Do you use a tourniquet for canulation, and if so, what type?
Absolutely. My fistula is a big floppy upper arm one, and it would be impossible for me to cannulate it consistently with buttonholes if I didn’t use a tourniquet. The one I have can be tightened and loosened with one hand. It’s a Propper brand. I think I’ve seen the same kind used when lab techs draw blood for blood work.
Pierre
Absolutely not lol, I was told never to use a tourniqet on my fistula arm and have never needed one. I would suggest trying without and if you have problems then use one but do no tighten it very tightly.
Cathy
No tourniquet here… :roll:
Tourniquet here . Not sure that my fistula would be big enough to go without . Maybe it is a bit like making the decision to not use local anaesthetic needles any more, I should just try it without tourniquet one day and see what happens I guess…
Used to forget to loosen it after needling (naughty) but am getting better. So many things to remember! 8)
I think some caution is in order in this forum. When it comes to specific aspects of conducting your dialysis treatment, you really should get your advice from your dialysis team. Everyone is different. Fistulas differ greatly. If you were taught to use a tourniquet, there was a reason for it. Same thing if you were taught not to use one.
Pierre
No offense meant to you Pierre, but I do want to note, that sometimes you are taught something just because that is the way they were taught. Like buttonholing, most centers have never heard of it and will tell patients that it doesn’t exist, it is unsafe, etc. Some are at the top of “what is new” and some are resistant to change.
I would certainly ask before changing methods, but I wouldn’t assume that just because that was how I was taught that it is necessarily unsafe to stick without a tourniquet. In the last couple of years there have really been a lot of advances in sticking fistulas and prolonging their lives.
Cathy
Don’t worry Pierre,
I would not be attempting anything like that without discussing it fully with my nurse first!
However, I agree with Cathy about knowledge amongst trainers/nurses. I live between 2 renal units headed by 2 very knowledgable nurses but with totally different techniques used. Talk to 4 different nurses and you will find 4 opinions of techniques.
What this forum gives us which I value greatly is courage and support above all else. 8)
Well, I don’t take offense, but there has been dialysis at the hospital where my program is located since the 1960’s, and the home hemo program takes its roots in a daily nocturnal hemo program that goes back more than a decade. There is not one training nurse but a whole team of them. I think they have got the procedures down by now.
What I said was that we shouldn’t infer that any particular thing we are taught applies to any other individual, because we all have little particularities that may have affected how we were taught in the first place. Hemodialysis is an inherently dangerous and risky procedure, after all.
Pierre
Pierre, it isn’t the procedures per se, it is acceptance of new procedures. As with some doctors, they don’t want to change what “has worked for decades”. Think of how many doctors are anti-home dialysis, anti-daily dialysis, anti-nocturnal dialysis, not only the doctors but the centers. Many are unaware of and/or anti buttonholeing. I’d be curious what your center says about needling without a tourniquet. Do they say never try, it doesn’t work, or that it wouldn’t work on your fistula?? Since some of us are quite successful never using a tourniquet, I’m simply curious.
Cathy
Exactly how to cannulate a vascular access with or without the Buttonhole Technique is more a matter of individual practice at this point than established science based on research. I’m not sure why it is, but there are very few studies that pertain to how to use the access, vs. the zillions on how to create it. So, it’s not at all surprising that y’all are finding practice variations from one center to another. People tend to do what works for them.
It’s like I said before, I use a tourniquet because my particular fistula requires it. And it’s not only for buttonholes either, because the nurses at the dialysis centre used a tourniquet on me too - and they did so for almost 3 years. Other people might not need one. It’s depends on what the fistula vein is like, how much skin and or muscle there is over it, etc. If someone initiated and developed the buttonholes using a tourniquet, then not using one would probably not work - because it changes the angle. You might never get the dull needle through the vein. If you need a tourniquet, you need it… And if you don’t need one, you don’t need one. It’s not a matter of using or not using a tourniquet being better.
Even with a tourniquet, we’re not talking about totally occluding the fistula, just a bit of pressure to stabilize the vein. If you ever get a fistulagram, you will know what a real tourniquet feels like!
To be honest, I haven’t encountered any nephrologists where I live who are against home hemo, and I’ve seen many. The general concensus seems to be that it’s recognized as the single best treatment nephrology has to offer, short of a transplant (and even then, under some circumstances, daily nocturnal hemo might even be better). In the Canadian system, at least in my Province, nobody profits from anything, so there’s no reason not to refer someone to the home dialysis unit. If anything, they like to do it, since it frees up a space in the dialysis unit and it costs the system less over time. When I asked to switch, I got nothing but a lot of encouragement from the nurses, the dieticians, and the doctors.
Pierre
I use a tourniquet - it’s an old fashioned blood pressure cuff that you pump up by hand. I pump it up to between my systolic and diastolic blood pressure and that works well. When I was in-center I would ask the staff person to “choke” my arm with two hands while I put in the needle. In my experience “choking” the arm allows greater control over the amount of pressure and it gives the staffer something to do while I cannulate.
If all else was equal I guess it’d be better to not use a tourniquet and go Cathy’s route but I’ve always done it with some occlusion and I think by using the cuff there really isn’t a down side.
Is the main purpose of a tourniquet to keep the vein from rolling or are there other reasons it is used?
The purpose is to stabilize the surface of the vein so that when the needle goes in, it goes in predictably. As I mentioned in another post, some fistula veins are in quite floppy tissue - especially upper arm ones. As sharp as a sharp needle is, it takes a surprising amount of pressure to get it through unless the vein is very close to the surface, and sometimes even when it is. As you push down, you increase the chances of misplacing it, or of going through the other side of the vein and getting infiltration. Especially at home, infiltration would be one heck of a big hassle to deal with, because you have to apply ice, and more importantly, you have to stop the blood - which can easily mean holding that site for a good 20 minutes. In the meantime, if you have the other needle in, it might clot, and everything would cascade to ruin that treatment.
Take mine for an example. It’s very big. Both nurses and I can easily cannulate it without a tourniquet if using sharps, if I had to. It’s big enough that you can’t miss. It’s not the kind of vein that will “roll over”. However, the tourniquet in my case is more necessary when using buttonholes. No matter how good they are, buttonholes tend to heal over a bit inside, and when you put it in, it takes a bit of pressure and twirling to get it in. The tourniquet serves to make the fistula vein harder so I can get the buttonhole through. Without the tourniquet, first, I would have a different angle of insertion, and second, I would be likely to get the dull needle in the tunnel, but then it would just deflect off the side of the vein without going in it.
Forget what you read on the internet. There’s no evidence whatsoever that using a tourniquet properly is hazardous to the fistula. When you start dialysis, a good nurse will know if you need a tourniquet or not. If you do, you do. Everyone is different. Fistula veins come in all shapes and sizes, and they change and evolve over time.
Pierre
A friend shared this response from a professional in the field:
Veins are very weak walled vessels - the use of a tourniquet is the approved recommended standard of care- not so much to stabilize them, but to Fill them - dilate them, which makes cannulation not only easier, but less chance of going thru the weak vessel wall. The tourniquet must provide a consistent-even tourniquet effect which is not as reliable from a hand / finger - or rubber glove( used by some).
Regarding using a Tournequet,
How tight should you put on the tournequet? Does anyone find it easier to find the veign through your buttonhole with a tighter wrap around ur arm or looser?
thanks
Not too tight, just enough to firm up the vein a little. You don’t want to be occluding the vein itself nor the smaller veins that are all over the area.
Pierre
FWIW, I use a tourniquet, well actually I get a nurse to apply pressure in the right area against the vessel, this until I adapt a tourniquet to press in just the right place with the right pressure.
I don’t need anything except slight pressure against my upper arm (fistula is ‘against’) my right elbow.
I can needlew without a tourniquet, but it’s not as easy, having a deep fistula, it needs to be ‘raised’ for me to needle.