Slide Courtesy: Deborah · PDF file2/5/2015 ASDIN 2015 1 Buttonholes: Should we use them? Arif...
Transcript of Slide Courtesy: Deborah · PDF file2/5/2015 ASDIN 2015 1 Buttonholes: Should we use them? Arif...
2/5/2015
ASDIN 2015 1
Buttonholes:Should we use them?
Arif Asif, MD, FASN, FNKF
Standard AVF Needles
Cut skin, Sub Q tissue and Vein withneedle insertion
Can cut the vein and cause an infiltrationonce inside the vein
Can also cut the same with needleremoval if the needle is compressed as theneedle is being removed (patients willcomplain of pain with the needle removal)
Slide Courtesy: Deborah Brouwer
“One-site-itis”
“One-site-itis” occurswhen you stick theneedle in the samegeneral area, dayafter day.
Causes aneurysm andstenosis formation.
Areapuncture
sitetechnique
AKA“One-site-it
is”
Slide Courtesy: Deborah Brouwer
Vesely TM: J Vasc Interv Radiol 16:1301-1306, 2005
Buttonhole Needles
Blunt or “Dull” edges
Will not cut Skin, Sub Q tissue or Veinwith needle insertion
Will advance into the scar tunnel track likea pieced earring enters the earring tunneltrack
Slide Courtesy: Deborah Brouwer
Buttonhole Needles
Can not cut skin, Sub Q tissue and Veinwith needle insertion
Can not cut the vein and cause aninfiltration once inside the vein
Can not cut with needle removal if theneedle is compressed as the needle isbeing removed
Slide Courtesy: Deborah Brouwer
2/5/2015
ASDIN 2015 2
Buttonhole History
First appeared in Poland in 1977
Dr Twardowski developed the technique in Poland over 25 yearsago
Dialysis supplies including AV fistula needle were very limitedsupplies.
AV fistula needles were reused for multiple cannulations.
The needles became dull after repeated use and would not cut theskin
The “dull” needles would enter smoothly if the exact samecannulation site was used (same skin entry, same angle of entryand same vessel entry angle).
Buttonhole technique was used to solve dull needle challenge
Slide Courtesy: Deborah Brouwer
What is buttonholetechnique?
Buttonhole technique is a cannulationmethod where an individual cannulatesthe AV fistula in the exact same spot, atthe same angle and depth of penetrationevery time.
A scar tissue tunnel tract developsallowing for the use of a buttonhole fistulaneedle.
Slide Courtesy: Deborah Brouwer
AVF Buttonhole Technique
Slide Courtesy: Deborah Brouwer
Cannulation Issues
Pain
Cannulation injuries and hematoma
Infection
Stenosis and thrombosis
Pseudoaneurysm formation.
Buttonholes and Infection
N=33.
Patients were followed-up for 18 monthsand pain, cannulation injuries and AVFinfection were assessed.
A significant reduction in pain andcannulation injuries was found.
3 AVFs developed infection at thecannulation site.
Verhallen et al: Nephrol Dial Transplant 2007
Buttonhole and Infection
N=21
47% had increased incidence of clottingafter the initiation of cannulation using thebuttonhole technique.
Infection of the AVF was observed in 10%of the patients.
Reduction of pain and cannulation injuries.
Silva et al: J Brasil Nephrol 2010
2/5/2015
ASDIN 2015 3
Buttonhole and Infection
177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.
The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.
The incidence of infectious events increased afterthe switch to the buttonhole method to 0.43events/1,000 AVF-days (P=0.003).
Labriola et al: Am J Kidney Dis 2011
Buttonholes and Infection
Randomized clinical trial.
N=70.
fistula cannulated for two to four weeks at thesame angle and direction with sharp needles(n=35).
Once the tunnel was developed, blunt needleswere used (n=35).
The control group continued with usual practice.
Pain, hematoma and infection were assessed.
Chow et al: Journal of Renal Care 2011
Buttonholes and Infection
Results: Infection at the cannulation siteoccurred in four patients in the buttonholegroup and one in the rope ladder rotationgroup (p=0.11).
Hematomas and site pain experiencedduring the dialysis session were moreoften recorded for the buttonhole group(p=0.05).
Chow et al: Journal of Renal Care 2011
Scab Removal and Cannulation
Don’t flip the scab offwith the needle you willuse for cannulation—this contaminates theneedle
Don’t use a sterile needle—you could cut thepatient’s skin and youwould also need a sharpscontainer nearby
Don’t allow patients topick at their scabs
Do use aseptic scabremover, or Soak two 2″ x 2″s with sterile
saline and apply over thescabs; or
Moisten 2″ x 2″s with alcohol-based gel; or
Have patient tape an alcoholsquare over sites prior todialysis
Have patient apply moist,warm washcloth to scab siteprior to arriving at dialysis tofacilitate scab removal
Buttonhole and Infection
177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.
The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.
The incidence of infectious events increased afterthe switch to the buttonhole method to 0.43events/1,000 AVF-days (P=0.003).
Labriola et al: Am J Kidney Dis 2011
2/5/2015
ASDIN 2015 4
Buttonhole and Infection
177 patients (aged 70.4±11.5 years) with 193AVFs were analyzed over 186,481 AVF-days.
The incidence of infectious events for conventionalcannulation was 0.17/events /1000 AVF days.
The incidence of infectious events for buttonholessignificantly decreased to 0.15 events/1,000 AVF-days; P=0.04) after the employment of qualityimprovement educational workshops.
Labriola et al: Am J Kidney Dis 2011
CONCLUSIONS Skin tunnel track provides bases for
repeated use of a cannulation site.
Careful aseptic technique is required.
Logically, it should reducepseudoaneurysm formation.
There does not seem to be an increasedrisk of infection as demonstrated by arandomized study.