Rope-ladder Needling and Buttonhole Needling Which technique results in higher infection rates?

Rope-Ladder Needling And Buttonhole Needling 3

Rope-ladderNeedling and Buttonhole Needling: Which technique results in higherinfection rates?

byStudent’s Name



Code+Course Name




Reviewingliterature basically implies providing an account of alreadypublished works by experts and researchers in a particular disciplineand it serves to convey the knowledge and insights established inthat field of knowledge (Taylor &amp Procter, 2008, p.1). In linewith this, the body of knowledge used here were scrutinized andsubsequently selected after establishing this definition in a periodthat lasted eight months. This duration was elongated to a furtherfour months due to access technicalities in obtaining some criticalworks that required a long formal process to acquire. In order tofacilitate the process of selecting the most appropriate works forreview, constant reference was made to three research-orientedjournal articles namely Levy &amp Ellis (2006), Jesson et al (2011)and Webster &amp Watson (2002). In searching for the relevantliterature to review, an array of strategies were employed so as toensure that the materials selected are not just the most relevant tothe topic of study but also that the entire search and selection wasas rigorous as possible. Electronic search and especiallycomputerized scrutiny was initially limited to MEDLARS since it isbelieved that it guarantees a high chance of obtaining the mostrelevant materials (Auston et al, 1992, p. 32). The GCC control ofinfection annual was as much employed, the search was also extendedto resources of the national network of libraries of medicine(NN/LM). The process largely utilized Google scholar in an endeavorto obtain peer reviewed journals, which have been established ascredible sources of information. In the search and selection processled to the access of medical databases such as Medscape NLM and EHSL.The key search words used included rope ladder, buttonhole andinfection. The search process yielded 35 materials to be reviewed.The number was reduced to 17 after 8 of the materials were found tocontain similar findings to other comprehensive sources. All the 17sources used were found to be highly credible based on rigor andverifiability of the outcomes.

Bythe end of this literature review, the answers to the followingquestion should manifest: Does rope-ladder needling result in lowerinfection rate relative to buttonhole needling? The literature reviewaddressed the following concerns.

  1. Infection rates

  2. The limits and demerits of rope-ladder and buttonhole needling.

  3. Qualifications, professionalism and experience of physicians.


Literaturesreviewed had mixed findings concerning the rates and extent ofinfection that accrue to a patient after both rope-ladder andbuttonhole needling. Conducting an extensive review of buttonholecannulation for heamodialysis, Evans (2012, p. 147) found out thatthe AVF infections are usually rare but must be treated with utmostcaution especially with regards to the inhibited immunology. Theseinfections, it was noted, are mostly triggered by the carelessapplication of aseptic techniques during the cannulation process. Thestudies have identified a certain kind of bacteria called theStaphylococcusaureusas responsible for most infections associated with buttonholeneedling. In the entire review carried out, 65.5% concluded thatthere was an increase in the rate of infections attributable tobuttonhole cannulation (p. 148). Existing body of knowledge have alsoascertained that the resulting infection is mostly due to other(intervening) factors other than the needling techniques themselves.Labriola et al (2011, p.445), while analyzing the causes of secondaryinfections in patients who have undergone needling, observed thatbacteraemia, which is a common kind of infection associated withbuttonhole needling, usually results when the skin is not adequatelyprepared before the needling procedures. The observations are alsoespoused by Van Eps et al (2010, p. 461) who noted that use ofunsterilized equipment prior to the cannulation in both rope-ladderand buttonhole needling may introduce disease causing pathogens intothe operation site and subsequently lead to infections (bacteraemia).

Rope-Laddervs. Buttonhole Needling: Resulting Infections

Studieshave endeavored out which among rope-ladder technique and buttonholetechnique results in more infections. In most analytical studiespitting rope-ladder against buttonhole technique, it has beenestablished that the resulting infections of the two needlingtechniques vary greatly. It has been ascertained that in a comparisonof patients’ perceived pain and complications from of fistularesulting from the two techniques, there was a significant reductionin infections for patients who had undergone buttonhole needlingrelative to those of rope-ladder technique (MacRae, 2012, p. 1636).This paper (MacRae, 2012), used a visual analog scale which is morepreferred to other qualitative scales to quantify the qualitativeresponse from their study sample of 140 patients of cannulation. Theethical standards relating to the study were of as much highstandards having been approved by the University of Calgary researchboard, a reputable research institute and supported by the KidneyFoundation of Canada. There are as much a similar number of studiesthat have conducted systematic review to assess the relative meritsof rope ladder needling and buttonhole needling. It has been foundthat compared to rope ladder technique, the buttonhole technique isnot associated with a substantial rate of systemic arteriovenousfistula-related infections (Muir et al, 2014, p.110). In the samestudy, findings showed that the incidence ratio was 2.71, p-value of0.17 at a 95% confidence interval for the 90 participants covered bythe prospective cohort study. Moreover, this outcome was confirmedusing seven randomized trials with a considerably high relative risksbetween the two techniques (3.34) at a 95% confidence interval. Ingeneral, the buttonhole cannulation was found to be highly correlatedwith increased probability of infections as compared to rope ladderneedling on home hemodialysis patients (p. 118).

Suriet al (2013) undertook to investigate the risks that are associatedwith vascular access complications with very frequent hemodialysis in245 heamodialysis patients. Using Cox Proportional methodology (p.503), the study espoused that the risk associated with a first accesswere about 76% more with daily hemodialysis as compared toconventional hemodialysis with a hazard ratio of 1.76, p-value of0.017 at a 95% confidence interval (p. 498). In a similar study,MacRae et al (2012, p. 1632) found out that the rate of infection inrope ladder needling relative to buttonhole needling was 22.4 versus50/1000 with a p-value of 0.003. Quite differently, there are studiesthat yielded outcomes consistent with those of Suri et al (2013) andMacRae et al (2012) despite the fact that they were undertaken incompletely different contexts. There are studies that have beenconducted to assess the resulting infections of both techniques basedon access patency. It has been espoused that the rates of infectionrelated to the two techniques do not differ substantially only thatdiabetes has been found to be very prevalent in patients ofbuttonhole cannulation relative to rope ladder cannulation withp-value = 0.002, 69% vs. 34% (Chan et al, 2014, p.210). As for theeffect of gender, results showed that there existed a hazard ratio of1.02 and p-value of 0.03 at a 96% confidence interval. The study byChan et al (2014) used a sample of 83 participants and used themultivariate cox proportional hazard technique which has beenespoused a robust technique for carrying out correlational studiesthat involve abstract and subjective concepts (Bender et al, 2005,1714).

Theresulting infections of the two techniques were found to be varyingdepending on the context in which the procedures were performed aswell as the specific purpose. Smyth et al (2013), conducted acorrelational study using 104 heamodialysis patients as participantsto assess the outcomes of buttonhole needling and rope ladderneedling in North Queensland Australia and found out that thevariations in the rates of infection did not differ substantiallybetween the two needling techniques especially with regards to theformation of hematoma (Smyth et al, 2013, 157). However, the findingsgenerated from a research design embodying a prospective cohorttechnique showed that there was a an increased probability for theoccurrence of aneurysm (p &lt 0.05) for the patients categorized inthe rope ladder group as compared to those in the buttonhole group.In general, however, the empirical analysis obtained using Excel 2003spreadsheet, a reliable statistical tool, concluded that buttonholecannulation resulted in lower infection rates as compared to the ropeladder technique. Atkar &amp MacRae (2013) conducted an extensivesystematic review to ascertain the merits and demerits of buttonholecannulation in patients of heamodialysis patients. It was found outthat the buttonhole cannulation not only results in increasedinfections but also is a much a complex and sophisticated procedureespecially when undertaken by rotating physicians (p. 629). A similarstudy by Vaux et al (2013) using a sample size of 140 participantsconducted in a controlled trial setting of a polycarbonate peg onin-center hemodialysis results showed that in buttonhole cannulation,the rates of infection are low and that no bacteremia was observed(p. 86). Quite to the contrary, bacteremia were observed in patientsin rope ladder group (0.09/1000 AVF days) which eventually resultedin staphylococcus aureus (Vaux et al, 2013, p.86). The distinctivevariations in the outcomes could be attributed to the log-rank testapplied by the study, which is the most preferred technique incircumstances where the deviations in observations are likely to bevolatile (Kleinbaum &amp Klein, 2012, p.57).

Researchers,as revealed in most studies, have in recent time have undertook tocompare the efficacy of the buttonhole cannulation as well as therope ladder cannulation on the basis of two common post cannulationinfections: formation of aneurysm and formation of hematoma. Incontrol studies, the patients in the rope ladder group have beenfound to experience a less unsuccessful cannulation (as far asrecurrent infections are concerned) relative to those in thebuttonhole group exhibiting a p value &lt 0.0001 (Van Loon et al,2009, p.225). Moreover, it was found that the probability of aneurysmformation (p &lt 0.0001) and hematoma formation (p &lt 0.0001) wereless likely (p.225) in a setting in which the p &lt 0.05 was used asthe benchmark for level of significance. The study by Van Loon et al(2009) is particularly important to this endeavor since having used asample of 140 participants it is the single largest ever-prospectiveobservational study (Atkar &amp MacRae, 2013, p. 630). Other typesof infections studied included the peripheral vascular infection andcardiovascular infection. The peripheral vascular infection andcardiovascular infection were found to have a 56% and 47% likelihoodof occurrence in buttonhole groups respectively as compared to 20%and 26% likelihood in patients of rope ladder technique (Chow et al,2011, p. 89). The impact of cannulation as a procedure in theaccumulation of micro-organisms at the site and the consequentinfections have also been studied for both techniques. In anobservational cohort study, Van Eps et al (2010, p. 458) establishedthat buttonhole cannulation leads to much higher infection rates ascompared to rope ladder cannulation due to increased organism load atthe very site of operation.

Professionalism,Experience and Ethics of Physicians

Thequalifications of physicians, ethics and professionalism have beenfound to play as much a critical role towards the probability of postcannulation infections, regardless of the technique employed. It hasbeen found out that it is necessary to establish a well define rolefor medical practitioners that encompass the EBP if the non-technicalcomplications and infections related to cannulation are to be reduced(Fineout et al, 2004, p.30). In yet another study using a sample sizeof 53 patients, it was also established that more experienced nursespreferred to use blunt needles as it is known to significantly reducethe probability of formation of aneurysm (Ward &amp Davenport, 2010,p. 126). It has also been ascertained that ethical codes of conductpertaining to the care-related obligations of nurses can reducecannulation-triggered infections. For instance, adequate skinpreparation by applying use of providone-iodine and other pre andpost treatment procedures reduce probability of infections(Birchenough, 2010, p. 497). Moreover, it is espoused that rates ofinfection resulting from buttonhole fistula can be reduced throughadequate staffing and patient education (Kandil et al, 2014, p. 97).The study by Kandil et al (2014) has come across as critical toresearchers due to its large sample size of 227 participants and itsrobustness to the extent of examining the finer aspects of theinquiry including the effect of the angle and depth of needle ininfluencing the rates of infections (p. 95).

of the Literature Review

Thereview hereof covered a variety of credible and highly authoritativeliterature in the discipline of cannulation for heamodialysispatients. A majority of the sources reviewed were conducted inreputable institutions of higher education and research centers inthe world. For instance, MacRae et al (2012), which has been referredto adversely by this review, was approved by the University ofCalgary Research Ethics Board, supported by the Kidney Foundation ofCanada and still, the paper was presented at the American Society ofNephrology Annual Meeting on 12thNovember 2011. The studies used in the reviewed materials were thebest in the contexts of the respective studies. A possible limitationof this review is that the materials covered were published between2004 and 2014, it is logical that a more comprehensive study coveringworks published within a range of over 20 years would be more robust.Additionally, most of the works reviewed tend to be biased againstrope-ladder cannulation.

Thegeneral outcomes of the literature review showed that the rope laddertechnique results in fewer infections as compared with the buttonholecannulation. To this end, the question of the literature review isanswered. Moreover, the literature revealed more details to theextent of types of infections and the intervening variables that mayresult in recurrent post cannulation infections regardless of thetechnique employed. Formation of aneurysm and hematoma have comeacross as the most common types of infection for which the efficacyof buttonhole and rope ladder cannulation were gauged so far asresulting infections are concerned. Finally, the literature reviewcould not overestimate the impact of experience, professionalism,staffing (number and rotation) as well as the ethics of nursesconducting cannulation.


Ambrósio,E. M. M., Bloor, K., &amp MacPherson, H. (2012). Costs andconsequences of acupuncture as a treatment for chronic pain: asystematic review of economic evaluations conducted alongsiderandomised controlled trials. Complementarytherapies in medicine,20(5),364-374.

Atkar,R. K., &amp MacRae, J. M. (2013). The buttonhole technique forfistula cannulation: pros and cons. Currentopinion in nephrology and hypertension,22(6),629-636.

Auston,I., Cahn, M. A., &amp Selden, C. R. (1992). Literaturesearch methods for the development of clinical practice guidelines.NICHSR.

Bender,R., Augustin, T., &amp Blettner, M. (2005). Generating survivaltimes to simulate Cox proportional hazards models. Statisticsin medicine,24(11),1713-1723.

Birchenough,E., Moore, C., Stevens, K., &amp Stewart, S. (2010). Buttonholecannulation in adult patients on hemodialysis: an increased risk ofinfection? NephrologyNursing Journal,37(5),491.

Chan,M. R., Shobande, O., Vats, H., Wakeen, M., Meyer, X., Bellingham, J.,&amp Yevzlin, A. S. (2014, March). The Effect of ButtonholeCannulation vs. Rope‐ladderTechnique on Hemodialysis Access Patency. In Seminarsin dialysis(Vol. 27, No. 2, pp. 210-216).

Chow,J., Rayment, G., Miguel, S. S., &amp Gilbert, M. (2011). Arandomised controlled trial of buttonhole cannulation for theprevention of fistula access complications. Journalof renal care,37(2),85-93.

Fabbrocini,G. (2012). Complications of Needling. In Managementof Complications of Cosmetic Procedures(pp. 119-124). Springer Berlin Heidelberg.

Fineout,E., Levin, R. F., &amp Melnyk, B. M. (2004). Strategies foradvancing evidence-based practice in clinical settings. JNYState Nurses Assoc,35(2),28-32.

Jesson,J., Matheson, L., &amp Lacey, F. M. (2011). Doingyour literature review: traditional and systematic techniques.Sage.

Kandil,H., Collier, S., Yewetu, E., Cross, J., &amp Davenport, A. (2014).Arteriovenous fistula survival with buttonhole (constant site)cannulation for hemodialysis access. ASAIOJournal,60(1),95-98.

Kleinbaum,D. G., &amp Klein, M. (2012). Kaplan-Meier survival curves and thelog-rank test. In Survivalanalysis(pp. 55-96). Springer New York.

Labriola,L., Crott, R., Desmet, C., André, G., &amp Jadoul, M. (2011).Infectious complications following conversion to buttonholecannulation of native arteriovenous fistulas: a quality improvementreport. AmericanJournal of Kidney Diseases,57(3),442-448.

Levy,Y., &amp Ellis, T. J. (2006). A systems approach to conduct aneffective literature review in support of information systemsresearch. InformingScience: International Journal of an Emerging Transdiscipline,9(1),181-212.

MacRae,J. M., Ahmed, S. B., Atkar, R., &amp Hemmelgarn, B. R. (2012). Arandomized trial comparing buttonhole with rope ladder needling inconventional hemodialysis patients. ClinicalJournal of the American Society of Nephrology,7(10),1632-1638.

Muir,C. A., Kotwal, S. S., Hawley, C. M., Polkinghorne, K., Gallagher, M.P., Snelling, P., &amp Jardine, M. J. (2014). Buttonhole cannulationand clinical outcomes in a home hemodialysis cohort and systematicreview. ClinicalJournal of the American Society of Nephrology,9(1),110-119.

Smyth,W., Hartig, V., &amp Manickam, V. (2013). Outcomes of buttonhole andrope‐laddercannulation techniques in a tropical renal service. Journalof renal care,39(3),157-165.

Suri,R. S., Larive, B., Sherer, S., Eggers, P., Gassman, J., James, S. H.,… &amp Kliger, A. S. (2013). Risk of vascular access complicationswith frequent hemodialysis. Journalof the American Society of Nephrology,24(3),498-505.

Taylor,D., &amp Procter, M. (2008). The literature review: a few tips onconducting it. WritingSupport, University of Toronto. Retrieved,19.

vanLoon, M. M., Goovaerts, T., Kessels, A. G., van der Sande, F. M., &ampTordoir, J. H. (2009). Buttonhole needling of haemodialysisarteriovenous fistulae results in less complications andinterventions compared to the rope-ladder technique. Nephrologydialysis transplantation,gfp420.

Vaux,E., King, J., Lloyd, S., Moore, J., Bailey, L., Reading, I., &ampNaik, R. (2013). Effect of buttonhole cannulation with apolycarbonate PEG on in-center hemodialysis fistula outcomes: arandomized controlled trial. AmericanJournal of Kidney Diseases,62(1),81-88.

Ward,J., Shaw, K., &amp Davenport, A. (2010). Patients’ perspectives ofconstant-site (buttonhole) cannulation for haemodialysis access.NephronClinical Practice,116(2),c123-c127.