Button Hole creation technique

1. Button Hole creation technique Poster presentation showed during the 2010 CANNT National event held at the Metro Convention Centre in Toronto November 18 to 20, 2010. by Mrs Christine Chadderton, RN, C. Neph (C) and Mrs Paulette MacKenzie, RN, C. Neph (C)

2. DISCLAIMER Please note This poster presentation was developed by Mrs Christine Chadderton and Mrs Paulette MacKenzie, while under contract with the Western Health, Newfoundland. Western Memorial Regional Hospital, Corner Brook, NL The contents presented do not necessarily reflect the Western Health policy. Button Hole creation technique

3. TABLE OF CONTENT • REVIEW • BENEFITS • MYTHS • BARRIERS TO SUCCESS • BARRIERS • WHO IS NOT A CANDIDATE? • WHO IS A CANDIDATE? • CASE STUDY • REASONS WHY WE CHOSE TO USE NIPRO BIOHOLE PLUGS • SO...... • REFERENCES Button Hole creation technique

4. REVIEW • is cannulating the fistula in the exact same spot, at the exact same angle and depth every time the needles are inserted. It has been a technique used worldwide to cannulate native AV fistulas for over 25 years (ref.:1). What is the «BUTTONHOLE TECHNIQUE»? Buttonhole a.k.a. : Constant site technique Button Hole creation technique

5. BENEFITS • Less painful cannulation and anesthetic use may be eliminated. • Insertion into a previously used site is easier and can be done very quickly by either staff or self cannulation. • Fewer missed needle sticks. • The infection rate is not significantly higher than with multiple site insertion. • The hematoma formation is reduced by more than 10 fold (ref.:2). Button Hole creation technique

6. MYTHS • Cannot be used on mature fistulas. • Will cause aneurysm formation. • Can only be used on limited length access fistula. • Is only for the home Hemodialysis population (ref.: 3). Button Hole creation technique

7. BARRIERS TO SUCCESS First of all: • Barriers need to be thought of as CHALLENGES to the technique rather than REASONS to exclude patients from using the technique (ref.:3). Button Hole creation technique

8. BARRIERS • One of, if not, the biggest barriers to the buttonhole technique is “multiple sticker” practice versus “single sticker” practice. • Large amount of subcutaneous tissue or excess skin especially in upper arm fistulas. • Heavily scarred accesses from : • Keloid formation • Long lived AV fistulas • Lidocaine use • numerous problematic needle sticks (ref.:3). Button Hole creation technique

9. WHO IS NOT A CANDIDATE? Patients with any of the following: • Thin subcutaneous tissue. • Valvular heart disease. • Prostatic inserts (permanent pacemaker). • Immune suppression (ref.:4). Button Hole creation technique

10. WHO IS A CANDIDATE? • Any patient with a native AV fistula. • Any potential self or home hemodialysis patient. • When there is limited area for cannulation site. • When preservation of the access is of critical concern because it is the patients last viable access option (ref.:5). Button Hole creation technique

11. CASE STUDY • December 1st 2009 AV Fistula created. • December 27th 2009 presented with Rigors, temperature of 39.3c and admitted to hospital diagnosis of Sepsis. Commenced antibiotics (Kefzol and Gentamycin) after blood cultures taken. • December 29th 2009 Blood cultures Gram + cocci sensitive to Kefzol , Gentamycin discontinued. • January 7th 2010 rash to both ankles and antibiotics changed to Vancomycin. • January 14th 2010 course of Vancomycin completed. • January 19th –fistula 7 weeks old, but needed to have line removed due to the sepsis. Therefore first needling. A 50 year old male with CRF due to Diabetic nephropathy commenced hemodialysis with a tunneled IJ line on March 12th, 2009. Button Hole creation technique

12. CASE STUDY (suite) • February 6th 2010 first time using 2 needles. Rigors during dialysis temp. 37.7c, complaining of severe back pain, blood cultures taken and Vancomycin 500mgm IV given and to be continued for 7 doses. Line ordered to be removed urgently. • February 11th 2010 continues to complain of severe back pain and admitted to hospital for MRI of same on February 12th 2010. • February 12th 2010 MRI complete with diagnosis of osteomyelitis. • February 17th 2010 Vancomycin 500mgm IV each treatment for 6 weeks ordered. • March 23rd 2010, LINE OUT......finally! Using rope /ladder technique the fistula was allowed to mature. Repeat MRI ordered. • April 29th2010, Repeat MRI. • May 8th 2010, Osteomyelitis worsening, urgent referral to orthopedics and Vancomycin to continue for 4 more weeks each dialysis treatment. Button Hole creation technique

13. CASE STUDY (suite) • May 25th 2010, the decision was made to use buttonholes for this patient and after dialysis treatment completed BIOHOLE plugs were inserted in the holes left behind by the previously inserted sharp needles, carefully secured in place to be left inside until next dialysis treatment day. • May 27th 2010 BIOHOLE plugs were removed and NIPRO blunt needles 15G were inserted into the tunnels created by the plugs with no difficulty to staff or patient. BIOHOLE plugs were inserted after dialysis for 5 more sessions, needling continued using NIPRO 15g Blunt needles successfully. • June 8th BIOHOLE plugs were not inserted post dialysis. • June 10th Scabs created at puncture sites were removed and NIPRO 15 g Blunt needles were successfully inserted. Seen by orthopedic surgeon who did not change treatment but ordered repeat MRI and blood cultures. • After 3 months. Button Hole creation technique

14. REASONS WHY WE CHOSE TO USE NIPRO BIOHOLE PLUGS • No dedicated vascular access nurse. • Patient and staff schedule could not be changed to accommodate primary nurse assignment to create buttonhole using traditional technique. • Track created after 6 sessions using BIOHOLE plugs versus 8-12 sessions using sharp needle technique. • Less discomfort for patient after first sharp used. • Decreasing probability of macerating track that would otherwise occur using sharp needles to create track. Button Hole creation technique

15. Nipro BioHole Device Button Hole creation technique

16. Nipro BioHole Device Button Hole creation technique

17. Nipro BioHole Device Button Hole creation technique

18. Nipro BioHole Device Button Hole creation technique

19. SO...... After 6 sessions using the NIPRO BIOHOLE DEVICE, do we need them anymore? • We have found that in patients that heal well it may be necessary to occasionally use a BIOHOLE plug to reestablish a track. • In patients with larger fluid gains over the weekend using the BIOHOLE plug on the last session of the week will allow less deviation of the track and easier access on the first session of the week. Button Hole creation technique

20. REFERENCES • Ball, L.K.(2004). Using the buttonhole technique for your AV fistula. www.nwrenalnetwork.org/fist1st/ButtonholeBrochureForPatients!.pdf • Twardowski, Z. Constant Site (Buttonhole) Method of Needle Insertion For Hemodialysis. Dialysis and Transplantation, October 1995, Volume 24, Number 10, Magazine pages 559-560,576 • Ball, L.K.(2005b) Buttonhole technique for cannulating AV fistulas. Paper presented Feb 27th 2006 at the Annual Dialysis Conference, San Francisco, CA • Cake.C and Ludlow.V, Presentation on Vascular Access at Provincial Dialysis Days, Grand Falls NL October 3rd 2010. • Nipro. (01 August 2006). Scientific report for Biohole needles set. Page 2 of 4.MPDBN-SF01 Button Hole creation technique