in his lower arm beneath the level of the fistula.

Thank you for this observation. My arterial site would leak blood under the skin on my sticks nearest the anastamosis. I have been holding 10 minutes instead of 5 when in that area and the problem is solved- no more brusing.

How much training does it take before one is ready to self stick with the buttonhole technique?

I think I answered for me at least eariler, but, I starting sticking myself on my first day of dialysis. Only two sticks of my fistula have ever been made by anyone other than me. The only way to learn is just to do it!!

Cathy writes:
The only way to learn is just to do it!!

Surely you had some training on where/how to put the needles?

Oh course the training nurses were right there. I’d never stick myself for no reason!! They will help hold your hand, get the angle right, decide where is the best place for the buttonhole etc. (at least for me since I hadn’t been on dialysis yet).

Since you weren’t on the list when I first started, I will also repeat that I think it is much less painful to stick yourself. I have never used either Lidocaine (which they believe is bad for your fistula) or EMLA. My theory, and it is only a theory, is that when your brain is concentrating so much on getting the stick right, it overrides the pain signals to the brain.

If you learn to do self-sticks in-center, I am also sure that they will help you do it.

Read a post about a bh that was giving trouble, but person got it to work. What would you do if you couldn’t get the bh to work one tx?

When you have a buttonhole, most people start using dull needles to cannulate. When the dull needle gives you problems you simply use a sharp needle to cannulate. Many people have two sets of buttonholes so you can also rotate, and with a sharp needle you can cannulate anywhere.

Only times I was unable to dialyze was in the very beginning when I had infiltrations, I missed one session two different times to allow my fistula to rest.

When you are trained in bh are you also trained in traditional cannulation? If you have to start a new bh, are you trained to do this or do you require help from nurse educator?

Is there any reason why Emla Cream can not be used with bh?

The folks from Medisystems (they make the buttonhole needles and do buttonhole workshops for staff) say that they don’t recommend the use of EMLA when you’re creating buttonholes because “it’s sticky and germs will adhere to it.” Since you wipe it off and clean off your arm carefully before cannulation, you might want to check in with your care team about whether they see that as an issue or not.

To start a buttonhole you need to use regular sharp needles, so yes you are trained on sharps. The only difference between buttonholes and regular cannulation is that you stick the same spot each time with a button hole, and most people use a special buttonhole needle, one that is dull and allows blood access from two areas on the needle.