Hemodialysis Literature Review By

Hemodialysis Literature Review 3

HemodialysisLiterature Review



Thebuttonhole technique is gaining reputation and acceptance among manypeople today. The technique has been in use in several healthcareinstitutions for a couple of years. The following review ofliterature seeks to compare the efficacy of the technology comparedto the rope-ladder technology.

Muir,et al. 2014 reviewed the clinical outcomes by cannulation method insome 90 hemodialysis patients. Initially, the patients were trainedin the rope ladder cannulation. Starting from the year 2004, all thepatients were started on buttonhole cannulation. The results of thestudy showed that buttonhole cannulation was not associated a highrate of systemic arteriovenous fistula—attributable infections.However, the use of button hole was linked to a higher rate of totalarteriovenous fistula infections. A review of four randomized controltrials found increased arteriovenous fistula-related infections withbuttonhole in comparison with rope ladder. In a nutshell, the studysuggested that buttonhole cannulation was associated with high ratesof infections[ CITATION Mui14 l 1033 ].

Suri,et al. 2013 undertook two separate trials with the aim of definingthe relationship between frequent hemodialysis and the risk ofvascular access complications. It was found that the risk for thefirst access event was higher with daily hemodialysis than with theconventional hemodialysis. An analysis of some 198 patients with anarteriovenous access, the risk was 90% higher with dailyhemodialysis. Daily hemodialysis patients experienced more total AVaccess repairs than the conventional hemodialysis patients. In short,the nature of the AV access repairs showed that increasedhemodialysis frequency is risky[ CITATION Sur13 l 1033 ].

MacRae,et al. 2012 sought to find the difference in pain scores betweenbuttonhole and standard needling. Some 140 patients were assigned tobuttonhole or standard needling. According to the study [ CITATION Mac12 l 1033 ],the rate of hematoma formation in standard needlingwas found to be higher. However, there was no difference in painscores between button hole and standard needling. The study concludedthat a routine use of buttonhole needling is associated withincreased risk of infection[ CITATION Mac12 l 1033 ].

Tocompare the outcomes of buttonhole and rope-ladder cannulationtechniques, Smyth, Hartig and Manickam 2013 assessed the cannulationsites at the dialysis sessions for some 12 weeks. Pain and fear werescored by the patients on a weekly basis. It was found that thestatistical differences in infection, pain or fear, and haematomaformations between the techniques were very minimal. The studyconfirmed that the negative outcomes of either technique were few.

Therope-ladder technique is the most common technique used forcannulation of arteriovenous fistulae. However, buttonholecannulation is the recommended technique. Chan, et al. 2014compared the outcomes of episodes of bacteremia, primary patency andthe quality of life scores between the RL and BHC patients. Aftercomparing some 45 dialysis patients using BHC with another group of38 using the RL technique over 12 months. The two groups failed todiffer significantly. The research found that the use of buttonholetechnique was not associated with improved primary patency[ CITATION Cha14 l 1033 ].

Dueto the increased interest in buttonhole cannulations, Atkar andMacRae 2013 analyzed recent randomized trials in order to find outthe possible harm and potential benefit of the buttonhole technique.Recent findings report a reduction in pain with buttonhole. A reviewof five randomized trials showed that when buttonhole cannulation isdelivered by a nurse, the technique fails to appear to be lesspainful than the rope-ladder technique. Many studies report fewerinfiltrations, a reduction of aneurysm formation and reduced hematomawith buttonhole. Current studies show that when the buttonholetechnique is done in an in-center environment with many rotatingstaff nurses, the technique proves to be complex and challenging.Therefore, buttonhole technique might be utilized best for limitedfistula needling sites. The study recommended the inclusion ofinfection prevention education in campaign programs. On top of that,many trials should be conducted with the aim of comparing buttonholeto rope ladder needling among the self-needled patients[ CITATION Atk13 l 1033 ].

Afterdeveloping the ARCC (Advancing Research and Clinical practice throughclose Collaboration), a study was conducted to test the efficacy ofARCC model. The study showed that for the successful implementationof the EBPs (Evidence Based Practice), certain essentials are needed.The essentials include redefining nurses’ roles, allocating timeand money to the EBP processes, and creating an organizationalculture that fosters EBP[ CITATION Fin05 l 1033 ].

Kandil,et al. 2014 reviewed the experience of buttonhole needling in some227 adult patients on hemodialysis. Ninety-six patients transferredto rope ladder AVF cannulation due to cannulation failure andpersistent bleeding at the needling site. Eleven episodes ofsuspected buttonhole bacteremia occurred and fifteen localinfections. Even though the rates of infection had increased, manypatients discontinued the needling due to technical cannulationproblems and excessive3 bleeding[ CITATION Kan14 l 1033 ].

Ward,Shaw and Davenport 2010 introduced the buttonhole technique into thesatellite dialysis centers. Ninety-three percent of the patients whoparticipated in the study reported shorter venipuncture bleedingtimes and less pain compared to the sharp needle rope-laddertechnique. It was concluded that buttonhole cannulation can besuccessful when introduced into a busy satellite dialysis center dueto the shorter bleeding times, lower pain scores and improved fistulaappearance. Furthermore, there is reduced recirculation rates andrequirement for fistuloplasty[ CITATION War10 l 1033 ].

Vaux,et al. 2013 conducted a randomized controlled trial on some 140patients with the aim of finding the effect of buttonhole cannulationwith a polycarbonate peg on. The results showed a significantincrease in AVF failure. There were less bacteremia events in thebuttonhole group and no significant differences in bleeding times. The study concluded that AVF survival was greater when usingbuttonhole cannulation. The buttonhole technique decreased the needto access interventions as well as reduced aneurysm enlargement[ CITATION Vau13 l 1033 ].The conclusion was similar to the one made by Birchenough,et al. 2010.

Asearch and review of literature by Leanne 2012 found five majorthemes connected to the cannulation techniques. The major themes areincreased infection rates, decreased aneurysm development, reducedpain, reduced hematoma formation as well as shortened time to achievehematosis post-treatment. Buttonhole cannulation provides severalbenefits to individuals with arteriovenous fistula. Since thefistula is caused by blunt needles, different needling technique isrequired in rope-ladder cannulation. The study concluded that thebuttonhole technique may be beneficial for individuals with frailfistula. However, it was recommended that careful consideration mustbe given with regard to the patient preference.

Inthe study conducted by Van Loon, et al. 2010 some 75 hemodialysispatients with autogenous AVF using BH technique were compared with another group of 70 patients using rope-ladder technique. Patientsin the BH group exhibited unsuccessful cannulations in comparisonwith the rope-ladder technique. However, the frequency of aneurysmformation and haematoma was less. Additionally, intervention such assangioplasty was higher in the group of patients using the rope-laddertechnique. In conclusion, the study showed that the BH method is avaluable technique with very few complications. However, theinfections used by the BH method should not be underestimated[ CITATION van10 l 1033 ].

Anobservation cohort study by Van EPS, et al. 2010 compared hospitaladmission rates for vascular access patients established on chronichemodialysis for more than three months. The simultaneous applicationof NHD and buttonhole cannulation techniques demonstrated anincreased risk of septic dialysis access events. The collected datasuggested that buttonhole cannulation technique should be used withcaution in patients when performing extended hours hemodialysis[ CITATION Van10 l 1033 ].

Inorder to determine whether buttonhole cannulation technique inhemodialysis fistula reduced complications, Chow, et al. 2011conducted a randomized controlled trial. The seventy subjectsrecruited for the study had their fistula cannulated by the staffmembers between two and four weeks. It was found that the infectionat the cannulation site occurred in four patients in the buttonholegroup and one in the rope-ladder group. In a nutshell, the studyshowed that buttonhole cannulation caused more infections such ashematoma formation during dialysis that with the rope-ladder group[ CITATION Cho11 l 1033 ].

Personally,I agree with the many pieces of documented works of research.in myopinion the advantages of the buttonhole technique are multiple. For instance, evidence has shown that there is less hematoma andinfiltration, and no aneurysm formation[ CITATION Dau07 l 1033 ].It would be a big mistake not to let all patients benefit from it. Onthe other hand, when it comes to the home setting, the needle isalways in the same place and the patient has to ensure that theneedle is taped correctly to avoid accidental disconnections.Moreover, patients are able to check the arterial pressure since thepressure should be the same in every season. The BH techniquehas been in use for more than ten years. The success of the techniquehas been felt in self-care units and in-Centre patients withfistula[ CITATION Bal10 l 1033 ].

Theimplementation of the technique is yet to be incorporated into asmany care units as possible. I understand that it might be difficultfor the nursing team to swap from the rope-ladder area cannulation tothe buttonhole cannulation. Obviously, much time is needed topractice and become a skilled buttonholer. In order to succeed in thetraining program, it would be good to start with a small team of twoor three nurses. The technique could also be initiated on a smallergroup of patients. When the initial group becomes acquainted with thetechniques, they can become teachers and more nurses and patients canbe incorporated into the program. Learning to cannulate with bluntneedles is preferred because of the lower infiltration rate (Wilson,S. E. 2013). Evidently, many patients would prefer the technique dueto the little pain experience that is associated with it togetherwith quicker hemostasis post dialysis and an improved body image.Although I would recommend the Buttonhole technique, I would notrecommend the use of the technique by inexperienced patients at home.Being easy to handle, the rope-ladder technique is the best techniqueto be used by new patients at home (Twardowski, Z. J. 2012). Usingthe technique, the patient is able to acquire the needling skills.Once he or she has acquired the skills, the transition from therope-ladder technique to the BH would then be possible.

Thenumber of patients utilizing the BH technique in the U.S isincreasing. However, the biggest issue is to make the transition fromthe sharp needles to the blunt ones especially in the cases ofpatients with thick and developed fistulae[ CITATION Ver07 l 1033 ].Such transitional problems, known as the “trampoline effect” canbe avoided by requesting the manufacture of needles that are not verythick for use in the buttonhole technique.


Atkar, Rajneet K, and Jennifer M MacRae. &quotThe buttonhole technique for fistula cannulation: pros and cons.&quot Curr Opin Nephrol Hypertens, 2013: 629-636.

Ball, Lynda K. &quotThe Buttonhole Technique: Strategies To Reduce Infections.&quot Nephrology Nursing Journal, 2010: 473-478.

Birchenough, Erin , Coleen Moore, Keri Stevens, and Steven Stewart. &quotButtonhole Cannulation in Adult Patients on Hemodialysis: An Increased Risk of Infection?&quot Nephrology Nursing Journal, 2010: 491-499.

Chan, Micah R, et al. &quotThe Effect of Buttonhole Cannulation vs. Rope-ladder Technique on Hemodialysis Access Patency.&quot Seminars in Dialysis, 2014: 210-216.

Chow, Josephine, Glenda Raymen, Susana San Miguel, and Margaret Gilbert. &quotA RANDOMISED CONTROLLED TRIAL OF BUTTONHOLE CANNULATION FOR THE PREVENTION OF FISTULA ACCESS COMPLICATIONS.&quot Journal of Renal care, 2011: 85-93.

Daugirdas, John T, Peter Gerard Blake, and Todd S Ing. Handbook of dialysis. New York: Lippincott Williams &amp Wilkins, 2007.

Fineout-Overholt, Ellen , Rona F Levin, and Bernadette Mazurek Melnyk. &quotStrategies for Advancing Evidence-Based Practice in Clinical Settings.&quot Journal of the New York State Nurses Association, 2005: 28-32.

Kandil, Hala , Sophie Collier, Enat Yewetu, Jennifer Cross, and Andrew Davenport. &quotArteriovenous Fistula Survival with Buttonhole (Constant Site) Cannulation for Hemodialysis Access.&quot ASAIO Journal, 2014: 95-98.

Leanne, Evans M. &quotButtonhole cannulation for hemodialysis: a nursing review.&quot Renal Society of Austrasiaa Journal, 2012: 146-151.

MacRae, Jennifer M, Sofia B Ahmed, Rajneet Atkar, and Brenda R Hemmelgarn. &quotA Randomized Trial Comparing Buttonhole with Rope Ladder Needling in Conventional Hemodialysis Patients.&quot Clin J Am Soc Nephrol, 2012: 1632-1638.

Muir, Christopher A, et al. &quotButtonhole Cannulation and Clinical Outcomes in a Home Hemodialysis Cohort and Systematic Review.&quot Clin J Am Soc Nephrol, 2014: 110-119.

Smyth, Wendy, Vicki Hartig, and Valli Manickam. &quotOUTCOMES OF BUTTONHOLE AND ROPE-LADDER CANNULATION TECHNIQUES IN A TROPICAL RENAL SERVICE.&quot Journal of Renal Care, 2013: 157-165.

Suri, Rita S, et al. &quotRisk of Vascular Access Complications with Frequent Hemodialysis.&quot J Am Soc Nephrol, 2013: 498-505.

Twardowski, Z. J. (2012). Around the World with Nephrology: An Autobiography. Hackensack, NJ 07601: World Scientific.

Van EPS, Carolyn L, et al. &quotThe impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access.&quot Hemodialysis International, 2010: 451-463.

van Loon, Magda M, Tony Goovaerts, Alfons G H, Kessels, Frank M van der Sande, and Jan H. M Tordoir. &quotButtonhole needling of haemodialysis arteriovenous fistulae results in less complications and interventions compared to the rope-ladder technique.&quot Nephrol Dial Transplant, 2010: 225-230.

Vaux, Emma , et al. &quotEffect of Buttonhole Cannulation With a Polycarbonate Peg on In-Center Hemodialysis Fistula Outcomes: A Randomized Controlled Trial.&quot AmJ Kidney Dis, 2013: 81-88.

Verhallen, Annemarie M, Menno P Kooistra, and Brigit C van Jaarsveld. &quotCannulating in haemodialysis: rope-ladder or buttonhole technique?&quot Nephrol. Dial. Transplant, 2007: 2601-2604.

Ward, Janice, Kate Shaw, and Andrew Davenport. &quotPatients’ Perspectives of Constant-Site (Buttonhole) Cannulation for Haemodialysis Access.&quot Nephron Clin Pract, 2010: 123-127.

Wilson, S. E. (2013). Vascular Access: Principles and Practice. New York: Lippincott Williams &amp Wilkins,.