Buttonholing seems to come in and out of favour. It has many boosters; I am one. Why? The fistula lasts longer, less pain, easy insertion, less chance of a blowout, less time holding the needles after removal – what’s not to like?
According to Roger (not his real name) and several dialysis units, one thing: infection.
Roger emailed me last week:
I’ve been meaning to send you a query about buttonholing for a while now.
I know that you buttonhole and advocate for it. Many of the posts on your blog which talk about units taking it up and it becoming more popular are a few years old now.
My experience has been a bit different.
I’m a home dialysis patient. My unit in Canberra has stopped letting people buttonhole across the board – whether they self-cannulate or not. I understand this is because they had a death in late 2011 from septicaemia, which was attributed to that person’s use of buttonholing. I also recently went to two units in Qld which had both stopped buttonholing in the last twelve months.
I have done a lot of research into the benefits and risks of buttonholing and it is my personal belief that with appropriate sterile technique and management of risks, the benefits (namely enhanced graft survival) outweigh the potential risks.
I had to fight to be allowed to start buttonholing and with the help of a few key advocates on my side among the unit staff, I have been allowed to start buttonholing and order the necessary equipment. However, the unit policy still remains a definite no, and asking questions about buttonholing is quite difficult. Everyone’s a bit nervous about it, so instead I’m seeking information from other sources.
I’ve been dialysing for just over 18 months now. I used rope ladder technique up until January. In that time my Fistula became reasonably large in the limited areas where I was able to cannulate (due to nerve pain and a bendy fistula) to the point that my doctor started talking about preparing a new graft and tying the original one off. This prompted me to want to start buttonholing to see if I could make my original fistula last longer and stop it increasing in size any further.
After gaining the support of my nurse and doctor (but not the unit policy) I started buttonholing. It didn’t start well, after only my 3rd attempt of sticking the same hole I ended up in hospital with a fairly high fever. There was no evidence to say that this was related to buttonholing, however it could not be ruled out. The admitting doctor believed it to be tonsillitis, but it wasn’t clear cut, so the detractors of buttonholing in the hospital used this as further evidence to their stance.
I went back to rope ladder for a couple of weeks, before starting again. I’ve not had any infection problems since and believe that my fistula may have even reduced in size slightly. It certainly looks better and is much easier to cannulate. However, I have had problems with transitioning to blunt needles. Of the four sites I have tried to establish I have only been able to use blunt needles on one. The blunt needles easily slide through the skin, however can’t penetrate the vessel. Even after extensive searching I have never been successful with a blunt needle on these 3 sites. I have doubled the time usually recommended using sharps to 12-15 sessions but still no success.
I have read that some people are never able to transition to blunts, however given that I have one successful buttonhole I’m not sure whether to keep trying, or to just buttonhole with sharps. I’m not aware if there are increased risks associated with this practice.
Do you have any experience with these types of problems or know anyone who would be a good point of contact?
I can only respond with my experience.
Buttonholing takes longer to learn than many people think. I have been doing it for about 15 years, and I am still finding ways to do it better.
As you know, the key is to insert the needles at a constant angle, so that a tunnel forms. At the end of the tunnel, the hole in the fistula forms an entry point like a cat’s bum – a pucker that contracts when not in use.
Moving to blunt needles once you have formed a tunnel with the sharps takes a little care. Up until about a year ago, I used to just gradually push the needle down the tunnel. Sometimes I would find the hole; sometimes it took a bit of searching. Then I experimented with different approaches. Here, in detail is the one I found the best:
- Take off the scab (I use sharp 18 or 19 gauge needles, 1 per hole – blunt draw-up needles are useless on long-term scabs) and be sure the entry hole is clearly exposed (I usually do this by poking the needle down the hole about half a centimetre)
- Hold the blunt needle at the barrel just above the wings, lightly between thumb and forefinger and making sure of the correct angle of entry, move it gently into the entrance
- Lightly twirl the needle back and forth, between your fingers, applying a very light pressure
- As long as it is in the hole correctly, the needle moves slowly down the tunnel (for me this usually mildly painful, like a pinching the skin firmly)
- While the fistula hole is at the end of the tunnel, it is not attached to it, so any deviation as the needle travels down can move the tip away from the hole. Slow, steady progress usually ensures that it arrives successfully at the hole entrance (I feel it when this happens, as a small increase in the sting, but located inside my arm, not on the surface)
- Slightly increase the pressure, still twirling slowly, until the tip enters the fistula
- Stop twirling and glide the needle into position for taping (I use gauze to fix the needle at the entry angle throughout the run)
- After the run, ask the nurse removing the needle to remove it at the same angle.
For me, the key is a light, slow and steady touch.
With all this rigmarole, buttonholing takes longer than sharp needling. The whole routine, including washing and sterilising with Betadine before I start usually takes me 15 – 20 minutes.
From a unit viewpoint, buttonholing represents an added workload for staff. It takes a little longer, and the risk of infection is slightly higher statistically, but like New York, it’s worth it.
More than half the people in our unit use the buttonhole technique, some self-cannulating, others staff-cannulated, and I can’t remember any fistula infection in the unit in the 17 years I have been dialysing there (touch wood).
Many buttonholes last for months, sometimes years. However, as they get to the end of their useful life, the fistula hole starts to move around like a staircase at Hogwarts Castle and it gets more difficult to find. If that happens, it’s time to start a new tunnel.
With regard to using sharps long term for buttonholing, I am not aware of any problems. But I would be surprised if the tunnel remained intact for a long period, especially if more than one person is inserting the needles. You would certainly have less trouble entering the fistula, but it is unlikely that each entry would be via the same hole, and multiple piercings over a small area may have consequences.
Over to you.