Touch Cannulation, Tear Drop, Emla

Hello Stuart -

My husband has been on home hemodialysis for 9 years. We’ve been using buttonholes for most of that time. He’s severely needle phobic so I (wife) do the cannulation. Recently, we lost both his buttonholes and were having issues with his fistula infiltrating and other problems. So he currently has a femoral tunneled catheter while we rested the fistula. Why femoral? Well he has a pacemaker on one side and a powerport in the other side of his chest. His fistula is in upper arm on his dominant hand. No good veins elsewhere. While his fistula is in the upper arm, it isn’t all that deep or long. We are getting ready to make new buttonholes so he can have the permcath out. I need some guidance. First question:

  1. When using the touch cannulation technique, do you use that with the sharps also while forming the buttonhole or only AFTER the buttonhole is formed and you are cannulating with blunts. I often have difficulty seeing the flash when I hold the wings of the needle. I have used the touch technique with blunts, but wonder if it also is appropriate to use while cannulating with sharps and making the buttonholes?

  2. when using the teardrop technique, you have a full saline syringe attached to the cannulation needle…once the needles are in…don’t you need to draw first before flushing? I am a bit confused as to the sequence if you already have a full saline flush attached to the line.

  3. I also have a question about using 3/5 needles. You said those are primarily for forearm fistulas. Should I consider requesting them also if my husband’s brachial fistula is not very deep. Previously, with his old buttonholes, I did notice we got high pressures, so high that it caused the machine to stop if I didn’t pull the needles part way out. Of course, that did not happen until the buttonholes had been in use for quite some time. He has a short fistula and I need his buttonholes to work well and stay patent for a long time.

I am really eager to get these buttonholes going and working well so the catheter can come out. My husband is less eager. He really feels he needs emla, but I also read that emla can be contributing to his problems with cannulation. His needle phobia is severe and is more related to the feeling of the needle in his vein than a fear of the pain.

I would really appreciate any support you can offer.

Emla thank you for your questions thankful I can answer them

  1. Fear of needles is common problem with all dialysis patents attached is Tap Cannualtion a article that is waiting publication, in the ANNA journal.
  2. Use touch cannualtion when starting and continue with buttonhole cannualtion. It was developed by me to save the tunnel tracks.
  3. The use of the 3/5 cannualtion needle I have been a great support for 15 years the reason infiltration is almost unheard of the article and venous pressure drop of 40 to 80 mg. save the access. Less pressure decrease in aneurysm.
  4. Go to home dialysis center and watch my videos this will help understand what I’m talking about.
  5. Please call me at 573-826-8237 if you need any thing else

Techniques for Self-Cannulation
The American Government has issued an Executive Order to motivate the nephrology healthcare community to shift the majority of treatments for kidney failure to home dialysis modalities or transplant, noting: “Greater rates of home dialysis and transplantation will improve quality of life and care for patients who require dialysis and may eliminate the need for dialysis altogether for many patients.” (Executive Order, 2019). As nephrology nurses develop strategies to facilitate this change, they have a key role to play in overcoming barriers to home modalities, particularly fear of needles and of self-cannulation that prevent people from choosing home hemodialysis (HHD). “Much of the fear and lack of self-efficacy of potential patients can be overcome by well trained and competent staff dedicated to home dialysis, for example, nurse-directed cannulation training,” a recent study found. (Karkar, et al, 2015). This article presents practical techniques that have been used successfully for years to help patients overcome fear of needles and lack of confidence in their ability to self-cannulate. (Mott & Moore, 2008).
Tap Cannulation: Cap On
Tap Cannulation is a teaching technique to reduce the fear and pain of self-cannulation for patients who have an arteriovenous fistula (AVF) or graft (AVG) placed and maturing for hemodialysis. The technique helps patients become comfortable with the hemodialysis needles, with the goal of changing their perception of the needle from a dangerous threat to a useful tool through repeated, non-threatening use. Tap Cannulation can be used with any patient with an AVF or AVG who is mentally competent and physically capable of holding a needle.
Three weeks before cannulation of the new fistula begins, the Vascular Access nurse who is educating about cannulation will give the patient a NxStage buttonhole needle (NxStage). The nurse instructs the patient in safe needle practices and encourages the patient to handle the needle often to become familiar with it, much like a driver’s education student practicing in a simulation car before actually driving. Patients will take the dull, harmless needle home to increase their familiarity with it. Showing the needle to family members at home also helps them overcome fear of the treatment their loved one will receive.
A patient who becomes comfortable handling a needle is ready to be taught Tap Cannulation. With the cap on a buttonhole needle, the Vascular Access nurse demonstrates tapping the needle on the arm along the AVF or AVG track (See Figure 1). The tapping is brisk and rhythmic, and is repeated 15-20 times in a row. Any discomfort will decrease after 8 or 9 taps. Note: the NxStage buttonhole needle is the only one dull enough for Tap Cannulation; all other needles will cut the skin, (see figure 7). During these training sessions, the nurse also teaches the patient infection control methods for cleaning the AVF or AVG site, according to the clinic’s Policies and Procedures.
Tap Cannulation: Cap Off
After two weeks of tapping with the needle cap on, the patient progresses to using the dull buttonhole needle with the cap off to tap along the AVF or AVG track. Using the “Touch Cannulation” (see below) hand position on the intended track of the AVF or AVG and holding the tubing 2 to 3 inches behind the wings, the nurse demonstrates tapping the uncovered needle on the skin 10-15 times (See Figure 2). The tapping sends a small pain signal to the brain—which is rapidly trained to become accustomed to the pain, because repetitive tapping activates the “gate threshold.” “Gate Theory” proposes that neural stimulation beyond a certain threshold level can overwhelm the ability of the nerve center to sense pain. (Deleo, 2006). Once a patient can demonstrate correct, safe tapping technique, he or she should perform tapping three or four times a day. The Vascular Access nurse observes and coaches to assure that the tapping is always done along the AVF or AVG track, with the goal of making the patient feel comfortable handling the needle and confident about the location of the track. By the time an access is mature, the patient is ready to begin learning the techniques for self-cannulation.
Touch Cannulation
Touch Cannulation, a different way to hold and deploy the needles, a cannulator holds the tubing behind the wings—not the wings themselves—with the palm of the cannulating hand resting on the patient’s arm. While the palm remains stationary, the thumb and forefinger only are used to gently push the sharp needle forward through the skin and tissue (see Figure 3). Touch Cannulation provides more sensitive pressure feedback during cannulation than holding the wings. Most of the time, it is possible to feel whether the needle is above or to the right or left side of a synthetic AVG, although the pressure feedback is not quite as sensitive for AVFs. With more precise feedback, the cannulator can move the needle slightly to the right or left, or center the needle above the AVF or AVG for insertion into the vessel. Another advantage of Touch Cannulation is that the blood flashback can be easily seen without the cannulator’s fingers blocking the view (Mott and Prowant 2008). A more detailed description of this technique is found in the article referenced.
Tandem Hand Cannulation
Following the Tap Cannulation training, with repetitive tapping on the skin of the AV track, the patient is ready to begin self-cannulation. The first author has had success teaching patients self- cannulation using a technique he calls “Tandem Hand Cannulation”. During the first of four phases for this training, the vascular access nurse demonstrates the correct procedure using a NxStage buttonhole needle just as it would be done during a dialysis session—but without needle insertion. Instead, the nurse touches the dull needle to the skin simulating cannulation. (Any other needle would pierce the skin, and would cause pain, bleeding and anxiety, ruining the training experience.) Next, the patient uses a buttonhole needle, “cannulating” his or her arm by touching it with the dull tip, which is familiar from Tap Cannulation. This helps the patient become comfortable with the procedure, the manipulation of the needle, and the feel of the needle touching the skin. This is repeated until the preceptor and patient both feel comfortable that the goals have been met for phase 1, and then move on to phase 2. (Mott & Moore, 2009)
During phase 2 of Tandem Hand Cannulation, the patient’s gloved cannulation hand (blue gloves, figure 4) is placed on top of the nurse’s gloved cannulation hand (green gloves, figure 4). With the patient’s thumb in tandem over the nurse’s thumb and the patient’s index finger over the nurse’s index finger, the patient can feel the movement and force used for a correct cannulation using a sharp needle. He or she may even be able to feel the “pop” as the needle enters the AVF or AVG. The patient is instructed to call out when the flashback is seen. (Mott & Moore, 2009) Three or more treatment days follow in phase two until the patient is confident and ready for phase 3.
During phase 3 of Tandem Hand Cannulation, the nurse’s gloved hand (green gloves, figure 5) are placed on top of the patient’s gloved hand. This tandem position gives the patient security and enables the nurse to gently guide the patient’s hand physically while also coaching verbally. The goal of this technique is to give the patient confidence and success during the first sharp needle cannulation attempts, as well as to prevent mistakes or potential complications to the access. This process is repeated for as many cannulations as necessary until the patient and preceptor are comfortable and confident in the patient’s ability to complete solo.
Finally, in phase 4, the patient can do his or her own cannulation unaided following the unit’s protocol for self-cannulation (see Figure 6). The vascular access nurse continues to observe the patient closely and offer support, guidance, and encouragement during the first few dialysis sessions. Once the nurse has assessed that the patient’s confidence and skills have developed, the patient may continue to self-cannulate at the In-center facility. This is an advantage to the patient who knows that his access will always be cannulated the same way, with aseptic technique, by the same person (him- or herself!) The patient is assured of consistent hand hygiene and asepsis by doing these tasks independently. Self-cannulation is an advantage for the staff of a busy in-center unit. With the fear of self-cannulation and needles overcome, the patient may also be more likely to choose HHD.
Nursing Implications
The techniques described have been most effective when used consistently by the same vascular access nurse who works with a patient from beginning of training to the end. This cannulation expert does not need to be the HHD nurse, but can be a specially designated In-center nurse who will work with patients who have a developing fistula or graft. Tap Cannulation, Touch Cannulation, and Tandem Hand Cannulation techniques work well for technicians and nurses who are cannulating multiple patients every day. The same vascular nurse can be used to train new staff who are unfamiliar with the large needles used for hemodialysis access. Fistula First recommends that the experienced cannulators on the staff are available to cannulate all new fistulae and to train inexperienced staff, (ESRD, n.d.). Improving staff cannulation skills may help to increase staffing by overcoming the fear of needles and lack of self-confidence in cannulating barrier that new employees share with new patients. As the nephrology community shifts towards more home dialysis, more nephrology nurses will be needed to train patients in home dialysis techniques, and nurses will be needed to train the trainers. “Nurses, like nephrologists, receive little to no type of specialized education or training regarding home modalities. Therefore, these professionals frequently do not possess the knowledge to provide patient education regarding home dialysis modalities,” observed one author (Metzger, 2016). Vascular access nurses who are trained to teach these techniques to patients and staff can help the program to multiply.

Tap Cannulation, Touch Cannulation and Tandem Hand Cannulation are three techniques that have been used in multiple clinics in many US states to successfully teach patients how to self-cannulate. Tap Cannulation is intended to help patients become familiar with and overcome fear of needles, and the goal of tapping before needles are inserted is to decrease the discomfort of the needle. Touch Cannulation is a way to hold the needle that improves sensitivity through the tubing to the cannulator’s fingers to improve the accuracy of needle placement into the access. Tandem Hand cannulation is a training technique that may feel awkward, yet is a practical way to give physical support to a patient or staff member learning a challenging skill. NxStage is using both Touch Cannulation and Tandem Hand cannulation techniques for training new patients for HHD. It is hoped that sharing these techniques with nephrology nurses will be useful for training patients and staff in the future.

Deleo, J.A. (2006). Basic science of pain. Journal of Bone & Joint Surgery, American Volume, 88, 58-62.
ESRD National Coordinating Center (n.d.) Fistula first catheter last: Concept 8- AV fistula cannulation training. Retrieved from
Executive Order on Advancing American Kidney Health. (2019, July 10). Retrieved January 16, 2020, from

Karkar A., Hegbrant J., Strippoli G.F., (2015) Benefits and implementation of home hemodialysis: A narrative review. Saudi Journal of Kidney Disease and Transplant, 26(6),1095–1107.

Metzger, S. (2016). Home dialysis modalities: Educational barriers to utilization. Nephrology Nursing Journal, 43(3), 251–255.

Mott, S., & Moore, H. (2009). Using “Tandem Hand” technique to facilitate self-cannulation in hemodialysis. Nephrology Nursing Journal, 36(3), 313–335.

Mott, S., & Prowant, B. F. (2008). The “Touch Cannulation” technique for hemodialysis. Nephrology Nursing Journal, 35(1), 65–66.

NxStage Buttonhole AV fistula needles with SteriPick. NxStage. (n.d.). Retrieved from 1-800-227-2862 to contact manufacturer, Braun

Figure 1 Tapping with cap on

Figure 2 Tapping with cap off

Figure 3 Touch cannulation

Figure 4 Patient Tandem Hand

Figure 3

Figure 5 Nurse Tandem Hand

Figure 6 Solo cannulation

Figure 7 NxStage buttonhole needle

All photos by Stuart Mott

Abstract: A successful program of instruction for self-cannulation that helps patients overcome the fear of needles. By handling the cannulation needle frequently in a harmless environment, the familiarity eases patient anxiety. Using the gate theory of pain, repeated needle tapping on the access site before cannulation reduces the perception of pain during needle insertion. A different technique for holding the cannulation needle gives the cannulator more sensitivity for accurate placement of the needle in the vascular access. A guided-hand approach placing the trainee’s fingers directly on top of the trainer’s fingers during cannulation gives the trainee a better view and feel for the skill. Followed by a reversal of tandem hand technique, the trainee receives very close physical and verbal support during the actual cannulation.

Extremely helpful Stuart. I am incredibly grateful!. I think it may be difficult get his clinic to source 3/5 needles. Not sure, even if they would, that nephrologist will OK because we run nocturnal. Yet fistula is short and shallow. We don’t have much space or options, plus his blood pressure runs low…so it can make cannulation even more difficult.

Stuart, I have been to 6 dialysis centers in different parts of the country and never heard of nor have ever seen a " vascular access nurse". I have been on dialysis for almost 10 years, half hemo and half PD. I live by myself so I cannot do home hemo nor would I ever go back to PD (what a pain that is!). I recently had to get a new fistula in my dominant arm. I have yet to get the second surgery done due to the fact that I do not want to have those huge aneurysms I had in old fistula from the techs doing the cannulation. Plus doing self cannulation with my left hand…hmmmm, not to sure I could. I have mentioned button hole technique and self cannulation to current team and all I get is glazed over eyes. Hoping you and other patients would be able to comment on this and any experiences they/you have had.

Kind Regards Cynthia

Cynthia, I am considering PD. Please expound on what " what a pain that is" means.

Thanks, Paul Eeds