RSA buttonhole presentation 2008

Buttonhole Cannulation

Anna Flynn & Annette Linton

Aim of PresentationDiscuss

• What is buttonholing

• Client selection

• Buttonhole establishment

• Benefits of buttonholing

• Bendigo buttonhole clients

• Client buttonhole evaluation surveys

• Staff surveys

CAN YOU RELATE TO THIS ?

Buttonholing Background

• Not a new technique• Used for homehaemo clients

• Used extensively in Europe

• Not generally been used in-centre

• Limited literature found on lit search

• Bendigo commenced in-centre buttonholing in Nov 2004

Button Hole puncture

Area Puncture

•Prone to aneurysmal dilatation

•Stenoses may develop in adjacent areas

Rope-ladder puncture

• Small dilatation occursover length of fistula

•“does not cause dilatation or stenosis”

Twardowski,1995; Krönung 1984

Buttonhole puncture site

Thanks to Nipro for use of photo

Onesititis

So how is a buttonhole site established?

Buttonhole Cannulation

• Establish reason for buttonhole ie•client to self cannulate•Short or difficult fistula

• The reason will dictate the position of the buttonholes

• Discuss & educate client re buttonholing

• Enlist support from Renal Physicians

Selection for Buttonhole• AV Fistula

• Challenging to access•Short•Onesititis•Repeat infiltrations

• Client• Agreement • ↑ anxiety level with cannulations• Requesting more autonomy• Considering home dialysis

• Renal Physician agreement

Buttonhole Cannulation• Select a site

• straight piece of vessel without aneurysm

• If client wishing to self cannulate then have them do so from the first cannulation

•Select a suitable site - easily reached & visualized by client

• One ‘cannulator’ when establishing a buttonhole

Buttonhole Cannulation

• Cannulate exactly the same • Site

• Angle

• Depth of penetration

• Literature suggests at least 6 cannulations with sharp needle – probably more like 9 to 12

Buttonhole Cannulation

• Insert approximately at a 25° angle

• On flashback, lower angle of insertion & advance needle into fistula

• Tape AV needle securely

Cannulating established buttonholes

1. Once sites are established anyone can use sites using dull AVF needles

2. Wash arm / access as per Unit protocol

3. Cover scabs with alcohol chlorhex soaked gauze

4. Remove scabs with sterile plastic forceps, gauze or sterile “blunt” needle

Removing Scab

Removing Scab

Cannulating established buttonholes

5. Swab puncture sites as per Unit protocol

6. Cannulate using dull AVF needles, when flashback is observed, decrease angle of insertion & advance needle to the hub

7. Securely tape needles

Cannulating

Tape Securely

Doppler Image

Buttonhole tunnel

What are the benefits?• Insertion is easy & quicker

• Cannulation is less painful

• Fewer missed attempts to place needles

• Haematoma formation is reduced

bleeding time post treatment

• Infection rate is no different to normal cannulation

BettySoft forearm fistula• Obese fleshy arm• Extreme anxiety presenting

for dialysis• Seriously considering

ceasing treatmentIn 7 months leading to

buttonholing• 21 of 87 HDX with

cannulation issues• 29 extra needle insertions in

the 7 months

Betty12 months post buttonhole

•↓ 2 extra needles in 156 HDX sessions

• Within 4 buttonhole sessions • client stated less pain

• staff noticed smoother needle insertion

• Within a month client had no wish to cease treatment

Venous

Arterial

Buttonholes @ 2½ years

Fay• Short soft forearm

fistula

• Onesititis developing

• 120 HDX sessions 12 extra needle insertions

• Some infection issues (scab picking)

Fay

12 months post buttonhole

• No cannulation difficulties

• 1 episode of fistula infection

Venous

Arterial

Buttonhole @18 months

Cubital fossa

Bob

• Short upper arm fistula

• Obese arm

• Onesititis developing

• Intermittent cannulation difficulties

Bob

12 months post buttonhole

• No problem cannulations experienced

• 2 sets of buttonholes developed

Venous

Arterial

Buttonholes @ 29 months

Doug

• Short upper arm fistula

• Obese arm

• Onesititis developing

• Intermittent cannulation difficulties

Doug

• 12 months post buttonhole

• No problem cannulations experienced

• 2 sets of buttonholes developed

Venous

Arterial

buttonholes @ 12 months

Buttonhole Evaluation

Questionnaires similar to the Gold Coast (Paula McLeister’s) presentation at RSA 2006 were given to 13 buttonhole clients and also the staff who had been present pre and post buttonhole experience.This has enabled Bendigo to compare results with the Gold Coast buttonhole experience.

Evaluation (Q1a - 1b)Q1a. What has been the best thing you have noticed

(with buttonholing)?

• ‘No lumpy bits on my arm’

• ‘Everyone can cannulate me now’

• ‘Needles go in 1st time’

• ‘No pain’

• ‘No searching for a place to go’

Q1b. Any bad things you have noticed?

• 13 unanimous NOTHING

Evaluation (Q2)Q2. Any difference in pain during cannulation?• 11 ↓ in pain• 2 felt no great difference

‘Through many patient surveys, it has been found that the buttonhole technique is a viable technique for reducing pain of cannulation and may help those patients who have needle fears.’Ball, L (2006 p 304)

Evaluation (Q3)

Q3. Any difference in time taken cannulate & commence dialysis?

• 9 stated much quicker

• 4 same time

Evaluation (Q4)Q4. Any difference in anxiety level when coming to

dialysis & being cannulated?• 11 reported considerable ↓ in anxiety• 2 had not noticed any change

‘haemodialysis patients experience higher levels of anxiety & depression than ESRD patients receiving other forms of RRT’Martin et al, 2003

‘Additional benefits (buttonholing) include ……….and perhaps most importantly to the patients, less pain and fear of cannulation)Network News – Special Edition Fistula First 2006

Evaluation (Q5 & 6)Q5. Any difference in relation to ‘blows’ during

cannulation with buttonholes?• 9 yes – no blows at all• 4 no blow problems pre buttonholes

Q6. Have post dialysis bleeding times changed with buttonholes?

• 7 definite ↓ in post bleed time• 6 no change

Further Comments

• ‘For me it’s been a life saver’

• ‘I would always choose buttonhole over rope ladder cannulation now’

• ‘Pleased I haven’t got big lumps up my arm like some people’

• ‘Good way to needle, ↓ anxiety’

• ‘Good practice, I can manage for self’

Infection Rates

• In total 20 clients buttonholed in Bendigo since 2004

• 1 incidence of infection seen in 28 months• Client had previous fistula infections pre

buttonholes

• Lit search found no evidence of ↑ infection rates with buttonhole cannulation

Advantages of the buttonhole Technique include: fewer infections, infiltrations, and missed sticks; decreased hematoma formation; and less pain, eliminating the need for anesthetic

(Twardowski, 1979 p 979)

Staff Questionnaires

9 staff were given questionnaires100% stated less pain noted for client100% stated clients more relaxed67% stated felt less anxious cannulating100% stated much quicker time to have

client dialysing

Staff Questionnaires

Summary of comments….Minimal scaring of fistulaMuch less pain for clientsEasier cannulation of challenging fistulas↑ confidence in difficult cannulationsMuch quicker, less time troubleshooting

Decreased anxiety for client and staff

Staff Questionnaires

Difficulties noted * challenging scab removal on some

fistulas* A client removing scabs at home* One fistula more mobile and careful

positioning of arm required to find track

Buttonholes 2 months

Buttonhole puncture sites

3 months

Buttonhole puncture sites

11 months

Approx 6 months

Buttonhole puncture sites

9 months

Buttonhole puncture sites

Considerations

• Development of 2 sets of holes for rotation

• How best to remove scabs• How best to educate/advise other

units should client need to be treated elsewhere

• Awareness there is an altered sensation when cannulating with a ‘Dull’ needle

While it may not be practical for

all haemodialysis units to establish buttonholing it is important for staff to have

knowledge of how to cannulate and/or care for buttonholes

Conclusion Buttonholing Positive outcomes for challenging fistulasIs not difficult to achieveNo infection rate increase demonstrated with in-

centre useDecreases stress levels for client & nurse (do not

under estimate the negative effect of stress)Facilitates increased client self care, autonomy &

confidence

Finally………..As the access is the client’s

lifeline, skilled & gentle venepuncture prolongs the life of the access & enhances client

comfort - then isn’t buttonholing worth

considering?

Betty

Thank You

References

1. Krönung,G. (1984) Plastic deformation of Cimino fistula by repeated puncture Dialysis & Transplantation. 13: 635-638.

2. Twardowski,Z. (1995) Constant Site (Buttonhole) Method of Needle Insertion for Haemodialysis. Dialysis & Transplantation. 24(10),559-560,576.

3. Toma,S. et al (2003) A timesaving method to create a fixed puncture route for the buttonhole technique. Nephrology Dialysis & Transplantation, 18:2118-2121

References• Ball, LK. (2005) “Improving Arteriovenous Fistula Cannulation Skills”

Nephrology Nursing Journal. 32(6) pp611-617• Ball, LK. (2006) “The Buttonhole Technique for Arteriovenous Fistula

Cannulation” Nephrology Nursing Journal. 33(3) pp 299-304• Network News, Special Edition ‘Fistula First’ (2006) {on line accessed

25 April 2007} http:/esrdnetwork8.org/assets/pdf/fistula_firsts_NL_fall06.pdf

• Martin, C.R.; Tweed, A.E. & Metcalfe, M.S. (2003) The impact of treatment modality on the affective status of patients with end-stage renal disease. Clinical Effectiveness in Nursing, 7, 99-101.

• Peterson, P. (2002) Fistula Cannulation: The Buttonhole Technique. Nephrology Nursing Journal. 29(2) pp 195

• Toma, S et al (2003) A timesaving method to create a fixed puncture route for the buttonhole technique. Nephrology Dialysis Transplantation; 18:2118-21. Updated to the latter part of 2005.

• Twardowski Z. Kubara H. (1979) Different sites versus constant sites of needle insertion into arteriovenous fistulas for treatment by repeated dialysis. Dial Transplant 8:978-980..