Tourniquet - to use or not to use

Question: When doing buttonhole, is it better to use a tourniquet or not use one

and WHY?

One guy told me to use it because it will keep my rolling AV Fistula more stable so that the buttonhole will become established (harder in my dialysis unit since I have a different nurse cannulating me all the time - they think as long as they get in the same hole all the time that they also cannulate the fistula in the same spot too … not neccessarily true) yet I just got a post from a guy on another forum saying this:

"With a buttonhole you shouldn’t need a tourniquet nor would I think its wise to use one in that situation IMO.

Being that the buttonhole is merely a formed tunnel and the blunt is to slide into it in the same manner as a earing being put into a ear with the exception that the blunt punctures the vein at the end. Putting a tourniquet on it causes the vein to swell which in turn can distort the buttonhole tunnel thus keeping the blunt from going in at all or if using a sharp in a buttonhole cause it to deviate from the formed tunnel itself."

I am taking everything in but still I don’t know enough about this to know which is best for me. Should I talk to my surgeon who made the fistula?

My fistula tends to roll and they started buttonhole on Dec 8th but they hadn’t been able to cannulate with blunts as all it did was push the fistula all over the place! THey had to use sharps up til Jan 31st! I told them to not attempt blunts after a weekend but instead on a Wed so this time they did and it worked.

I think what makes it so hard is I keep having a different cannulator even though I have said I don’t want a different one but always the same one! I am tired of them cannulating me at different angles but then telling me off saying they have been doing this for years!! It is my arm not theirs and I am only 33 which means there is a good chance I will end up having quite a few fistulas in my life time! I want to take care of this one that I have (as it is it is my 2nd one as the first one failed after only 10 days because I was too dried out).

ANy advice is welcome! Even additional to the tourniquet use! Advice on why the blunts push my fistula (is it becuase even though they cannulate in the same buttonhole, since it isn’t established yet it is not cannulating into the fistula in the same spot all the time??) and how to explain to the cannulators why I should have the same one all the time AND how do I know when my buttonholes are established (seems my nurses can’t agree on that neither)!

I think every fistula is different so most important would be to find what worked. I am not sure there is a right answer. I use an old fashioned pump up pressure cuff so I can control how much pressure I apply, keeping it below my blood pressure. This seems to make cannulation go easier.

Angie I’m sorry as I am sure you’ve posted this elsewhere but I don’t recall why you’re not self-cannulating? If I had to use different cannulators each time on my buttonholes I would try to develop a shared vocabulary and perhaps a visual device to indicate the proper angle. I’ve found that I need to start steeper than what I thought 35 degrees looks like but if I took a 35 degree angle represented by a piece of paper and held it up to my initial needle position I am right there until the flash and then I decrease the angle as I finish cannulation.

ALWAYS USE A TOURNIQUET, even with well-developed fistulas. NO EXCEPTIONS!
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http://www.esrdnet15.org/QI/C8C.pdf

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[QUOTE=billable;12484]ALWAYS USE A TOURNIQUET, even with well-developed fistulas. NO EXCEPTIONS!
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Copied and pasted from
http://www.esrdnet15.org/QI/C8C.pdf

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I agree, Bill, but not because I have any particular expertise in this area. The vascular access experts who wrote and reviewed the updated Vascular Access module of the Core Curriculum for the Dialysis Technician (download it at http//www.meiresearch.org) all agreed that a tourniquet (or blood pressure cuff) should always be used on a fistula–and they did not make an exception for use of the Buttonhole technique. There was no dissention–so I have to believe that use of a tourniquet is the best practice.

Angie, Bill P asked why you are not cannulating yourself, and I think I’ve asked that, too. It’s great that you know how important it is for you to protect your fistula, because at 33, you’ll be needing it for a long time. But your best chance of doing that successfully is to not let anyone but you put needles in it. It’s your arm, and it needs to be your choice.

That is a Cannulation of New Fistula Policy and Procedure which would need not apply to ongoing buttonhole cannulation. I would worry about the the variation in how tourniquets are used. Those rubber band tourniquets normally employed by units can fully occlude a fistula if a person has low blood pressure going in or if they are tied too tight.

I do not give the pronouncements of the networks any sort of papal authority.

I wasn’t posting that as my advice, simply passing on a quote from the reference.

I’m a firm believer in getting as much information as possible and then making an informed decision that is best for you, even if it goes against convention.

I wondered about tourniquets when I was getting prepared to do learn how to self-cannulate and later do buttonhole. IN my case, I do not need a touniquet at all. Have no problem at all getting needles in without one. Guess it would depend on one’s access. Also, it might depend on who’s doing the cannulating, the patient or caregiver. I can not grasp how a caregiver can get the needles in without hurting the patient. I do my own needles and if someone was doing it for me, I can not see how they could find the tunnel without hurting me. Because when I cannulate, I am able to feel around internally until I find the tunnel, but don’t see how someone else could do that without causing any pain. Maybe I am wrong and the caregiver can locate the tunnel, too, just as painlessly, but it is hard for me to picture this. Since you have had different nurses work with your bhs Angie, what have you experienced? Having someone else do it seems like it would be more painful than just sticking the needles in the traditional way. Hope I am wrong, because you did not mention having any great pain. I have asked others about what it is like having a caregiver put in the bh needles, but didn’t get any great answers. That’s something I’ve wanted to know.

[QUOTE=Dori Schatell;12489]I agree, Bill, but not because I have any particular expertise in this area. The vascular access experts who wrote and reviewed the updated Vascular Access module of the Core Curriculum for the Dialysis Technician (download it at http//www.meiresearch.org) all agreed that a tourniquet (or blood pressure cuff) should always be used on a fistula–and they did not make an exception for use of the Buttonhole technique. There was no dissention–so I have to believe that use of a tourniquet is the best practice.

Angie, Bill P asked why you are not cannulating yourself, and I think I’ve asked that, too. It’s great that you know how important it is for you to protect your fistula, because at 33, you’ll be needing it for a long time. But your best chance of doing that successfully is to not let anyone but you put needles in it. It’s your arm, and it needs to be your choice.[/QUOTE]

Hi Dori and thanks BillP and Billable!

I was using the tourniquet but the last two times I didn’t with the buttonhole. We are still seeing what works. It seems that with the buttonhole that maybe it still hasn’t established because the nurses were using sharps til last wednesday and they would do different angles or I was holding my arm not the same each time and with my rolling fistula, sure they would cannulate me in the same holes in my skin but it would not go into the same holes under the skin in the fistula. Does that make sense?

Today the arterial wasn’t so bad but the venous … took 7 tries including pulling the needle back out (they thought it would bleed but I told them I knew it wouldn’t as I could tell it wasn’t in) and fishing around for 10 min.

Another nurse came over and when I pointed out where the fistula was (beside the needle) she said, “Why is the buttonhole there when the fistula is over here???” I said because it rolled over there as the blunt needle is only pushing it and not cannulating :frowning:

I know they don’t listen to me. They say that my talking is only frustrating them. They just want to do their job.

I can’t cannulate myself until it is established.

Sorry to disagree with the experts, but I have never used a tourniqet on my fistula and have had buttonholes going strong (knock on wood) for over 2 years now. I do have an upper arm transverse so the fistula is VERY noticable and raised. I was trained to NEVER let anyone put a tourniquet on my arm with the fistula, not even a blood pressure cuff.

Cathy
home hemo 9/04

Why on earth not? It’s your arm, Angie, and with the rolling, you’re clearly the one who can tell best what’s going on. I hope you’re not in one of those centers that will only allow dialyzors to use blunt needles, but not sharp ones. That is flat-out ridiculous, when nobody can cannulate your arm better than you can. You can feel both ends of the needle. No healthcare professional, however experienced, has that advantage. If your center is worried about liability, the attorneys should be informed that it is much more likely that a staff member will damage your access using a sharp than that you will.

Particularly when you are establishing buttonholes, you need to be the one doing it. If I were you, I’d go to the Director of Nursing in your center, calmly explain the difficulties the staff has been having, and ask to be trained to cannulate yourself. It’s your best hope.