Fistula & Buttonhole question

The thrill in dad’s fistula is stronger in his lower arm and he has an upper arm fistula is this normal.

If you don’t get a flashback when you insert the needle how do you know when your in the vein and should level off? Does it feel different when you go through the vein?

Haven’t had opportunity to needle yet. First day nurse did holes and couldn’t get a good blood flow. Said we might need to get a fistulagram. I said I wasn’t go home and needle dad to form the holes without knowing the fistula was going to be OK. (Was I wrong?) She did the needles the second day and got the flow; she said she might have been off the 1st time. She also infiltrated the arm a little so I came home and am going back Tuesday.

I saw under the buttonhole technique they say to pull the skin taut it causes less pain. She didn’t do this. Do you pull your skin taut?

Okay Marty, biggggg breath, slowly out, another big breath, okay, a bit more relaxed now??

I believe most people get a flash back, be sure the needle is unclamped. I believe you probably can tell when it goes it, you should suddenly feel less resistance.

My trill is strongest by my elbow, mostly unnoticeable near my armpit, also upper arm fistula.

I personally don’t hold the skin taunt, primarily because I only have two hands. I don’t find it painful except when it is a bit irritated and then only until I get through the very beginning of the buttonhole. Depending on how deep it is and how well you can feel it, you might think of trying the method where it is partially occluded. Mine is so big and near the surface that it isn’t necessary, but many use the other method.

We know you can do it!! Keep us posted on your progress.


hi Marty
I often don’t seem to have a flashback on my venous cannula. I put this down to a lower than usual blood pressure, even with tourniquet. But I am pretty sure I have reached gold so I open the cap slightly and sure enough the blood comes up as usual.

You will be “done and dusted” in no time and you will LOVE it!

Cheers 8)

Personally, I think it must be very hard to start buttonholes in a new fistula that isn’t well-developed yet. I know they do this, from reading your messages, but I don’t think it’s the best situation. Just my opinion. It’s hard and problematic enough to start the ordinary kind of cannulation in a new fistula. I remember a number of infiltrations, but worse was the cramping, pain and numbness in my arm during the treatment. It took about a month, as I recall, for that to pass.

I have a pretty strong trill in my upper arm fistula, but it’s actually strongest below the elbow, where the vein and artery connection was made. I can’t needle in that part though. It’s pretty strong everywhere. Sometimes it’s so loud I get sick of hearing it at night.

I don’t get any flashback until I pinch the tube near the needle. Then I get it, and I know it’s in. I do get a flashback on blood collection night, simply because for that, my arterial needle is not flushed with saline until after I’ve taken the blood. But there’s no flashback when the needle is already flushed with saline. I also don’t level off. I go straight in. That’s how I was taught, and it works fine for me.

I can feel it when the needle is in the vein. It’s hard to describe in words.

There’s no need to pull the skin taut if you use a tourniquet. Good thing too, because there’s really no way to do that if you’re the patient cannulating yourself. You only have one hand to work with, and only so many fingers.


Thanks for all the answers. They have at least calmed me down so I can live through the weekend and face the challenge thats ahead on Tuesday. Cathy,
your right deep breaths and right now I’d like a beer with Pierre and Bear.

Hey, now just you wait a minute, why can’t I have a beer with you guys too?? You aren’t sexist now are you??


Since we’re on daily nocturnal, make it a pitcher of draft :slight_smile:

Don’t worry, you will do fine. When you put sharp needles in and you have to choose a new spot each time, there’s lots of opportunity for infiltration, because you’re cannulating into an unknown each time you do it. Buttonholes are different. Once they are established, you are going in the same place each time, so it’s unlikely you will poke through the other side of the vein. If it’s Ok once, it will be Ok every other time. Now, what you do still have to pay attention to is not only the angle of entry, but the angle the needle is in when you tape it down. Even though it’s in a buttonhole tunnel, it can still deviate a bit sideways once it’s in and end up scraping up against the side of the vein. That will not only cause pressure alarms all night, but it could potentially cause infiltration later in the treatment. Make sure that every time you put a needle in, your Dad’s arm is in exactly the same position as every other time, including whether his hand is facing up or down, and how straight the arm is. I found that what is most consistent and easily achieved with me is to keep my arm straight and my hand facing up. Different hand or arm position definitely change the angle of that buttonhole and make it harder to get the dull needle in.

As I said, I just go straight in, no levelling off. But my vein is fairly large, and, I go in at a fairly shallow angle. It might be different for someone else.


Pierre writes:

Even though it’s in a buttonhole tunnel, it can still deviate a bit sideways once it’s in and end up scraping up against the side of the vein. That will not only cause pressure alarms all night, but it could potentially cause infiltration later in the treatment

I’ve read numerous times where ppl have said that the dull needles can’t infliltrate. But you seem to be saying that if they are positioned wrong they can?

It could if the tip of the needle is positioned right up against the vein wall and it keeps scraping against it all night as the person moves the arm. It’s only a remote possibility, if the veins happen to be fragile as they are in some people. Vein tissue, which is really smooth muscle, seems pretty tough though, as you find out when despite having established buttonholes, the dull needle just won’t punch through the vein wall some night when you’re trying to get yourself on at 11 o’clock. I’ve had infiltrations when I was in-centre, only during the first couple of months or so, but I’ve had no problems at all since using buttonholes. I’ve also never heard of anyone having infiltrations. I’ve only heard of it as a possibility. When you’re on nocturnal, you soon learn on your own anyway about proper positioning of the needle when taping, because if you don’t, you’re going to be up all night resetting the machine - which is not a pleasant prospect when you’re on for 8 hours :!:

With conventional self-sticking (not bh), do you find that as the patient doing the sticking, you have better control of the needles than a nurse? It makes sense that a self-sticker should be able to feel where the needle is going better than another person can, thus having more control over it and able to prevent infiltrations totally.

I think it depends on how big and well-developed the fistula is. You can feel the vein with your fingers before you go in, but you can’t really “feel” anything that helps guide you as the sharp needle goes in. The best you can do is to not get too close to the sides, and hope you’re not going to poke through the bottom. This one reason why you “level off”. If I had to return to in-centre and for some hypothetical reason, I couldn’t use the buttonhole technique anymore, I think I would just let the nurses do it.

Hi Marty, I would say generally speaking that it depends on if the upper arm fistula is a transposition or not. The blood supply is deep within arm at upper level so although it’s strong might not be perceived as strong because it’s deeper than in the lower arm accesses. I actually have an upper arm transposition (meaning the access was created and then moved close to the surface) and it’s quite strong and I can hear it at night through my shoulder. Learn what is normal concerning thrill; in regards to both how it feels, and how it sounds. I used a stethoscope right from the beginning so I would know how my access sounds, and if there were any changes. Hope this helps! Lin. ( had very narrow veins)

Lin., do you disinfect your steth. with anything before use on your access?

Not when the skin is intact, not every time , but with alcohol. A fistula is not like cath and unless open or irritated for some reason need not be sterile. Too, my stethoscope is only used on me. On non tx days clothing is usually over my access and I don’t keep bandaids or dressings covering it. In fact recently it became irritated from the adhesive on the bandaids they were using and neph.thought it was fungus so wrote me a script for Mycolog creme (for diaper rash lol) and he told me to let it air more. Lin.

You only have to worry about sterility when the needles are going in or coming out. For example, you could infect the insertion site if you held it with a dirty gauze. Other than that, you can consider the outside of the fistula to be just normal, everyday skin. No special precautions are needed.

Occaisionally if I cant see a flashback, if its not clotted, you have a look up under where the tubing meets the bevel and you can see a slight flashback. If unsure, open the cap to see the blood flows. If not, try using an empty syringe to see if you can pull any clots out. If all else fails, I tend to get another cannula and try again. Usually works on the second go. I really hate digging around with needles, Id rather take it out and try again.

If I go in-centre for dialysis I always take all my own needles and everything. And I set up and cannulate myself. Dont want my buttonholes mucked up. The only time I let the nurse do it was when I was so sick I didnt care.

To help prevent infection, we put alco wipes on the gauze that you use to hold the site after the needles come out. And we use this green stuff when cannulating, which apparently is effective for 9 hours.

I get sick of my fistula buzzing too. Before I got it I was sure I would end up wanting to cut my arm off, but its not as bad as I thought. My main problem is I can sleep in my most comfy position anymore, because I cant bend that arm too much.