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Staying Ahead of Buttonhole Access Issues by Developing New Buttonhole Sites

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  • Staying Ahead of Buttonhole Access Issues by Developing New Buttonhole Sites

    Is it better to be skillfull than lucky? Perhaps a little of both. I've been an HHD patient since July 2012 when I started HHD training and have been performing hemodialysis with the NxStage System 1 Cycler and Pureflow SL at home since early September 2012. I didn't get the urge to develop a new buttonhole access site until March of 2013 when I started to have some challenges with my original venous buttonhole access. Through use, the fistula developed and the original flap moved up toward the elbow and away from the orignal buttonhole tract. Toward the end of its use, the 1" 15 GA blunt dialysis needle had to be 1/2 way in before I reached the flap and got a blood flash. It was just a matter of time before I was going to be unable to reach the flap and/or tunnel into the surrounding tissue.

    I have an array of fistula vessels in my right forearm, the result of a fistullogram performed at the end of July 2012 that led to a clearing of a stenosis near the anastomosis. I selected an upstream (toward the wrist) site on the vessel that contained the original venous site, because it was a relative straight section, just below the skin, and far enough away from the elbow joint so as not to cause needle "pinching" if I would happen to bend my arm at the elbow during treatment.

    I had my crack HHD clinic staff attempt to cannulate the smallish vessel, and the result was an almost immediate infiltration. The consensus was that the vessel was too small to accomodate a 15 GA sharp needle without infiltration. I went home with a different idea. I then used a 15 GA sharp dialysis needle to begin to cut the buttonhole tract and pierce the fistula to create the flap to achieve a blood flash but not advance the needle and risk an infiltration. I couldn't treat with the needle just barely below the skin and barely in the fistula, so I withdrew the sharp needle, held pressure for 10 minutes or so and then repreped the site and proceeded to place a 15 GA blunt dialysis needle into the not quite healed up tract and fistula flap and proceed with my normal treatment. I used soft touch cannulation with the blunt needle - holding the needle tube - not the wings, and "augered" the blunt needle into the vessle. If I encountered any resistance, e.g. the tip of the blunt getting caught on the fistula wall, I backed off slightly and adjusted my needle angle. A sharp needle would have infiltrated but the blunt would merely get stuck and I would "unstick" it. I did this through 5 to 7 daily cannulations and treatments, and by the 6th or 7th cannulation/treatment I was able to use a 15 GA blunt dialysis needle alone to cannulate the new button hole.

    I repeated this technique successfully on another buttonhole site in an even narrower vessel. While I was developing this site, my original arterial buttonhole access site became inflamed with a minor infection in the tract (treated by IV antibiotics in spite of negative blood cultures). I was barred from using the nearly 14 month old site for fear of the infection enteriing the fistula and my blood stream. Thanks to having a new site available, I was able to conduct my 5X weekly HHD treatments without missing a sheduled treatment.

    I've used both sites as venous and arterial interchangeably, as they are on different vessels, and while both get their blood source from the anastomsis, both find their way back to my heart via different and separate vessels. Not to completely thumb my nose at the classically accepted technique for developing buttonhole access, I've developed two more buttonhole sites on the largest portion of my fistula, one that can accomodate a 15 GA sharp dialysis needle with very low risk of infiltration, especially with me putting the needle in the same place at the same angle over 5 to 6 consecutive treatment days and then cannulating on the 6th or 7th day with a 15 GA Nipro (Dull) dialysis needle and after that 15 GA blunt dialysis needles.

    The reward for these efforts are 4 viable buttonhole access sites, all of which can be used as arterial sites, and three of which can be used as venous sites. The enabled site rotation should help ease the dermatitis I've developed in response the alcohol prep of the sites before cannulation, although that has also been aided my my constant moisturizing of the skin when not in treatment.

  • #2
    I have used my upper arm AVF since January 2013. It wasn't quite mature yet, but we had no choice as I developed a blood infection from the perma cath and had to have it removed. I started out with 2 sites as well, developed problem after problem and then in July found out I also had a stenosis in the lower part of the fistula near my elbow. Once the surgeon cleared it with a balloon, it worked great. The situation made me realize that I needed to have more than 2 accesses. My care partner started 2 more sites as I could not do the initial stick. One took the requisite 5 sharps before accepting a blunt, the 2nd one took a blunt after 2 sharps and has developed nicely. One is a needle length away from one of the orginals, however the 2nd is a bit less than a needle length as the tunnel for the orginal near it is vertical and does not level out like the others. I also know not to use 2 that are right next to each other. My schedule has always been 5 treatments but until the additional 2 sites, I could only manage 3 on most weeks because of the pain associated using the same 2 sites over and over again. Using the lidocaine cream did not work by the 2nd treatment even with a day in between. Now I have no problems treating 5 days in a row or however I want to work them.
    Stumpr54, you say you use alcohol to prep your sites; have you tried using "Except" from Sterling medical? I use it every treatment and have not encountered any allergic reactions despite having "sensitive" skin. I wash my arm with Mckesson antimicrobial soap, cover the sites to help loosen the scabs and then wipe down with the Except before inserting the needles.


    • #3
      This is great stuff MsBull76, just what I hoped in a response.

      Being able to work a blunt after two sharp cannulations is quite an achievement, but given the variables in skin, tissue and fistula, most anything is possible. My original arterial site required a near vertical needle angle to access the fistula flap, but the needle did level out somewhat once in the fistula. I'm at a loss to understand the pain issues with continuous use of the same sites, unless there is some nerve proximity.

      I'm amazed at how relatively pain free the process of soft touch cannulation is once a site is adequately developed, e.g. the skin around the site becomes tough, almost calloused. Of course, when you are sticking yourself, there should be no element of surprise and if there is discomfort, you can make adjustments in needle angle and speed of advance.

      I've got one site where the development of the fistula over 3 months required a dramatically different needle angle and restraint of the fistula (quite a trick with one hand, actually a forefinger, middle finger and thumb) in order to prevent the fistula from moving away from the blunt needle. The needle enters the side of the fistula and not the top as was the case when the site was originally developed. Cannulating the site is a classic example of Gunny Seargeant Highway's, "Improvise, Adapt and Overcome.

      I started out using Except, and after 6 months or so developed a skin sensitivity to it - dry, red, bumpy. My clinic suggested using straight alcohol (70%), which by its nature dries out the skin. My other prep is Hibiclens (also a antimicrobial soap), which hasn't caused any issues. I also abandoned the triple antibiotic on the site before applying the bandaids after holding pressure. The Hibiclens does a good job of loosening any scab and membrane that I may have over the site.

      My care partner/wife has watched me do things like pick scabs - more like scrape, and also put in needles (sharp and blunts) and she says it looks like it hurts, it doesn't, or if there is discomfort it is so short lived that it is immediately forgotten. I just guess you could say I embrace the Tom Berringer "Bad Seargeant" from "Platoon"'s command, "Take the Pain". Any brief discomfort is greatly outweighed by the therapeutic benefits and necessity of hemodialysis, and the comforts of home make it even more tolerable.


      • #4
        Hi Stumpr54, the pain is only at initial contact to the access site with a blunt needle. No one seems to know why. My access has not bulged out with maturation like most do, and my HD nurse said that might be why or I just have sensitive skin. I know a lot of people who just "grit their teeth and bare it", but unfortunately I'm not one of them. One day between sticks using alternate sites has helped considerably. I use a rolled up 2x2 taped with plastic tape under a Velcro tourniquet as a "fistula brace" as my fistula moves a lot when sticking and I am just not coordinated enough to use my fingers from my sticking hand. My care partner and I argued a lot about using the touch method until he figured out he wasn't the one in the "hot" seat and if it worked for me, then just let it be. I also cover my fistula after washing with "Press n Seal" which pretty much takes off most of the scab when I remove it. The times that I have not used it were very regrettable. My situaltion is a bit different than most home dialysis patients in that I trained with a care partner but it was understood that after a certain amount of time, he would no longer be involved. Everything I learned was geared to that end.


        • #5
          Hello MsBull76,

          I'm enthralled with your creation of the "fistula brace". My HHD clinic team provided me with a plastic "fistula brace" that surrounds the fistula on two sides and is to be taped in place before a stick. While I had my care partner apply a finger for a week's worth of sticks on the "moving fistula" site, I wasn't fond of the additional process step, especially since her work takes place at the end of treatment with pulling my second needle and cleaning the machine and prepping a SAK in the Pureflow SL whilst I hold pressure.

          I was successful, though a bit shakey on the first try - restraining with index finger and rolling and pushing the needle by the tube with the thumb and middle finger, I'm now quite good at it - practice, and in fact can be relentless, though if I'm off target (not on the flap), it does poke the tissue and hurt a bit, which causes me to adjust needle angle and then advance until I get a flash.

          I've abandoned the use of a tourniquet for months now, as another step in the hemodialysis process that I do not need. I get more than adequate flash from each site, have no needle cannulation issues on all but the one site that requires the special hold, which tends to obscure the flash - but I know that I've got to be in the fistula because it doesn't hurt and there's very little silver (needle) showing. When I loosen each needle tube cap, the blood flows very quickly to the cap on all four sites. I don't use Heparin for daily treatments and only a 0.8 ml bolus at the start of Tx for nocturnal. I can thank chronically low platelet count for that, made up for by 20 minute holds at the end of Tx to stop the bleeding.

          I was in my HHD clinic this morning (took a day of vacation) for transonic testing of my three new buttonhole sites, and I had three needles in place in order to test the various site combinations. It was quite a feat of sterile plumbing accomplished by the dialysis nurse running the transonic test. It was the firt time she had to test two combinations of three sites on a single arm. All three sites pulled and pushed adequately.

          During the associated daily treatment, my HHD trainer suggested that I abandon the practice of flushing each needle after cannuation before hook up, as I never have needle issues that would be detected with a syringe push and pull. I'm all for things that reduce waste (time, materials) and variation, and I will incorporate his suggestion upon my next HHD treatment.

          I've dramatically cut down my gauze use with better pressure holds, and I can now cut my 10 CC syringe use by 50%!!!! I'm even using my chux for two consecutive treatments, provided I don't have anyhing but a drop or two of blood/blood/saline on it at the end of the first treatment.

          I use an over the bed hospital table (on wheels) to lay out all of my materials (suspend my "garbage bag/cartridge bag") on a chux held in place by picnic table cloth spring loaded clamps. I secure my blood lines via velcro to the underside of the table, saline bag and syringes secured by velco on the face of the NxStage System 1, and elastic velcro arm bands to secure my needle tubes and cartridge blood lines to my arm, giving me complete freedom of motion with my fistula arm. My use of paper tape is limited to the access sites on my fistula arm. In the summer and during nocturnal Tx's I use a forearm "warmer" to cover the arm and secure the tubes/lines.

          I''ve found all sorts of ways to streamline the HHD process and reduce waste and variation as has my care partner/wife. When I started HHD training in July 2012, the waste bugged me, and it took several months to become capable enough at the proces to start to develop and implement the improvements that make HHD as unobstrusive and as waste free as it can be.
          Last edited by stumpr54; 10-18-2013, 06:20 PM.


          • #6
            Hi Stumpr54,

            With no care partner I've had to come up with alternatives when hooking, up and coming off. Because my blood clots very easily, I have to use .5 heparin and have to use flushes (sometimes 2 or 3) before I hook up. But the flip side is that my hold time at the end of treatment is usually only 3-4 minutes. I did notice that with the 2 new access sites, the hold time for at least the first 5 sticks was closer to 10-15 minutes. The hold time is gradually coming down with each use.

            I've not heard of a "transonic test" to check the viability of access sites. Very interesting.

            My blood flow rate is usually 500 on all 4 sites now. Starting out the two new sites would only run at 450 without alarms. They have gradually increased to 500 which makes my treatment time usually about 2hr 10min. The only time it drops is if I use a sharp without a back-eye.

            I also use a hospital table but my supplies are permanently located on it. I have a separate 3 drawer cabinet with supplies that I use to replenish the table once or twice a week. I keep several treatments worth of supplies on the table. I have 2 cats so I keep a plastic cover over the table to keep out dust and cat hair. It's made from one of the saks that I cleaned and then cut apart. I use the other section of the sak to cover my machine. I also use the softer inside plastic of the sak under the cat's meal dishes. I recycle the cartridge bags too; they come in handy for just about anything. I used one yesterday to cover a new tape board as it is similar to wax paper but doesn't tear as easily.

            I like your use of velcro for the lines. I've tried several things but still just use a piece of the plastic tape to secure them to my lower arm especially when using the bottom 2 sites. I no longer use the paper tape, I found it to be totally useless and was glad when Sterling said I could switch. Because of the variations of my sites (2 level 2 vertical) I use 3 pieces of tape to anchor. One small steri-strip across the base of the needle on all 4; one medium piece across the wings for the 2 level sites, and a very long piece to go over the wings and secure the cotton roll under the needle, on the 2 vertical. The third piece is the chevron for all 4. I sometimes forgot to tear the strips before treatment or different times ran out of tape. Now I use a "tape" board. I can put as many as 3 treatments worth of tape the various sizes I need on it. I keep it in a gallon size plastic bag to keep out dirt and to keep it from getting stuck to any of the other supplies.

            It's amazing the various processes we come up with to suit our individual needs. I wish more people would join so we could learn from each other. Things like; all the supplies you need to take with you if you are traveling for more than 2 days and are taking your machine with you. I could have used that information before I took a 4 day trip to New York from Cleveland. Luckily I was traveling with a friend, his son and his grandson. All I had to do was pack the boxes (15 total including hanging bags). They loaded and unloaded them and the machine 4 times for the trip. Any trips I take in the future I will have Davita try to get me into the closest center as a transient. Less stress, less headache, less worry and only one extra bag to pack. Using the “press n seal” came from a day I was in center for anti-biotic treatments and saw a gentleman pull it off his arm before the techs cannulated him.

            You said you also do nocturnal dialysis. I know about nocturnal, home PD; are you talking about nocturnal home hemodialysis? If so, what is involved with that? I know my center offers nocturnal dialysis in center, but it was not something I could do since I am a very light sleeper who moves a lot during the night.

            I was working when all this started last year and continued to work up until September this year. The people I worked directly with were absolutely great when it came to having to take time off for appointments, taking sick days and even allowing me to take an extra half hour to forty five minute breaks when I continued to experience fatigue by 1 or 2 in the afternoon. I thought the fatigue was due to stress, but even now at home I still have to take 1 or 2 quick naps during the day, due in part to the other health issues I have. It’s very doubtful I would ever find an employer who would be so accommodating from the very start.

            Even though my kidneys still have some function, I am reminded daily with pain, that they are "in the process" of shutting down completely. And though this process started out suddenly and will last the rest of my life, I'm glad that I have had this time to learn about my lifeline. It hasn't made it easier to accept; (needed some serious attitude adjusting during the first year), but it has made it easier to deal with.
            Last edited by MsBull76; 10-27-2013, 12:03 PM.


            • #7
              Hello MsBull76,

              This reply to your 10-27-13 reply to my 10-18-13 reply is another case of the difficulties of achieving "real time" responses in the forum. I likely checked this post for several days after my 10-18-13 reply and not seeing anything, went on to other posts. I've determined that the most expeditious manner to communicate directly through the DaVita website is through messages sent directly to a member. You receive a notification when you log on to your Profile and also get an email notification of any messages at your designated email address.

              I'm surprised that your HHD clinic has not conducted transonic tests on your access - specifically your 4 button hole sites. This was mandatory when I was in HHD training. My venous site at that time did not pass the transonic test as that portion of the fistula - created during a fistullogram and clearing of a stenosis at the anastomosis only weeks earlier, had not matured to the point where it could withstand the pull forces if used as the arterial site. In time it did develop and pass the transonic as all 4 of my current button hole sites have done.

              I can't agree more about the value of sharing the process details that HHD and other dialysis patients have come up with during the course of treatments. You've done an excellent job describing how you have your "dialysis room" layed out, the management of your supplies and the securing of needles and lines. In spite of the information rich verbiage, photos of these things would certainly enhance the words. I have photographed the details of my dialysis room and a typical treatment. The photos have been arranged in two PowerPoint presentations. I am strongly considering filming "my HHD operation" and editing it into a DVD that I will share with family members and select relatives so they get some appreciation of what I have been spending nearly 20 hours a week doing since September 2012.

              I am glad to have piqued your interest in nocturnal HHD. My HHD clinic, DaVita Bluemound at Home in Wauwatosa, WI has been an innovator in HHD for some time now. They have participated in what is now two separate studies directed by NxStage Medical for FDA approval of the NxStage System 1 Cycler for use in nocturnal HHD. I participated in the most recent study begun in early 2013, which consisted of 2 months of short daily Tx's and 3 months of nocturnal Tx's. I learned how to program the System1 for a nocturnal Tx and conduct a nocturnal Tx. There are a few different requirements such as a cycler leak detection mat that resides under the cycler, a blood leak sensor that is placed on the venous needle, use of a heparin pump throughout the treatment to prevent clotting, and of course far lower Blood Flow and Dialysate rates to accommodate a 6 to 10 hour treatment. The therapeutic benefits of nocturnal dialysis are well documented as you are receiving far more dialysis than during short daily or in-center and this more closely mimics the function of normal kidneys, which work 24-7. Opportunities to reduce or eliminate BP meds, greatly reduce the affects of fluid removal - 6 to 8 hours to remove the fluid normally removed in 2 to 4 hours, far better removal of phosphorus and potassium, and of course time not spent during normal functioning hours all add up to quite a win-win for the patient. I now conduct 2 ea. nocturnal Tx's per week along with 3 ea. daily Tx's with the ability to mix these in any manner that coincides with the 60L batches of dialysate that I produce with the PureFlow SL. I usually do a 40L nocturnal Tx and follow with a 23L daily Tx. Yes, that's more than 60L, as I discovered that the PureFlow with SAK actually produces nearly 64 liters of dialysate. I figure that I paid for the water and energy to make that dialysate, more dialysis is better than less and I may as well use what I paid for.

              Regarding, a check list for traveling with the System1 Cycler, NxStage sent out such a list about a year ago. My care partner/spouse and I used it with great success for a driving trip to New York state back in June 2013 when I was particpating in the NxStage Nocturnal HHD study. I treated 4X during the week using bags and cartridges that NxStage delivered to our destination. It was the only time I was able to treat nocturnally in the same bed with my spouse. My "dialysis room" is equipped with a day bed, which serves just fine for sleeping and sitting during treatments and has the needed space for the PureFlow SL and System1 Cycler.

              I too have residual kidney function that I am reminded of when I have to break off what I am doing at home or work to head to the bathroom to urinate. I don't have any pain, in spite of the football size of my polycystic kidneys. I'd love to be able to take naps in the office, especially after eating a meal. That is when I am most prone to somnolence - fading out in front of the computer or in a meeting when I am not being directly engaged. I've tried CPAP therapy for what was diagnosed via sleep study as mild apnea but the results have not been significant enough to justify the hassles of using the equipment every night. I have found that I do need more sleep than I did before reaching Stage V kidney failure. I used to be able to function acceptably on 6 to 7 hours and now find that 7 to 8 produces a mentally sharper me. I am able to put in 11 hour days in the office and that and beyond when out of town travel is required. I can thank the effectiveness of my treatments and the stage of my disease for that.