A Further Guide to Self-cannulation with the Rope Ladder technique: Single-handed Needling

This blog post was made by Ant de Villiers on October 19th, 2017.
A Further Guide to Self-cannulation with the Rope Ladder technique: Single-handed Needling

Those who cannulate alone (and therefore with one hand!) gain valuable tips here and at the Home Dialysis Central FaceBook page, empowering adaptations that suit personal temperament and aptitude. Whilst the running of a dialysis machine follows impersonal prescription the insertion of needles is an area where individual skill and method evolve. This tends to keep one focused and interested in one’s own dialysis as there’s no limit to the refinement and skill that can be developed.

My previous blogs on cannulation dealt with needle spacing, direction and angle of entry, and preserving the life of the fistula by site rotation.

In this one we revisit angle of entry, and also touch on taping, method of insertion, and gauge of needle.

There is always the temptation to enter the needle at too shallow an angle. 25-40 degrees is indicated by Fresenius, John Agar recommends 45 degrees. Initially I tended to insert the needle at too shallow an angle resulting in copious blood squirts. 45 degrees, though scary in terms of the groundless fear of shoving the thing right through to the other side, results in a swift, clean penetration, with little to no blood loss.

needle-angle needle-insertion

Fiddling one-handed with sticking tape and attempting to efficiently apply the widely approved “chevron fold” after the needles are seated is frustrating. It is better to place the tapes on the needles before setting up. The needle wings may be readily detached with a simple twist, leaving space for the tape to be affixed underneath, sticky side up.

needle-position needle-taping

With the ever-increasing popularity of long, frequent, slow, low volume dialysis, there is opportunity to reduce stress on the fistula by using a 17G needle as recommended by Fresenius for pump speeds 250 ml/min and below. Given a nicely located needle—away from the vessel endothelium (inner walls)—pressures well under -200 (arterial) and 200 (venous) are attainable. Consider: three to four dialysis sessions per week results in well over 300 needle penetrations of the vessel per annum. A thinner needle will be kinder in the long run, and for those starting out on dialysis, less intimidating.

Comments

  • John Agar

    Oct 19, 5:41 PM

    Ant ... a beautiful, clear, encouraging post that offers so much more than just a method for single-handed, lone operator self-cannulation.

    Every phrase in this post screams ‘good dialysis’ ... ‘low flow (read volume) dialysis’ .. ‘17 gauge needles’, the finer gauge being predicated on ‘low pump speeds of 250 or less’ .. ‘low AP and VP values’ .. ‘greater frequency dialysis’ .. ‘a steeper angle of entry’ .. ‘pre-positioned primary tapes’ .. and, especially, the use of ‘long, frequent, and slow’ .. even your subliminal message in the final sentence where you use the phrase (possibly unwittingly) ‘in the long run’ .. this is a post from a thoughtful dialysis user, steeped in experience and superbly trained.

    Well said. My congratulations, too, to your home support team for grounding you so well from the start. All users of home HD should read this.

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  • charlotte A Bohner

    Oct 19, 5:39 PM

    I have been on dialysis for almost 1 year. I would love to do Home Hemo. My concerns, no body in my family is anxious to help needle. We are all a little, no a lot squeamish. But I think we could do it.

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    • Ant

      Oct 19, 10:46 PM

      The rewards of home hemo outweigh by a long shot the aversion/trauma/distaste of self-needling. I can't speak for buttonholing, but if you are a ladderer and your fistula is clearly visible its (simply!) a matter of penetrating a thin layer of skin and a thin walled blood vessel. Initially many use an anaesthetic but with familiarity most go without. What's helped me is focusing on refining my technique, discovering what works best and honing needling as personal skill. Its one thing to set up the machine and press buttons; quite another to 'discover' your access, learn ways of honouring and being kind to it. Best wishes!

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    • John Agar

      Oct 19, 8:00 PM

      Charlotte ... the most impotant message in Ant’s blog is that the very best, most competent, gentlest, and most fistula-protective person to needle your fistula is YOU. Not a nurse, not a family member, but YOU. Self-needling has some speed-bumps to overcome .. undoubtedly .. but (and I am sure Ant will chime in on this) you CAN learn, you CAN overcome the twin heebie-jeebies of fear and dexterity, and learn to cannulate your own fistula.

      Any comments, Ant?

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