Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
The Buttonhole Cannulation
technique
Tony Goovaerts
University Hospital St. Luc
Brussels, Belgium
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
UCL ST.Luc: Prevalent patients
Service
de
Néphrologie
•
•
•
•
In-centre HD: 95 (49.0%)
Home HD: 45 (23, 5%)
Self-care satellite HD: 24(12%)
PD: 30 (15,5%)
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Puncture techniques
Service
de
Néphrologie
Rope ladder
Regional
Buttonhole
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Rope ladder puncture
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Reasons for not respecting
“Rope ladder”
Service
de
Néphrologie
Nurses don’t like to miss sticks
Patients don’t like missed sticks
Older dialysis population
More diabetes patients
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Regional or area puncture
Service
de
Néphrologie
Small puncture area
with:
Thinning of the vessel
wall
Aneurismal formation
Stenosis
Oozing
Longer bleeding times
after needle removal
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Aneurysm
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Doppler Ultrasound: Aneurysm
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Doppler Ultrasound: Bloodflow Aneurisma
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole puncture sites
Service
de
Néphrologie
Well established
buttonhole puncture
sites
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Buttonhole puncture site
after 53 months in older
patient
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Doppler Ultrasound: vessel integrity
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Doppler Ultrasound: tunnel track
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Doppler Ultrasound: bloodflow
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
History of buttonhole puncture
Service
de
Néphrologie
• Dr. Twardowski first reported on
buttonhole cannulation
• Originally used for patients with
limited puncture sites
• Proved to be efficient for other
patients with native fistula
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
History of buttonhole puncture
Service
de
Néphrologie
• Dr. Twardowski
• Dr. Scribner
• Dr. Krönung
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Our ‘Buttonhole’ history
Service
de
Néphrologie
• 1997: visit University of Missouri,
Columbia
• Scepticism
• End 1997: ‘buttonhole’ technique in
first Home HD patients
• Enthusiasm
• No blunt needles available!
Comparison of 2 methods of needle
insertion
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Different sites
Number of fistulas
Number of dialysis
Time of setting up
Reinsertion (%)
Hematoma formation
Fistula limb failure
Fistula failure
Infection
Service
de
Néphrologie
Patients’ preference
Nurses’ preference
22
4060
15-25
9.91 %
12.5 %
3
1
1
-
Constant sites
25
6180
5-15
0.96 %
0.1 %
1
1
3
+
+
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole cannulation
Service
de
Néphrologie
• Growing opinion that the technique has
several advantages compared to the
other cannulation techniques
• Infections!?
• Easy but completely different
• Nurses have to be trained to become
skilled “buttonholers”using blunt
needles!!
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Advantages of Buttonhole
puncture
Less hematoma
Less pain
Fewer missed sticks
Shorter bleeding
times
Less scar formation
Service
de
Néphrologie
Perfect for patients
with limited
cannulation sites
Perfect for home HD
or self-care patients
Staff: reduced risk of
accidental needle
sticks
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Bleeding times after dialysis
Service
de
Néphrologie
N=14
Arterial
Venous
W.A.
H.P.
F.N.
S.G.
S.L.
E.B.
E.A.
R.B.
B.R.
S.A.
Y.S.
D.J.
C.S.
R.M.
1’30’’
2’
13’
6’
1’30’’
2
2’30’’
1’30
8
1’45’’
3’
3’
3’30’’
1’3’’
5’
12’
4’
2’
2’30’’
2’30’’
1’30’’
0’45’’
4’15’’
2’15’’
4
5’30’’
2’
Mean
3’45 ’’
3’50’’
Shortest
1’30’’
0’45’’
10 patients
 3’
8 patients
3’
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Bleeding at puncture sites after HD
(86 patients )
Service
de
Néphrologie
Buttonhole group
54.1% < 5 min
40.5% 5 – 10 min
5.4% > 10 min
Control group
27.9 % < 5 min
58.1% 5 – 10 min
14% > 10 min
S. Toma et al.
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Comparison of demographics of the
study population
Service
de
Néphrologie
Characteristics
Rope-ladder
(n=70)
Buttonhole
(n=75)
P-value
Female
Male
23 (33%)
47 (67%)
31 (41%)
48 (69%)
0.28
< 60 years
> 60 years
22 (31%)
48 (69%)
29 (39%)
46 (61%)
0.36
Gender
Age
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Diagnostic tests and interventions with the
different cannulation techniques during 9 months
Service
de
Néphrologie
Patients with diagnostics tests
Diagnostics tests
Duplex
Fistulogram
MRA
Patients with interventions
Interventions
Angioplastie
Trombectomy
Surgical revisions
AB treatments because of
access-related infections
Rope-ladder
(n = 70)
Buttonhole
(n = 75)
28
73
14
51
8
21
41
35
3
3
-
15
24
11
10
3
6
10
2
1
3
4
P -value
0.004
0.001
0.001
0.81
0.55
0.001
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole puncture technique
Service
de
Néphrologie
Two sequences:
 First: Creation of the tunnel track or
“Break-in” period
 Second: sliding of dull needle through an
established path
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Select the sites
Service
de
Néphrologie
Healthiest sections
Easy to cannulate
Distance of preferable 8 cm between
needle tips
preferable 8 cm
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Establishing Tunnel Track
Service
de
Néphrologie
• Standard procedure
• Biohole procedure
• Catheter
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole puncture technique
Service
de
Néphrologie
Cannulation:
-
Disinfection!
Exact same spots
Same insertion angle
Same depth of penetration
Ideally single sticker!
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
25 degrees angle!
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Remove scabs
Service
de
Néphrologie
Mandatory :
- Not going “approximately”
into the same spot!!!
- Disinfection before and
after!
25°
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Removal of scabs
Service
de
Néphrologie
Service
de
Néphrologie
R. Morticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Removal of scabs
Service
de
Néphrologie
•
•
•
•
•
•
Saline
Alcohol gel
Emla
Chlorexidine creme
Disinfecting Soap
……
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Establishing Tunnel Track
Service
de
Néphrologie
• Standard procedure
• Biohole procedure
• Catheter
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Insertion of plug
Service
de
Néphrologie
stick
skin
vessel
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
BioHole Buttonhole Device*
Service
de
Néphrologie
plug
Support unit
Support unit
plug
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Test of BioHole Device (1)
• 12 new patients with new AV fistula
• Team of 8 nurses cannulating randomly
• Tunnel track creation
– 10 patients: 6 sessions
– 2 patients: 8 sessions
• Blunt needles
Service
de
Néphrologie
– 7 patients from second dialysis onwards
– 5 patients from third, fourth or fifth dialysis
onwards
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Test of BioHole Device(2)
Service
de
Néphrologie
• 3 X BioHole plug came out of tunnel
track
• 1 X haematoma after insertion of plug
• 1 x bleeding after removal of plug
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Advantages of the BioHole Device
Service
de
Néphrologie
• No single sticker?
• Faster tunnel track formation
• Better tunnel track formation
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Drawback of the Biohole Device
Service
de
Néphrologie
Only one length!
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Establishing Tunnel Track
Service
de
Néphrologie
• Standard procedure
• Biohole procedure
• Catheter
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Courtesy R. Marticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Courtesy R. Marticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Courtesy R. Marticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole puncture technique
Service
de
Néphrologie
Two sequences:
 First: Creation of the tunnel track or “Break-in”
period
 Second: sliding of dull needle through an
established path
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Needles
Sharp needle
Service
de
Néphrologie
Dull needle
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Sliding of dull needle through an
established path
Service
de
Néphrologie
• Holding needle by wings
• “Touch” Cannulation
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Second disinfection
Service
de
Néphrologie
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Taping
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Checking
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Secure fixation
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Touch Cannulation
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Touch Cannulation
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Overall Problem
Service
de
Néphrologie
Frequently intermittent use of sharp
needles instead of dull needles, which
may lead to increased infection rate
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Comparison of cannulation characteristics in
percentages between both cannulation techniques
Service
de
Néphrologie
Cannulation Practice
Rope-ladder (n=70)
Buttonhole (n=75)
6882 dialysis sessions 6847 dialysis sessions
Type of needle
Metal sharp
Metal dull
Catheter
90 %
10 %
44 %
56 %
Strict protocol with primary cannulators
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Name
Date
Arterial
Nurse
1st trial dull
2nd trial dull
Primary cannulator
1st trial dull
2nd trial dull
Service
de
Néphrologie
sharp
venous
Signature
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Results of intervention
Service
de
Néphrologie
• Reduction from 44 % to < 2 % use of
sharp needles
• Dramatically improved infection rate
Prospective observational cross-over study to
test the impact of the use of semi-blunt
needles on the quality of the puncture and
the frequency of sharp needles use.
Semi-Dull Needle
= Dull Needle but with sharper angle
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Prospective observational cross-over
study
Service
de
Néphrologie
•
•
•
•
03/11/2008-O6/03/2009
51 patients with native AV fistula
Age 71 + 9yr, 60% Males, 36% Diabetics
5672 cannulations
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Phase 1 a (n=29)
BN
BN
Group: Mo, We, Fr
BN
All
patiens
Group: Tu, Th, So
BN
BN
SBN
SBN
n=51
Phase 1 b (n=2O)
Month 1
Service
de
Néphrologie
SBN
SBN
Phase 2 a (n=28)
Month 2
Month 3
Phase 2 b (n=19)
Month 4
Month 5
BN
100
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
90
80
70
60
First attempt
50
Second attempt
40
ref. nurse
Sharp needle
30
20
10
0
All
Service
de
Néphrologie
BN
1a
SBN
2a
BN
1b
2b
BN
SBN
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Blunt Needle
Semi-Blunt
Needle
P-value
1 st Attempt
94,3 %
94,2 %
0.9897
2 nd Attempt
1,89 %
1,47 %
Prim. Cannulator
Blunt needle
2,19 %
2,62 %
Prim. Cannulator
Sharp needle
1,55 %
1,68 %
0.7141
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole Wrong Angle
Service
de
Néphrologie
• Needle inserted
into the
buttonhole
tunnel trackbut the angle is
not in
alignment with
the vessel flap
• The needle can
bounce on the
vein and not
displace the
vessel flap
Courtesy D. Brouwer
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Buttonhole Wrong Angle
 Adjust angle to find the
flap
 Lift up or down on the
needle to readjust the
angle (10° until the
needle drops into the
vessel flap
 Causes: moving needle
from angle used to enter
the skin, arm
positioning not in
routine place, fluid
status change with
edema or patient body
weight gain or loss
Service
de
Néphrologie
Courtesy D. Brouwer
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Implementing a Programme
Service
de
Néphrologie
•
•
•
•
•
•
•
Small group of nurses
Small group of patients
Which protocol?
Expand
Be vigilant!!!!!!
Primary/reference nurses/cannulators
Promote self-cannulation
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Teaching self-cannulation
Service
de
Néphrologie
•
•
•
•
Importance of disinfection
Importance of removal of scabs
Signs of infection
Minimal use of sharp needles
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Touch Cannulation
Service
de
Néphrologie
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Create new puncture site if
necessary!
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Some discussion points
Service
de
Néphrologie
•
•
•
•
•
Tourniquet?
Bevel up or down?
Needle size?
Rotation of needle?
Antegrade or retrograde needling?
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Antegrade or retrograde
needling?
Service
de
Néphrologie
Antegrade: with the flow
Retrograde: against the flow
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Antegrade (ven) and Retrograde (art)
Service
de
Néphrologie
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
2
cm
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Service
de
Néphrologie
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Optimal needle directions
Service
de
Néphrologie
Both needles antegrade
- Easier for nurse to puncture
- Easier for self-puncturing
- May be fistula protective
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Antegrade puncturing: may be
fistula protective
Service
de
Néphrologie
Increased risk of haematoma formation from
retrograde filling
Tract closure through flow force by antegrade
puncture
Exit site infection
• HD patients have more
Staphylococcus Aureus
on their skin than the
general population (Ball,
2006)
Exit site infection:
• Caused by a break in
technique such as
improper cleansing of the
skin or scab removal
• Sites may be inflamed,
red, draining, painful
Courtesy R. Morticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Prevention of infections!
Strict protocols
Soaking of scabs
Scab removers
Contact time desinfecting agent
Use of sharp needles
Reference nurses..?
New devices……
Service
de
Néphrologie
Mupirocine?
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Prevention of infections!
Service
de
Néphrologie
I am a physician and a dialysis patient using
the buttonhole method without any
complications now for nearly 4 years.
I believe the increased infection rates seen
with BH are due NOT to the procedure
itself, but due to patient and staff
technique! I have now dialyzed in 9 units
in 7 States and ALL of these units have
infection control issues especially with
changing gloves and washing hands!
Peter Laird, MD
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
BH Contra-indications?!
Service
de
Néphrologie
• Thin subcutaneous tissue
• Valvular heart disease
• Other prosthetic material (pacemaker)
• Immune suppression
Other Complications
of BH Cannulation
Contact Dermatitis caused
by exposure to cleansing
solution (Chlorhexidine):
Progress over 2 weeks
changing the cleansing
solution and applying
corticoid cream
Day 1
Day 3
Day 14
R. Morticorena
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Conclusion (1)
Service
de
Néphrologie
• Buttonhole is a rapidly growing
cannulation technique for AVF
throughout the world
• Much better than “Area puncturing”
• The technique is still evolving
• Strict protocols are mandatory to avoid
complications
Cliniques Universitaires Saint-Luc - Bruxelles - Belgique
Conclusion (2)
Service
de
Néphrologie
• Several studies are underway
• The use of sharp needles should be
reduced to a minimum
• Primary cannulators?