I saw the following post and wonder if those doing buttonhole technique would concur:
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Recommend Message 3 of 4 in Discussion
From: bighoobajooba in response to Message 2 Sent: 6/16/2006 9:24 AM
Go7,
The Buttonhole technique is good if you have staff that is not competent in sticking AV fistulas. It’s good for them, because they never have to worry about developing any sticking skills. It’s partially good for the patient, because they don’t have Forest Gump constantly infiltrating their veins.
The negative side to the Buttonhole technique is that you end up with a large scarred up exit site, which, if you have a lot of pressure, will bleed, forever and ever. The larger the hole gets, the worse the bleeding situation will become.
Another major concern is that this permanent exit site will be more prone to infection. This is a big problem, which is given little thought. All dialysis patients have some degree of problems fighting off infections. This problem will become magnified if you have staff that are not good at prepping the Buttonhole site with betadine, or other prep solution, properly.
Another infection concern is that, the “plug” that accumulates in the Buttonhole can gather bacteria and viruses, in between treatments. When the patient is cannulated, the blunt or regular needle being used will push these microbes directly into the patient’s blood stream. Sweeeet!
I’m not a fan of the Buttonhole technique, for the exact reasons I’ve posted, here. For many patients, with small and fragile veins, it may be their only solution to multiple infiltrations. But, for the average dialysis patient, who has decent veins, it’s not a good idea.
There isn’t a lot of published data on the Buttonhole technique, but what there is says that it is less prone to infection than standard cannulation.
The negative side to the Buttonhole technique is that you end up with a large scarred up exit site, which, if you have a lot of pressure, will bleed, forever and ever. The larger the hole gets, the worse the bleeding situation will become.
Long before a buttonhole could ever get to this stage, there would be seeping around the needles during a treatment that would be likely to get people to stop using it. Done correctly, there is one clear channel for the needle to follow. This is much less likely in-center, with multiple cannulators. The buttonhole technique works best if only one person puts in the needles–preferably the dialyzor. When 5 or 6 different techs all put in needles, they will use different angles. They won’t be able to get the blunt needles in, and they’ll use sharps, which will expand the track.
Another infection concern is that, the “plug” that accumulates in the Buttonhole can gather bacteria and viruses, in between treatments.
Let’s see. Before using the Buttonhole Technique for a treatment, you remove the scabs from previous needle insertions with tweezers, using aseptic technique. Then you cleanse the sites with betadine. Then you insert sterile needles. So, where are the “bacteria and viruses” coming from? This doesn’t even make sense, IMHO. I think this is someone who doesn’t like the technique and is trying to scare people away from it.
Done correctly, the Buttonhole Technique is safe and effective. The Fistula First program is encouraging data collection to better demonstrate its benefits, but in the meantime they’re supportive of it.
I completely disagree with Rich Green’s overstatements…non of what he says has happened to me. Bleeding stops alot faster than AV Sharp needles…an infection can only occur on beeing careless…we weren’t trained to be careless. Also, there’s no large scarred up exit hole…on the other hand AV sharp needles do cause large scarred damage all across the fistula…
I do believe that a buttonhole can be damaged by overly inserting sharp needles through it…
Hey Dori and Gus!
Of course I knew how you would reply and wanted first hand accounts to share with the poster. Possibly he does not know how well trained and careful home patients are. Happy Saturday!
Actually using a buttonhole takes a lot of attention. It’s a very precise thing. A sharp needle will go in through anything, but a buttonhole needle will only go in through its established track. You have to be right on. You have to be meticulous in removing the scab from the previous treatment, etc.
There’s no comparison. A well-placed buttonhole is reusable for hundreds of treatments. If you did the same number of treatments with sharps using the common stepladder method, you would have so much scar tissue in the form of aneurysms that you would run out of usable real estate on your fistula - and you would need a new one. Many people don’t realize that you can’t keep putting dialysis needles into aneurysms because the covering skins is too thin.
You also would not be able to benefit from a fistula and nocturnal hemo. The reason is that routine use of sharps outside of an established, known-to-work buttonhole tract would be dangerous. You would not be able to do nocturnal hemo like that because you could not sleep with the very probable risk of hematoma and infiltration because of arm movement.
Home hemodialysis is made possible with a fistula because once that buttonhole tract is established, you know it’s reliable treatment after treatment. You know it’s not going to infiltrate. Even if the needle tip did brush up against the vein wall as you move, the buttonhole needle is too dull to go through the vein wall in situations where a sharp needle would go through instantly.
I have heard that some units in-center are going to the buttonhole technique on all their fistula patients. Obviously, if they are doing this, they have decided it is a better/safer method.
I wonder how the units who provide daily dialysis in-center are able to do it?
I disagree with most of this comment too. Here are my thoughts…
“The Buttonhole technique is good if you have staff that is not competent in sticking AV fistulas.”
absolutely not true!! If you have uncompetent staff sticking your fistula they could damage it. The whole idea for a buttonhole, is you cannulate at the same angle EACH TIME. You start off with sharps, and once the tunnel is developed, you move onto blunts. Someone who is uncompetent shouldnt be going anywhere near any fistula, unless they are fully supervised and instructed by a trained professional. If you have a different person cannulating you each time, then buttonholing would be quite difficult. Even I have trouble with my own somtimes, as you have to be pretty accurate.
“The negative side to the Buttonhole technique is that you end up with a large scarred up exit site”
I dont know about everyone else but I dont have a large scarred up buttonhole, and Ive been using the same sites for over a year. Bleeding time hasnt really changed either.
Infection can be a problem with any fistula. Its all about aseptic technique and hygeine. Before I cannulate, I wash my arm with antibacterial wash, then wipe it down with alcohol before removing the “plugs”. I then wipe it down with another antibacterial solution, which is active at killing bacteria for 9 hours. We dont just willy nilly wipe it with the alco or anti, there is a certain technique for that too. You then cannulate with sterile needles.
We also administer the local just inside the buttonhole tunnel, to stop bleeding at the site. If there is bleeding at the site during the course of treatment, it provides a lovely moist warm environment for bacteria to grow.
“For many patients, with small and fragile veins, it may be their only solution to multiple infiltrations. But, for the average dialysis patient, who has decent veins, it’s not a good idea.”
having “decent veins” is even more reason to use buttonhole technique. The ladder technique causes alot of scarring, so its goodbye “decent” veins.
We also administer the local just inside the buttonhole tunnel, to stop bleeding at the site. If there is bleeding at the site during the course of treatment, it provides a lovely moist warm environment for bacteria to grow.
I am asking because I didn’t quite get the meaning out of that statement.
I, too, am a huge fan of the buttonhole technique. I was the first patient to use it at my clinic. In fact, when I read about it and wanted to start using it, no one at my clinic had even heard of the term “buttonhole”. After I successfully created and started using my own, I would get a lot of inquiries from the staff about the technique. The FA even asked to meet with me to talk about it. She told me that several of the doctors at the clinic wanted to start using the technique, but since none of her staff knew how to do it - she couldn’t start implementing a plan.
One of the techs was so interested in the technique and the benefits it offered, she asked if she could see my research on it. I gave her what little I had actually saved, but told her to go on the web and search for “buttonhole technique”.
She did, and learned all about it. Since that time, she has become the “Buttonhole Queen” in my clinic, and she is the staff person that is responsible for creating buttonholes in those patients that want one.
It also works out great for the home hemo program, too. Before a person starts training for home hemo, she first works with that patient on the floor to establish buttonholes in their fistula and once they are completed, she teaches them how to cannulate themselves.
That helps the training staff a lot, because their students already know how to cannulate themselves before they ever get into training.
estonb, I’ll try my best to explain what I mean. After you have removed scabs from the buttonhole site, you are left with a little hole correct? You put the local needle just into the hole and veer off slightly into the tissue, and administer the local. Before you administer the local it is important to drawback the syringe a little to make sure you arent in your fistula. So obviously if you draw back, and there is blood in the syringe, you have gone in too far. This is important, as you dont want local going into your blood stream.
Doing it this way helps prevent bleeding from where you have inserted the local needle. It does bleed a bit, but not as much as if you have inserted it into the skin on the surface. If if continues to bleed once your all taped up and on the machine, the blood creates an ideal environment for bacteria to grow, which we dont want.
I hope this is understandable, its hard to explain :oops:
Are you talking about local anasthetic? I’ve never heard of using that with buttonholes. There shouldn’t be that much pain when using an established buttonhole, plus, being able to feel pain seems to me like an important sign that you’re going off the beaten track with the needle a bit, so that you can correct your angle or entry point.
Its purely my choice to use local anaesthetic. I get a bit of pain on insertion without it, or if I havent used enough. Also sometimes if cannulation requires a bit more force than usual, its painful without the local. I find it easier to cannulate without pain.
I do not use local on Ralph but we do use emla cream (or generic).
This really helps soften up the plug and it usually comes right out.
If not I use benedine swabs and a benedine square with a plastic tweezer.
It than comes right out. This has to be done rearly.
As for his arm. His fistula is in his upper left arm and there are really no visible signs of it but 2 tiny holes with plugs. Me as the person who canulates him, let me tell you how great it is. Very easy as long as you use the channel.
I am all for Fistula First.
Pat
I’m planning on doing home hemo, but the unit I’m currently at is using the buttonhole method on all the pts… At first and until the channels are establlished the same person sticks, but then anyone can. If I understand correctly the buttonhole method should only be used if the same person does the sticking, even after channels are secured; is that correct? If so should I let staff start buttonholes on me, or wait until I’m training for home hemo… They’ve told me they must start them incenter prior to training but I’ve been reluctant to do that. I have an upper arm fistula in dominant arm. I have really no other choices/areas if anything should go wrong so I’m being very protective of my access. For those with buttonholes how did you handle this situation? Too, I asked about traveling and was told this method is now used in most units and that anyone anywhere could use my buttonholes once established, but that’s not what I’ve heard prior. Thanks, Lin.
do not use local on Ralph but we do use emla cream (or generic).
These are local anesthetics, they’re just creams or gels instead of being injected. Local just means applied to the site (rather than “general” anesthesia, which affects the whole body).
Lin wrote:
If I understand correctly the buttonhole method should only be used if the same person does the sticking, even after channels are secured; is that correct? If so should I let staff start buttonholes on me, or wait until I’m training for home hemo… They’ve told me they must start them incenter prior to training but I’ve been reluctant to do that.
My recommendation is to go ahead and let the staff start buttonholes for you if they promise you only one person will get them established–and then put your needles in yourself. You’ll have to do this for home hemo anyway, so it will shorten your training time to learn to do this–plus it will protect your access from others who might have trouble and damage your buttonholes.
Thankyou very much Dori. That makes more sense to me. I will suggest it and if I’m not allowed to for some reason will wait until training. What they told me was once established ANYONE could stick, even if I had to travel to another unit. I don’t travel but in the future have hopes of at least going to visit my son and his family in Baltimore. I guess for me it will be “Nxstage, don’t leave home without it” lol Lin.
I don’t see how anyone but you or the same helper all the time can cannulate your buttonholes, Lin. Once the buttonhole is established, only you know what the angles are. It’s not like you stick the dull needle in there and it finds its own path. There’s just the tiny little hole on the surface. Even when you do it yourself, if you scrape the sides of the buttonhole a little some day, you can have trouble getting the dull needle in the next few times due to scar tissue forming.
… but I guess anything’s possible.
There’s no big mystery to starting a buttonhole. You just pick a good spot (since the buttonhole will be “permanent”, you have to be sure it’s going to be well inside the middle of the vein so it doesn’t cause pressure problems later, and also ensure that you have sufficient distance between the venous and arterial sites). In my home dialysis program, a nurse picks the spots, and then you simply use the exact same hole and needle orientation (up-and-down and sideways angles). This is done with a sharp needle on 6 consecutive days, and then you try it with the dull needle. It should work by then, but sometimes it can take a few more sharps.
I’ve had to dialyze in hospital a few times since I’ve had my buttonholes, and I’m the only one who can cannulate them. If I was incapacitated, they would just use sharps the usual way (and hopefully not stick them too near my existing buttonholes).
Mine is an upper arm fistula too. There’s a lot of floppy tissue up there, and it makes it a little harder to use buttonholes. You have to be very sure your arm and hand are at exactly the same position every time, or else it changes the angles because everything moves. It’s also harder to judge your angle up there. The vein twists and dips, and there are no reference points to use – unless you have to have a freckle that’s in the right place.
P.S. I still don’t think you sissies need local anasthetic for buttonholes
