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New to HHD, with questions

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  • New to HHD, with questions

    Hi Everyone, I am a 32 year old and I just started HHD with my mom as my caregiver maybe 2 weeks ago. My training staff at Davita was wonderful and I've never done in center so I have nothing to compare HHD with. My question there anything I can do to deal with the tenderness and soreness in my access. I use Lidocaine before, sometimes it works, sometimes it doesn't but I'm starting to get anxious about the sticks because its so sore. Does the pain ever go away or decrease?

  • #2
    Hello Tiffanienco,

    I've been conducting HHD since the start of training and hemodialysis in July 2012. You don't mention if you are cannulating with button hole sites in your vascular access. The use of button hole sites, which are created through 5 to 9 consecutive "sticks" with sharp hemodialysis needles, develop a tract in the skin to the fistula and a "flap" in the fistula both of which can then be cannulated with "blunt dialysis needles" that do not cut but instead twist, slide and push through the button hole and into the fistula. The tract develops scar tissue or a callous that reduces sensation of the blunt needle. The proximity of the each button hole site to nearby nerves will determine the amount of discomfort upon cannulation.

    I have developed 8 button hole sites to either replace sites that became unuseable for reasons of poor flow, long tracts and difficult fistula access, proximity to a narrowiing in the fistula or site inflammation. I have five button hole sites in current use and rotate through different pairs of these during my 5X weekly treatments. I've never used any form of topical pain relief but did experience some rather uncomfortable dermatitis on the skin of my lower right arm in the area of the button hole sites. The dermatitis took some 6 months to clear up with the help of a dermatological cream for laser abrasion called Glytone. The skin drying from arm washing and site prep with alcohol took some getting used to.

    Self-cannulation is a sure way to reduce the anxiety of a stick as you are in complete control and can modify needle position and advance based on what you are feeeling.
    Last edited by stumpr54; 11-19-2014, 09:01 PM.


    • #3
      Hi Stumpr54

      Thanks for answering, I am using buttonholes with 16g buttonhole needles in my vascular access. Do you remember how long it takes to stop hurting? It's only been a month and a half but I would like to look forward to some relief.


      • #4
        Tiffanienco... mine hurts for about two weeks while they developed it. As soon as I started cannulation, I had no pain. Sometimes since I am in center, it is a hard push into the buttonhole but that doesn't even hurt. It also does not hurt to take off the scabs first but if the techs do that then it hurts. I would much rather be in charge of me. Problem is if the tech pushes the needle in all the way after I have adjusted it which causes the hole to be bigger and then that causes bleed drips at the last hour of treatment. Usually a drop or two and then when the needles come out they have to take them out fast so there would not be extra bleeding. The blunt needles should be taped with part of the top of the needle visible.


        • #5
          Hello Tiffanienco,

          The first few sticks with a sharp dialysis needle during the development of a new buttonhole offered some discomfort, although even this was minimal as I was the one doing the sticking. Self cannulation with either sharps or blunts removes the element of the unknown and surprise that is associated with someone else doing the sticking.

          My lower arm fistula is comprised of three different vessels, all of which are just under the skin. The button hole tracts in each vessel are quite shallow, with a blood flash produced almost immediately after the needle is placed. The absence of tissue through which the tract runs reduces the likelihood of engaging nearby nerves, which would otherwise result in some discomfort.

          If you have an upper arm fistula or even a lower arm fistula that resides under tissue layer, chances are the button hole tracts are very near or in contact with nerves, thus the discomfort. Under those circumstances, it is unlikely that after 1-1/2 months of sticking that the discomfort will ever go away. The only thing you can do is mentally getting used to it, e.g. deal with it. This is the state that I have reached when I get stuck for an IV, blood specimen, vaccination, fistulogram. I mentally recognize that the needle that I am being stuck with is a fraction of the size that I stick myself with and realize that if discomfort if a function of needle size, they are poking me with mosquito beaks, and I laugh at their efforts to produce discomfort.

          During my last fistulogram (June 2014), which was a follow up to a declotting (very uncomfortable without sedative) and balloon venoplasty (with sedative) procedure, knowing the minimal invasiveness of the procedure, I expressly requested no sedative of any kind. I was lucid during the entire 10 to 15 minute procedure and thus could feel everything. As the vascular surgeon informed me before each needle stick, I asked what the needle gauge was, as which point the 18 gauge and smaller needles caused me to laugh at these "baby needles", and "is that the biggest you've got?". The surgeon was well aware of my button hole development and self cannulation abilities, and was not insultated but instead entertained by my remarks.

          I was able to watch a portion of the procedure on the black and white monitor to my left (working on my right arm), the surgeon pointed out the line that contained the ballon that had been run into my fistula. I did grit my teeth a bit when he expanded the balloon to open a narrowing in the vessel - the same narrowing that led to a 10" long clot and a rather uncomfortable declotting procedure some 4 to 5 weeks earlier. I recognized that this procedure would assure proper functioning of this vessel and trouble free HHD on the soon to be two button hole sites that would be in place and in use on the vessel. Looking back on that procedure, it is clear that it was a worthwhile investment as the vessel has been trouble free and the two button holes on that vessel have worked very wel

          When you consider the alternatives to the discomfort you experience during cannulation of your button holes, you will realize that it is a small price to pay for the good health you can have only through dialysis.


          • #6
            Thanks Stumpr54

            Thank you so much Stumpr54,

            I had a feeling that I was going to have to get used to it. My access is in the upper inside of my right arm, an already sensitive spot. So far its worked great, although I had to retrain my mom on how to stick so it wouldn't make my access more sore than it already is. I'll look at the upside of the access and try not to focus so much on the pain.


            • #7
              I think the place where mine is has a lot of nerves and it will probably hurt for a while if not always. I'll keep using my lidocaine and look for the positive things that dialysis brings instead of focusing on the pain.



              • #8
                I have experienced a lot of pain, we keep hitting a nerve and the pain is excruciating. Two different times the pain lasted for many hours. I have a pretty high pain tolerance, I'm allergic to most pain meds and have had some major surgeries without any pain meds, such as bilateral knee replacement, so I don't feel like am being a baby. When the pain explodes from your shoulder to your hand, then sometimes lasts all night, I won't be getting used to it. We just started a new arterial button hole today, hoping it will be better, if not I will be talking to the surgeon. My fistula is in the upper part of my left arm and we use lidocaine cream, lidocaine shots and freezing spray, nothing helps when we hit the nerve. I'm scared!


                • #9
                  Hello Gailr46,

                  It seems that upper arm fistulas are more common than lower arm fistulas, especially in women. That is unfortunate as the veins in the upper arm are generally not as close to the skin as those in the lower arm - if present. The deeper the vein, the more the tissue the needle must go through to access the vessel. Add diabetes to the mix, and the vascular issues it presents, and the creation of a reliable fistula becomes even more challenging than the access to same.

                  I have been very "veiny" all my life and this proved a boon to the creation of a lower arm fistula. If I experience any discomfort whatsoever during self cannulation of any of my 5 ea. self developed button hole sites, it is so short lived that it is virtually unnoticeable. Besides, the realization that these button holes and the three vessels upon which they reside that comprise my rather unique fistula, are my lifeline and the permit me to go on living as I have before I began hemodialysis (HHD).

                  I'm a big proponent of fistulograms to resolve flow issues in a fistula, and I would not be where I am today without the two fistulograms and single declotting procedure that I have had in the past 2-1/2 years. You may want to see a vascular surgeon who specializes in fistulograms to see what he/she could do for your fistula to produce different access that may avoid hitting nerve bundles in and around your needle placements.

                  A well development buttonhole has plenty of scar tissue at the surface of the skin, which deadens those nerves but those nerves below the skin and in the tissue surrounding the tract to the fistula flap are another matter. No amount of lidocaine or topical anesthetic is going to relieve that pain. Keep trying different site locations until you find at least two that avoid nerve contact. Persistence is a virtue.