Buttonhole Cannulation: RCT Finds Higher Complications

By Peter Laird, MD

Buttonhole cannulation, also known as constant site cannulation , is a technique for accessing dialysis fistulas utilizing dull needles in an established tract. However, there are very few studies available on how well it compares to standard techniques such as the "rope ladder" technique that moves up and down the fistula. A recent study on 70 patients randomized to either rope ladder or buttonhole technique revealed higher complication rates in the buttonhole cohort:

A randomized controlled trial of Buttonhole cannulation for prevention of fistula access complications

Method:  70 subjects were recruited for this study. Subjects randomised to the buttonhole group had their fistula cannulated by the same staff member for two to four weeks at the same angle and direction with sharp needles.  Once the tunnel was developed, blunt needles were used.  The control group continued with usual practice (rope ladder rotation technique).   

Results:  Infection at the cannulation site occurred in four patients in the buttonhole group and one in the rope ladder rotation group (p= 0.11).  Haematomas at the cannulation site and site pain experienced during the dialysis session were more often recorded for the buttonhole group (p< 0.05). 

Conclusions: This study showed that buttonhole cannulation resulted more infections, haematoma formation, and site pain during dialysis than with the rope ladder rotation group.  A further larger scale longitudinal study is recommended.

It is unclear at this time what the advantages of Buttonhole cannulation serves in the incenter population where nurses may not have the necessary time to adequately prepare the buttonhole before cannulation. Removing the scab prior to cannulation takes me several minutes, something that most dialysis technicians and nurses don't have in abundance. The finding of increased pain in this study is also interesting and I wonder if that was in relation to the process of scab removal by the nurses or the actual needle insertion. I greatly appreciate my own gentle hand when it comes to removing my scabs , but in the beginning before I acquired that task, the nurses removing the scab often hurt me more than the actual cannulation.

I would also like to see the same study in self care dialysis patients at home to see how well the incenter results compare to home patients. The issue of increased infections is a serious issue that in my opinion is related to individual preparation techniques more so than the buttonhole constant site technique itself since I have utilized buttonhole cannulation for four years without a single infection to date. Likewise, I know Bill Peckham has also avoided access infections while utilizing constant site cannulation for several years.

In addition to proper preparation and scab removal, I take great care with my fistula after dialysis, changing my band aids soaked with blood when I remove the pressure dressing in two hours, first cleaning around the site with alcohol pads.  I only use a sterile needle for each site to pick the scabs as well as sterile disposable plastic tweezers to help clean the scab, never using the same needle or tweezer for both. For my own care, the pain of inserting needles in an established buttonhole is greatly diminished. Adding to that, I have never had a hematoma formation. Buttonhole cannulation in the hands of a self care patient is still a consideration in my opinion based on my own experiences. I believe it simply takes dedication to the fundamental principles of infection control before, during and after dialysis as well as a willing patient to learn self cannulation.

I would hope that this study does not diminish the utilization of the only proven method of decreasing aneurysm formation that thousands of patients worldwide utilize on a daily basis. Further studies are warranted but I would suggest comparing self care buttonhole cannulation at home to that of in-center care where the technicians and nurses perform the cannulation. For myself, I am grateful for this useful technique and that I further have not had any of these complications listed in this study. Longitudinal studies employing self cannulation hopefully will improve upon the results in this study as some smaller studies already show:

Cannulating in haemodialysis: rope-ladder or buttonhole technique?

According to the nurses, in 26 cases (79%) the use of the buttonhole method was considered a success, especially because of easier cannulation with less pain. The cosmetic effects of the buttonhole method, compared with the rope-ladder method, were considered favourable in 12 patients: less haematomas and less scar tissue were present compared with the rope-ladder technique; none of the patients suffered from negative cosmetic effects (Table 2).

The paradoxical findings between the prior observational studies conducted over several months and years and this randomized and controlled trial needs further explanation before application in the clinical setting.  Certainly we do know that adherence to proper buttonhole technique including complete scab removal and infection control is the key to success for many dialysis patients who continue to note the benefits of buttonhole cannulation.  Regardless of the disappointing results of this RCT on buttonhole cannulation, it remains in my opinion a useful technique especially in the home hemodialysis population. 

 

Comments

[roberta mikles]

As a Dialysis Patient Safety Advocate, I have communicated with patients from all over the United States. I find that many have a buttonhole, however, were not told anything about a buttonhole, etc. Many, who are educated to buttonholes, continue to tell staff to remove the scab and use blunt needles, etc.(when appropriate, of course).

Many patients have pseudoaneurysms due to staff cannulating in the same place and NOT, even though they are supposedly taught, to perform the rope ladder technique. One staff told me that he was cannulating in the same place/area as it was less painful for the patient and easier on him, not taking into account the consequences for the patient with fistula problems.

Of course, not to say the lack of infection control techniques contributes to infection. This is supported by the surveys conducted that clearly show staff are NOT following the most basic infection control practices. In California, the first six months of 2010, 23 of 25 facilities surveyed had deficiencies cited in areas of infection prevention. This is totally UNACEPTABLE. IF staff are correctly trained and are not implementing such as they have learned, then they are deliberately placing patients in situations for potential infections. (my opinion and that of our organization). If you know what to do and don't do it, you are aware you are not doing a correct procedure.
Staff, in many facilities, need to put themselves in the patients place and think 'is this the care I would want to receive?' I.E. would I want staff to not implement correct practices?
Roberta Mikles www.qualitysafepatientcare.com
View California 2010 surveys

[Kimk chan]

I have been a dialysis patient for 15 years in M alaysia and the hospital where I amtreated have been using rope ladder method of late they await to try the buttonhole method and I refused because ironically I have a phobia of needles and when the nurse prick me I turned my face away the hospital had recently tried the buttonhole method on two patients for 2 weeks unfortunately their fistula failed and dyalysising via IJC and complication set in and one of currently in coma he had been using the rope ladder method without problems for about 4 years what do you I should think about the so called buttonhole method I am horrific bythe mere mention of the buttonhole method I find yr article above interesting but I feel you are not truthffully saying abou the disadvantages of buttonhole method clearly what do think I should do Tq.

[Peter Laird, MD]

Dear Kimk chan, I assure you I have spoken truthfully of the preliminary data Stuart Mott and his team has compiled to date. I have used the buttonhole for about 5 years with no adverse complications other than having to shift them a few times for various reasons. Nearly 6 years of dialysis and not a single infection thank the Lord.

Buttonholes are actually very simple and easy to establish and use ONCE you know how to do it. I would strongly recommend contacting Stuart directly for any questions you may have at Home Dialysis Central, ask the experts section.

http://forums.homedialysis.org/forums/20-Stuart-Mott-Cannulation-Expert

I would highly recommend you consider the buttonhole method if your health care team concurs you are a good candidate. You can review the buttonhole technique that Stuart teaches in the following link. Best wishes.

http://www.esrdnet15.org/qi/ff/buttonholeprocedure.pdf

[Kimk chan]

Dear Peter Laird MD thank you very much for your reply I am not ready to try this buttonhole method as yet because my fistula is on my right hand and is has been my life line all these years and using the rope ladder method thank the Lord that he have been with me all through these years and thank you for your suggestion

[Roberta Mikles BA RN]

Many patients are informed that staff can not do the buttonhole as there schedules (work) do not accommodate such -- meaning same person must initated the buttonhole.. (in fact this is what we were also told)..
opinion of Roberta Mikles
www.qualitysafepatientcare.com

[Roberta Mikles BA RN]

As an added note, I remember a patient in our unit who had a buttonhole but was never told that was what the staff were doing -- when I mentioned such to him, he was surprised -- it was terribly painful and he continued to tell staff, but told me no one would address it - I wonder how many patients have buttonholes but do not know they do because staff have not educated them

opinions of Roberta Mikles
www.qualitysafepatientcare.com

[John J Rogers]

I presently have buttonholes which have been utilized for the 1.5 yrs I have been on dialysis, my MD now tell me that the center where I Dialysis will begin using sharp needles and placing them in a different location in my Fistula each time, I have great concern in regards to this procedure and have ask the center to furnish me the present of infections experienced due to the use of buttonholes over the past year, so far I have not received the information I have requested and shall continue using my buttonholes until I receiver the information I have requested and can make an educated evaluaition

John J Rogers
Fesenius Patient
Olympia, WA

[Peter Laird, MD]

Dear John,

Bottom line my friend, you are in charge of your health care legally and ethically. I don't know all of the details of your case to be able to give specific advice, but ALL physicians MUST have your permission to perform any procedure whether a major or minor procedure.

In such, if there is no clinical issue to prevent you from performing buttonhole cannulation, they cannot legally force you into a different practice. Even if there is a clinical issue that they are concerned about, they are legally and ethically bound to provide "informed consent" which would include risk of infection and other issues. For those of us at home that self cannulate and are able to control the infection issue, buttonhole cannulation is absolutely a better way to cannulate.

In an in-center situation where you have different people cannulating, the complications have risen. The key most of us in dialysis advocacy agree upon is that self cannulation is the best way to control those issues.

I do have a couple of questions. Do you perform self cannulation? Do you pick your own scabs? I did 3 days of in-center care last month when I was traveling. To facilitate cannulation time, I picked my scabs at home, place betadine and band aide to keep it clean and then went to the unit. That saved me 10-15 minutes of time which the units care about.

If the center is concerned about infection risk with buttonholes, they may wish to reevaluate their procedures. Stuart Mott, a cannulation expert may have solved the increased risk of infection with buttonhole cannulation and is now proceeding with a large, multi-national study to confirm his initial results.

You can discuss your situation directly with Stuart Mott at Home Dialysis Central, Ask the Experts section:

http://forums.homedialysis.org/forums/15-Ask-Our-Experts

I wish you the best in your health care and I hope the link to Stuart Mott gives you access to one of the world's foremost experts.

God bless, Peter