rsa buttonhole presentation 2008
DESCRIPTION
A presentation to the Renal Society of Australia, showing the what, why, when, where, who and how of buttonholing for dialysis.TRANSCRIPT
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..