RSA buttonhole presentation 2008


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

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  • No doubt many of you who work in haemodialysis can relate to this cartoon. It was situations like this that lead us to explore butthole cannulation Buttonholing is not a new technique Used for homehaemo clients Used extensively in Europe for some decades Not generally been used in-centre Limited literature found on lit search Bendigo commenced in-centre buttonholing in Nov 2004 and have buttonholed 19 clients todate We use dull fistula needles after the establishment phase with the buttonhole
  • Rope ladder cannulation appears to be the most commonly taught method however area puncture appears to be the most common practice, especially when a difficult fistula is faced and probably more so when less experienced staff are cannulating. Tendency to follow the previous cannulation in around the same area
  • If buttonholing is being contemplated then the reasons why need to be examined as they will influence where the holes should be created and on what angle Support may need to be sought from the Physician or surgeon and this needs to be ongoing support
  • The initial clients selected had cannulation difficulties frequently required transfer to Parent Hospital to facilitate dialysis treatment Inconvenient for clients Frustrating for staff - regional & metro After establishment of buttonholing there were no cannulation issues requiring transfer to Parent Hospital
  • Observe and palpate fistula and plan out the areas for buttonholes and include plans for a 2 nd set of holes at a later date If the establisher not available for a cannulation episode then other staff can cannulate but must avoid the planned sites
  • The entire buttonhole creation is hinged on the exact same site, angle and depth – hence the need for one cannulator in the break in or establishment phase Our experience has been that establishing probably takes between 6 to 12 cannulations but is very much dependant on the fistula and client
  • Establishing is really no different to an ordinary cannulation except for the repeat site/angle/depth each time
  • Scab removing can be time consuming for some fistulas. We find soaking with alcohol chlohex for 5 minutes or more does generally help soften and aid lifting of scab
  • Again no different to any other cannulation
  • Insertion is quicker but removing scabs can take a little time Bleeding time for some problem clients has been reduced I guess because it is a clean cannulation without trauma We have buttonholed approx 20 clients in 2 years and in that time 2 clients have had fistula infections. One clients hygiene is such that infections had occurred pre buttonholing and the other client works out in dirt and dust and therefore is a candidate for infection regardless of cannulation method
  • Betty was our driving force to commence buttonholing She was seriously considering ceasing treatment purely because of the pain, anxiety and frustration experienced with her cannulation for her haemodialysis treatment
  • Fay has a short fistula which is quite soft onesititis was becoming obvious She had had some infection issues as a result of picking at her fistula when infection was present there was even more limited cannulatable areas
  • Fay now has very successful buttonholes She has had one episode of infection but as mentioned this was occuring pre buttoholing as well
  • To evaluate the effectiveness of our buttonhole program we developed questionnaires similar to the Gold Coast presentation at RSA 2006. 13 clients and 9 staff undertook the questionnaires
  • Firstly we asked about the good and bad things associated with the method It was reassuring to see that there was unanimous agreement that there was nothing bad about buttonholing from the patients perspective
  • Clients were questioned regarding pain during buttonholing & 11 of the 13 experienced less pain with the new buttonhole method
  • TIME - 9 Clients noted reduced time from sitting in their chair to begining their treatment and the all important time count down on the dialysis machine
  • 11 clients stated that they experienced less anxiety with the buttonhole method of cannulation Prior to buttonholing some clients had experienced on average 2 dialysis sessions per week with cannulation troubles so anxiety had become a BIG problem
  • 9 of the 13 clients had experienced frequent "blows" of their accesses during cannulation prior to commencing buttonholing. Following buttonholing commencement there have been NO blows for any of these clients. 7 clients commented they had reduced post bleeding times with the buttonhole method
  • These are some comments pulled from the questionnaires The top comment says it all for our first client as she is still dialysing. Comments like 'I am pleased I haven't got big lumps up my arm' make you realise that body image is a concern for some clients
  • Infection rates contry to some beliefs in the renal world we have not seen any increased fistula infections associated with our in centre buttonholing We have experienced one infection but this client had had previous fistula infections prior to buttonhole commencement We had 2 fistula infections in the non buttonhole clients over the same two year period. A Lit search could find no documented evidence of increased infection rates associated with buttonholing
  • Twardowski probably the most published person with regard to buttonholing todate sums up the advantages of buttonholing succinctly in this quote
  • 9 of our staff who were present pre and post buttonholing were given questionnaires Again all the comments were positive less pain less anxiety less time to cannulate were all noted
  • This slide again shows staff comments like * increased confidence with difficult fistulas * decreased time troubleshooting * decreased time looking for suitable cannulation sites As a result of our buttonholing program all staff members in Bendigo regardless of experience can now cannulate every client in the unit
  • 2 difficulties were noted by staff 1. scab removal............. remains an ongoing issue as it is individual client dependant * some scabs lift easier than others * We soak to moisten with Chlorhex soaked gauze * Scrape with the gauze or lift with a blunt drawing up needle 2. Need for careful positioning of the fistula arm to align the fistula and buttonhole tracks correctly
  • This client had a very deep fistula and quite fleshy arm. With a very poor cardiac & medical history the surgeons were extremely reluctant to take her back to theatre for superficialisation of the fistula. After some limited success with cannulations and an ongoing reliance on her permcath we decided to try buttonholing. We used the site rite machine in the initial stages to give a guide for needle attempts and after many agonizing sessions managed to create some buttonholes
  • With the thought to trying to get this client home we commenced buttonholes and self cannulation with this client
  • Another success with what was a short and difficult access
  • Left short forearm fistula about 5mm available area initially This pic shows how mushy to buttonholes can become when attempting scab removal
  • 2 sets of sites are good if there is room for these then alternating sites is possible Education for both nurses and medical staff is very important for the acceptance of buttonholing Need to be aware that when using the dull needle the cannulation sensation for the cannulator can be different may need to push harder and there can be the trampoline effect May need to slightly rotate the needle on insertion to cut through the vessel
  • we acknowledge that buttonholong is not necessarily possible/suitable for all haemodialysis areas but it would be advantagous if all staff had an understanding of the principles of cannulation & management for a buttonhole and when they are not able or confident to buttonhole then to be aware to cannulate away from the buttonhole areas.
  • in conclusion our experience in Bendigo has shown that buttonholing ......... * has positive outcomes * is not difficult * has shown no increased fistula infection rates * has decreased stress levels for client and staff * and promotes greater client self care, autonomy & confidence
  • finally Anything which can potentially promote the logevity of the fistula is surely worth doing.
  • Betty is now a very happy lady
  • These are our eferences and we would like to acknowledge the clients and staff who have embraced the buttonhole program and made this presentation possible. Thanks also to the clients for allowing us to use their photos and tell their stories
  • RSA buttonhole presentation 2008

    1. 1. Buttonhole Cannulation Anna Flynn & Annette Linton
    2. 2. Aim of Presentation <ul><li>Discuss </li></ul><ul><li>What is buttonholing </li></ul><ul><li>Client selection </li></ul><ul><li>Buttonhole establishment </li></ul><ul><li>Benefits of buttonholing </li></ul><ul><li>Bendigo buttonhole clients </li></ul><ul><li>Client buttonhole evaluation surveys </li></ul><ul><li>Staff surveys </li></ul>
    4. 4. Buttonholing Background <ul><li>Not a new technique </li></ul><ul><ul><li>Used for homehaemo clients </li></ul></ul><ul><ul><li>Used extensively in Europe </li></ul></ul><ul><li>Not generally been used in-centre </li></ul><ul><li>Limited literature found on lit search </li></ul><ul><li>Bendigo commenced in-centre buttonholing in Nov 2004 </li></ul>
    5. 5. Button Hole puncture Area Puncture <ul><li>Prone to aneurysmal dilatation </li></ul><ul><li>Stenoses may develop in adjacent areas </li></ul>Rope-ladder puncture <ul><li>Small dilatation occurs </li></ul><ul><li>over length of fistula </li></ul><ul><li>“ does not cause dilatation or stenosis” </li></ul>Twardowski,1995; Kr önung 1984
    6. 6. Buttonhole puncture site Thanks to Nipro for use of photo
    7. 7. Onesititis
    8. 8. So how is a buttonhole site established?
    9. 9. Buttonhole Cannulation <ul><li>Establish reason for buttonhole ie </li></ul><ul><ul><li>client to self cannulate </li></ul></ul><ul><ul><li>Short or difficult fistula </li></ul></ul><ul><li>The reason will dictate the position of the buttonholes </li></ul><ul><li>Discuss & educate client re buttonholing </li></ul><ul><li>Enlist support from Renal Physicians </li></ul>
    10. 10. Selection for Buttonhole <ul><li>AV Fistula </li></ul><ul><ul><li>Challenging to access </li></ul></ul><ul><ul><ul><li>Short </li></ul></ul></ul><ul><ul><ul><li>Onesititis </li></ul></ul></ul><ul><ul><ul><li>Repeat infiltrations </li></ul></ul></ul><ul><li>Client </li></ul><ul><ul><li>Agreement </li></ul></ul><ul><ul><li>↑ anxiety level with cannulations </li></ul></ul><ul><ul><li>Requesting more autonomy </li></ul></ul><ul><ul><li>Considering home dialysis </li></ul></ul><ul><li>Renal Physician agreement </li></ul>
    11. 11. Buttonhole Cannulation <ul><li>Select a site </li></ul><ul><ul><li>straight piece of vessel without aneurysm </li></ul></ul><ul><ul><li>If client wishing to self cannulate then have them do so from the first cannulation </li></ul></ul><ul><ul><li>Select a suitable site - easily reached & visualized by client </li></ul></ul><ul><li>One ‘cannulator’ when establishing a buttonhole </li></ul>
    12. 12. Buttonhole Cannulation <ul><li>Cannulate exactly the same </li></ul><ul><ul><li>Site </li></ul></ul><ul><ul><li>Angle </li></ul></ul><ul><ul><li>Depth of penetration </li></ul></ul><ul><li>Literature suggests at least 6 cannulations with sharp needle – probably more like 9 to 12 </li></ul>
    13. 13. Buttonhole Cannulation <ul><li>Insert approximately at a 25° angle </li></ul><ul><li>On flashback, lower angle of insertion & advance needle into fistula </li></ul><ul><li>Tape AV needle securely </li></ul>
    14. 14. Cannulating established buttonholes <ul><li>Once sites are established anyone can use sites using dull AVF needles </li></ul><ul><li>Wash arm / access as per Unit protocol </li></ul><ul><li>Cover scabs with alcohol chlorhex soaked gauze </li></ul><ul><li>Remove scabs with sterile plastic forceps, gauze or sterile “blunt” needle </li></ul>
    15. 15. Removing Scab
    16. 16. Removing Scab
    17. 17. Cannulating established buttonholes <ul><li>Swab puncture sites as per Unit protocol </li></ul><ul><li>Cannulate using dull AVF needles, when flashback is observed, decrease angle of insertion & advance needle to the hub </li></ul><ul><li>Securely tape needles </li></ul>
    18. 18. Cannulating
    19. 19. Tape Securely
    20. 20. Doppler Image Buttonhole tunnel
    21. 21. What are the benefits? <ul><li>Insertion is easy & quicker </li></ul><ul><li>Cannulation is less painful </li></ul><ul><li>Fewer missed attempts to place needles </li></ul><ul><li>Haematoma formation is reduced </li></ul><ul><li> bleeding time post treatment </li></ul><ul><li>Infection rate is no different to normal cannulation </li></ul>
    22. 22. Betty <ul><li>Soft forearm fistula </li></ul><ul><li>Obese fleshy arm </li></ul><ul><li>Extreme anxiety presenting for dialysis </li></ul><ul><li>Seriously considering ceasing treatment </li></ul><ul><li>In 7 months leading to buttonholing </li></ul><ul><li>21 of 87 HDX with cannulation issues </li></ul><ul><li>29 extra needle insertions in the 7 months </li></ul>
    23. 23. Betty <ul><li>12 months post buttonhole </li></ul><ul><li>↓ 2 extra needles in 156 HDX sessions </li></ul><ul><li>Within 4 buttonhole sessions </li></ul><ul><ul><li>client stated less pain </li></ul></ul><ul><ul><li>staff noticed smoother needle insertion </li></ul></ul><ul><li>Within a month client had no wish to cease treatment </li></ul>Venous Arterial Buttonholes @ 2 ½ year s
    24. 24. Fay <ul><li>Short soft forearm fistula </li></ul><ul><li>Onesititis developing </li></ul><ul><li>120 HDX sessions 12 extra needle insertions </li></ul><ul><li>Some infection issues (scab picking) </li></ul>
    25. 25. Fay <ul><li>12 months post buttonhole </li></ul><ul><li>No cannulation difficulties </li></ul><ul><li>1 episode of fistula infection </li></ul>Venous Arterial Buttonhole @18 months Cubital fossa
    26. 26. Bob <ul><li>Short upper arm fistula </li></ul><ul><li>Obese arm </li></ul><ul><li>Onesititis developing </li></ul><ul><li>Intermittent cannulation difficulties </li></ul>
    27. 27. Bob <ul><li>12 months post buttonhole </li></ul><ul><li>No problem cannulations experienced </li></ul><ul><li>2 sets of buttonholes developed </li></ul>Venous Arterial Buttonholes @ 29 months
    28. 28. Doug <ul><li>Short upper arm fistula </li></ul><ul><li>Obese arm </li></ul><ul><li>Onesititis developing </li></ul><ul><li>Intermittent cannulation difficulties </li></ul>
    29. 29. Doug <ul><li>12 months post buttonhole </li></ul><ul><li>No problem cannulations experienced </li></ul><ul><li>2 sets of buttonholes developed </li></ul>Venous Arterial buttonholes @ 12 months
    30. 30. 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.
    31. 31. Evaluation (Q1a - 1b) <ul><li>Q1a. What has been the best thing you have noticed (with buttonholing)? </li></ul><ul><li>‘ No lumpy bits on my arm’ </li></ul><ul><li>‘ Everyone can cannulate me now’ </li></ul><ul><li>‘ Needles go in 1 st time’ </li></ul><ul><li>‘ No pain’ </li></ul><ul><li>‘ No searching for a place to go’ </li></ul><ul><li>Q1b. Any bad things you have noticed? </li></ul><ul><li>13 unanimous NOTHING </li></ul>
    32. 32. Evaluation (Q2) <ul><li>Q2. Any difference in pain during cannulation? </li></ul><ul><li>11 ↓ in pain </li></ul><ul><li>2 felt no great difference </li></ul><ul><li>‘ 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. ’ </li></ul><ul><li>Ball, L (2006 p 304) </li></ul>
    33. 33. Evaluation (Q3) <ul><li>Q3 . Any difference in time taken cannulate & commence dialysis? </li></ul><ul><li>9 stated much quicker </li></ul><ul><li>4 same time </li></ul>
    34. 34. Evaluation (Q4) <ul><li>Q4. Any difference in anxiety level when coming to dialysis & being cannulated? </li></ul><ul><li>11 reported considerable ↓ in anxiety </li></ul><ul><li>2 had not noticed any change </li></ul><ul><li>‘ haemodialysis patients experience higher levels of anxiety & depression than ESRD patients receiving other forms of RRT ’ </li></ul><ul><li>Martin et al, 2003 </li></ul><ul><li>‘ Additional benefits (buttonholing) include ……… .and perhaps most importantly to the patients, less pain and fear of cannulation) </li></ul><ul><li>Network News – Special Edition Fistula First 2006 </li></ul>
    35. 35. Evaluation (Q5 & 6) <ul><li>Q5. Any difference in relation to ‘blows’ during cannulation with buttonholes? </li></ul><ul><li>9 yes – no blows at all </li></ul><ul><li>4 no blow problems pre buttonholes </li></ul><ul><li>Q6. Have post dialysis bleeding times changed with buttonholes? </li></ul><ul><li>7 definite ↓ in post bleed time </li></ul><ul><li>6 no change </li></ul>
    36. 36. Further Comments <ul><li>‘ For me it’s been a life saver’ </li></ul><ul><li>‘ I would always choose buttonhole over rope ladder cannulation now’ </li></ul><ul><li>‘ Pleased I haven’t got big lumps up my arm like some people’ </li></ul><ul><li>‘ Good way to needle, ↓ anxiety ’ </li></ul><ul><li>‘ Good practice, I can manage for self’ </li></ul>
    37. 37. Infection Rates <ul><li>In total 20 clients buttonholed in Bendigo since 2004 </li></ul><ul><li>1 incidence of infection seen in 28 months </li></ul><ul><ul><li>Client had previous fistula infections pre buttonholes </li></ul></ul><ul><li>Lit search found no evidence of ↑ infection rates with buttonhole cannulation </li></ul>
    38. 38. <ul><li>Advantages of the buttonhole Technique include: fewer infections, infiltrations, and missed sticks; decreased hematoma formation; and less pain, eliminating the need for anesthetic </li></ul><ul><li>(Twardowski, 1979 p 979) </li></ul>
    39. 39. Staff Questionnaires <ul><li>9 staff were given questionnaires </li></ul><ul><li>100% stated less pain noted for client </li></ul><ul><li>100% stated clients more relaxed </li></ul><ul><li>67% stated felt less anxious cannulating </li></ul><ul><li>100% stated much quicker time to have client dialysing </li></ul>
    40. 40. Staff Questionnaires <ul><li>Summary of comments…. </li></ul><ul><li>Minimal scaring of fistula </li></ul><ul><li>Much less pain for clients </li></ul><ul><li>Easier cannulation of challenging fistulas </li></ul><ul><li>↑ confidence in difficult cannulations </li></ul><ul><li>Much quicker, less time troubleshooting </li></ul><ul><li>Decreased anxiety for client and staff </li></ul>
    41. 41. Staff Questionnaires <ul><li>Difficulties noted </li></ul><ul><li>challenging scab removal on some fistulas </li></ul><ul><li>A client removing scabs at home </li></ul><ul><li>One fistula more mobile and careful positioning of arm required to find track </li></ul>
    42. 42. Buttonholes 2 months Buttonhole puncture sites
    43. 43. 3 months Buttonhole puncture sites 11 months
    44. 44. Approx 6 months Buttonhole puncture sites
    45. 45. 9 months Buttonhole puncture sites
    46. 46. Considerations <ul><li>Development of 2 sets of holes for rotation </li></ul><ul><li>How best to remove scabs </li></ul><ul><li>How best to educate/advise other units should client need to be treated elsewhere </li></ul><ul><li>Awareness there is an altered sensation when cannulating with a ‘Dull’ needle </li></ul>
    47. 47. <ul><li>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 </li></ul>
    48. 48. Conclusion <ul><li>Buttonholing </li></ul><ul><li>Positive outcomes for challenging fistulas </li></ul><ul><li>Is not difficult to achieve </li></ul><ul><li>No infection rate increase demonstrated with in-centre use </li></ul><ul><li>Decreases stress levels for client & nurse (do not under estimate the negative effect of stress) </li></ul><ul><li>Facilitates increased client self care, autonomy & confidence </li></ul>
    49. 49. Finally……….. <ul><li>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? </li></ul>
    50. 50. Betty Thank You
    51. 51. References <ul><li>Kr önung,G. (1984) Plastic deformation of Cimino fistula by repeated puncture Dialysis & Transplantation. 13: 635-638. </li></ul><ul><li>Twardowski,Z. (1995) Constant Site (Buttonhole) Method of Needle Insertion for Haemodialysis. Dialysis & Transplantation. 24(10),559-560,576. </li></ul><ul><li>Toma,S. et al (2003) A timesaving method to create a fixed puncture route for the buttonhole technique. Nephrology Dialysis & Transplantation, 18:2118-2121 </li></ul>
    52. 52. References <ul><li>Ball, LK. (2005) “Improving Arteriovenous Fistula Cannulation Skills” Nephrology Nursing Journal . 32(6) pp611-617 </li></ul><ul><li>Ball, LK. (2006) “The Buttonhole Technique for Arteriovenous Fistula Cannulation” Nephrology Nursing Journal . 33(3) pp 299-304 </li></ul><ul><li>Network News, Special Edition ‘Fistula First’ (2006) {on line accessed 25 April 2007} http:/ </li></ul><ul><li>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. </li></ul><ul><li>Peterson, P. (2002) Fistula Cannulation: The Buttonhole Technique. Nephrology Nursing Journal . 29(2) pp 195 </li></ul><ul><li>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. </li></ul><ul><li>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.. </li></ul>