Self Cannulation: A Sticking Point

This blog post was made by Ant de Villiers on January 26th, 2017.
Self Cannulation: A Sticking Point

With a background in Biology and endless bloody dissections I came to HD with little aversion to needles and began self-cannulating during my first week of training. My clinic teaches solely the ladder technique in the belief that the 4% increased infection potential with buttonholing is not worth the risk.

In spite of great care I had several infiltrations in those early days with attendant bruising causing widespread discoloration of my arm (below), persisting after many months.

Cannulation

Those of us who use ladder needling have been advised to spread the sticks as widely as possible over the length of the fistula to avoid what has been unimaginatively termed "one-site-itis,"- the outcome of the weakening of the vessel wall due to repeated penetrations in one spot. Places of damage often lead to aneurisms. Proper needle site rotation is essential to ensure even development of fibrous tissue along the fistula’s length so that there are no weak spots. Early in training my renal nurse advised the vessel should be cannulated from the sides (Series 1 and 2 in the image) as well as on top along the median to greatly expand the number of sticking sites.

How to space the needling? A scan of the literature suggests 6.3 mm minimum between successive entry points and 70 mm between arterial needle entry and venous needle entry on any given session. To maximise the entire fistula length, especially in the case of my shorter upper arm one, I plotted a "sticking map" to convince myself I had plenty of room to avoid the dreaded "one-site-itis."

A stick is done at each number: lower red "arterial 1" is matched with lower blue "venous 1". Then on to the "twos" By the time blue venous 6 is reached red arterial 6 is closing in on blue venous 1’s earlier entry point and its time to move over to the other side of the fistula (Series 2) where the sequence is repeated.

The dashed line shows the fistula median and marks further access for six sessions in the same manner. So in all that’s 18 tx sessions (@ 4 sessions per week), or at least 4 weeks before a needle re-enters a previously cannulated site.

Comments

  • Jeff Stumpe

    Feb 15, 11:56 AM

    I was taught buttonhole technique and soft touch cannulation during my HHD training. My HHD clinic cited a buttonhole infection rate that was 2X that of ladder needling, or 2% vs. 1%.

    While learned buttonholing during HHD training, it was not long before I felt the need to develop a third buttonhole site to accompany the two that were developed for me during HHD training.

    Tentative at first, I did develop the requisite skill set to competently cannulate with 15 GA sharp dialysis needles. The wisdom to then create and use additional buttonhole sites has allowed me to abandon sites when they can no longer be cannulated with 15 GA blunts owed to changes in the fistula flap access.

    Over the past 4-1/2 years, I have had to abandon 7 different sites including the two that were developed during training.

    I've settled on five buttonhole sites on my three vessel fistula that features two separate venous returns, giving me 9 different working Arterial/Venous combinations with only one of these combinations occurring on the same vessel and balance between vessels.

    It is a very unique fistula that started as a single vessel from anastomosis in my right wrist and expanded to the three vessels on my forearm after a fistulagram and stenosis removal just two weeks after starting HHD training.

    I have maximized the utilization thereof, and in spite of clotting off (and subsequent declotting and fistulagram) each venous return at least once since May 2014, I've not missed a single treatment or needed a CVC because I had a second venous return available for my HHD treatments.

    Keeping all 5 buttonholes active is a challenge owed to the natural healing process and an alternating 5, 4, 5 weekly treatment schedule.

    I am very aggressive in scab removal and buttonhole site prep - the chief sources for buttonhole technique infections.

    My reward for buttonhole cannulation is the absence of painful and treatment stopping infiltrations and never missing an HHD treatment in 4-1/2 years.

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    • Ant

      Feb 17, 12:32 AM

      Fantastic! It shows what's possible with careful application and dedication. A contribution to the blog channel with images would be helpful for many as buttonholing is popular and widely applied.

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  • DebraNull

    Jan 27, 5:30 PM

    Hello Ant, Nicely done! However there are those of us with limited options due to having what I like to term a "West Virginia roadmap" for a fistula. Mine takes so many twists and turns it really makes maximizing sites difficult. I do try to use the bits after a turn, but some are impossible due to not have adequate length to accommodate the length of the needle. Still, I'd like to keep this one for a very long time (4 years now) so I will work with what I have.

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  • Talker

    Jan 27, 8:55 AM

    Any words on when there is fistula damage, like a small balloon? Believe it called a aneurysm.
    Thanks

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  • Lisa Goodwin

    Jan 27, 7:21 AM

    This is a great article that would help our patients that don't self-cannulate understand the reasoning for rotating needle sites. We have too many people that don't want staff to rotate due to pain at new site. I will print this and have available for staff to discuss with patients in hopes to foster more communication and cooperation. Well said, Thanks!

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    • Ant

      Jan 28, 3:40 PM

      Thanks Lisa.
      Meantime I've improved the rather tatty image and saved the document as a PDF. I can forward this to you if you'd like but will need an email contact.

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  • Sheree B

    Jan 26, 7:21 PM

    Thank you so much for this guide. We tried buttonholes, but we couldn't get them to work. Much appreciated!

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  • Richard Vallone

    Jan 26, 5:24 PM

    I have ben doing home hemo for about weeks and the hardest part is the needle part. If you have any suggestions please email me. I have the machine down ok but reposition of needless when the pressures go thru the ceiling I don't know how to adjust the needles. Please let me know some of your solutions.

    Richard Vallone

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    • Ant

      Jan 26, 8:05 PM

      Hi Richard
      Sorry to hear of your needle and pressure difficulties.
      Sounds like the tip of the needle is either lying too superficially or is pressing against one of the vessel walls. Here's what works for me:
      Once I've decided the exact entry point for the needle I make a spot there with a felt and then draw a thin line to mark the exact direction the needle will follow once under the skin. Tourniquet is optional (I don't). Next I rest the needle tip lightly on the spot then check the needle shaft is true-aligned to exactly follow the path I've drawn. I check on this again once the needle is 3 mm in and the blood flashback looks good, before sliding it the rest of the way in.

      Bad pressure can sometimes be overcome by placing a small wad of gauze under the needle hilt against the skin (needle tip pressing on vessel upper wall) or by withdrawing the needle a few mm (needle tip against a side wall or lower wall)

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