Effect of two different techniques of arteriovenous fistula puncture on wound infection in haemodialysis patients.

Safe and effective arteriovenous fistula (AVF) puncture is very important to reduce the wound complications of haemodialysis (HD). For AVF puncture in dialysis patients, there is a lack of clarity and consistency regarding the relative advantage of buttonhole (BH) over rope-ladder (RL) cannulae in terms of wound complications. The study was published in several scientific databases including Cochrane Library, PubMed and Embase by October 2023. Data from all controlled trials looking at the effect of BH and RL on wound complications in haemodialysis patients were included. The articles were written in English, and they were about adult who had AVF while on dialysis. Studies with or without BH or RL treatment were excluded from the analysis. The data was analysed with RevMan5.3 software. Out of 215 trials, 9 were chosen for the final analysis. The study publication dates were between 2000 and 2023. Of these, 17 326 patients received AVF therapy. Among them, there were 3070 BH and 14 256 RL. In 9 studies, RL had a lower risk of postoperative wound infection compared to BH (OR, 3.38; 95% CI, 3.06, 3.73 p < 0.0001); In all 3 studies, there were no statistically significant differences in the risk of post operative bleeding in RL versus BH(OR, 0.76; 95% CI, 0.25, 2.33 p = 0.63). Our studies have demonstrated that RL trocars are superior to BH trocars in the prevention of wound infection.

A time-saving method of creating AVF buttonholes: indwelling trocar technique.

AIMS AND OBJECTIVES: This study aims to explore the convenience and practicality of the method of establishing buttonholes with indwelling trocars. BACKGROUND: Compared with rope-ladder technique, buttonhole cannulation has better applicability for haemodialysis patients, and the method of buttonhole establishment is particularly important. DESIGN: Prospective, observational and cohort study. METHODS: We conducted a 12-month observational study on 30 patients who used sharp needles to establish buttonholes and 33 patients who used indwelling trocars to establish buttonholes, and compared the differences between the two groups in the buttonhole formation time, patient-reported cannulation pain, buttonhole success rate, AVF-related infection and patency of AVF. The study adhered to STROBE guidelines. RESULTS: The buttonhole formation time of the indwelling trocar group is less than that of the sharp needle group (5.48 ± 0.51 vs. 23.23 ± 3.07, p < .01). When the buttonhole was used for the first time, the cannulation pain of the indwelling trocar group was less than that of the sharp needle group (4.94 ± 1.50 vs. 6.03 ± 1.13, p = .002), but there was no significant difference in this result after 1 month (sharp needle group with 4.50 ± 0.94 vs. indwelling trocar group with 4.12 ± 1.19, p = .169). Compared with all the buttonholes in the indwelling trocar group were established successfully, there were 5 unsuccessful buttonholes in the sharp needle group (p = .02). Three cases of unsuccessful buttonhole patients in the sharp needle group developed AVF-related infection, this result did not appear in the indwelling trocar group (p = .102). The difference in arterial pressure and venous pressure between the two groups was not significant (p = .061, p = .222). CONCLUSIONS: Our new method can help buttonhole patients get less track formation time, less cannulation pain, and less fistula infection, thereby bringing them a more comfortable dialysis experience. RELEVANCE TO CLINICAL PRACTICE: The new method used in this study not only meets the needs of patients to protect AVF, but also provides convenience for clinical work. In addition, this study analyzed the causes of the AVF infection in buttonhole patients, and provided directions for future research.

Risk of Vascular Access Infection Associated With Buttonhole Cannulation of Fistulas: Data From the National Healthcare Safety Network.

RATIONALE & OBJECTIVE: Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access-related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC. STUDY DESIGN: Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data. SETTING & PARTICIPANTS: US patients receiving hemodialysis treated in outpatient dialysis centers. PREDICTORS: AVF cannulation methods, dialysis facility characteristics, and infection control practices. OUTCOMES: Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start. ANALYTIC APPROACH: Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression. RESULTS: During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access-related bloodstream infections. Hospitalization was frequent among BHC access-related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start. LIMITATIONS: Data for facility practices were self-reported and not patient specific. CONCLUSIONS: BHC was associated with higher risk for vascular access-related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

Intensive Hemodialysis and Potential Risks With Increasing Treatment.

Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.

Pro: Buttonhole cannulation of arteriovenous fistulae.

Arteriovenous fistulae remain the access of choice for most hemodialysis patients. However, several factors limit their uptake and long-term patency, resulting in suboptimal prevalent rates in many high-income countries. Patients place considerable value on the avoidance of vascular access complications, pain and disfigurement. The approach to cannulation is a modifiable practice that could improve patient-important outcomes, with buttonhole needling offering some theoretical advantages over the standard rope-ladder and area methods. In this narrative review, we summarize key findings of studies reporting the benefits and risks associated with the buttonhole method, highlighting methodological limitations as well as recent refinements to the technique that may represent potential opportunities for reducing infection risk. We highlight the need for greater certainty surrounding the potential benefits of the buttonhole cannulation technique and propose some directions for future research.

Application of vacuum-sealing drainage in buttonhole-related arteriovenous fistula infection: A case report.

Few studies have reported the application of vacuum-sealing drainage of infected dialysis vascular access wounds. Herein, we present a case of buttonhole-related arteriovenous fistula infection treated with vacuum-sealing drainage. A 53-year-old female hemodialysis patient was hospitalized with an inflamed arteriovenous fistula. The patient underwent non-tunneled catheterization for dialysis and was treated with moxifloxacin and vancomycin for staphylococcal infection. On Day 3, the skin overlying the inflamed fistula was ulcerated, resulting in severe hemorrhage. Emergency surgery was performed along with vacuum-sealing drainage for fistula reconstruction. Vacuum-sealing drainage accelerated the recovery of the wound without complications. No further access complications occurred during over a 3-year follow-up.

Characteristics, practices, and outcomes in a Belgian cohort of incident home hemodialysis patients: A 6-year experience.

BACKGROUND: Home hemodialysis (HHD) remains underused in patients with kidney failure. Current literature on HHD mostly originates from non-European countries, making generalization difficult. The present study describes patients' profile and practice patterns from a Belgian HHD center, and assesses patient and technique survival and complications associated with HHD. METHODS: We analyzed data from all our incident patients during a 6-year period. The patient's characteristics were summarized using descriptive statistics. Transition to another therapeutic modality, estimated using a risk model with death and transplantation as competing events, episodes of respite cares and hospitalizations, and access complications were analyzed. RESULTS: Eighty patients (mean age: 47 years; male: 64%) met the inclusion criteria. Fifty-one percent of patients initiated dialysis with a central venous catheter (CVC) and 96% were not assisted. Arterio-venous fistula (AVF) cannulation was performed using buttonhole technique. Standard-frequent HD (47%) and short-frequent low-flow dialysate HD (34%) were mostly used at HHD initiation. Cumulative incidences of technique failure and death were 15%, 24%, and 32% at 1, 2, and 5 years. Incidence rates for respite dialysis and hospitalizations were 2.39 and 0.54 per patient-year of HHD. In comparison with AVF, incidence rate ratios of overall access complications and access-related infections for CVC were 4.3 (95% CI: 3.1-6, p < 0.01) and 4.4 (95% CI: 2.1-10, p < 0.01), respectively. Buttonhole cannulation was complicated by 0.26 (95% CI: 0.15-0.46) infections per 1000 AVF-days. CONCLUSIONS: This present study provides important information about patient's profile and practice patterns and safety in a cohort of 80 incident Belgian HHD patients, with encouraging techniques and patient survival.

Considerations in Access Cannulation: Traditional and Evolving Approaches.

Needle cannulation of hemodialysis access is the soft underbelly of hemodialysis access care that has remained unchanged for a long time. Cannulation error results in complications such as infiltration, hematoma, subsequent revision procedures, and potential loss of hard-earned access. The "best" cannulation method is contingent upon access type and characteristics along with local expertise. The rope ladder technique of cannulation, characterized by successive rotation of puncture sites with each hemodialysis session, permits sufficient time for healing of prior cannulation sites, and reduction in complications such as bleeding, infection, and aneurysm development. A steeper needle angle, higher blood flow rates, and deep needle tip can lead to wall stress on the posterior wall and up to 10 cm from the needle cannulation site. Plastic cannulas provide a viable alternative to metallic needles; they have lower complications and a favorable cost-benefit ratio. There is lack of evidence to support an optimal arterial needle direction configuration. Needle injury may promote intimal thickening, but its effect on access outcomes is currently unknown. Percutaneous creation of arteriovenous fistula presents new challenges in dialysis access cannulation. Point-of-care ultrasound-guided cannulation will likely lead to a paradigm shift in access cannulation. Novel care delivery using cannulation stations is a promising development.

Nursing care of a case of intimal hyperplasia at buttonhole puncture site of arteriovenous fistula / 中华护理杂志

The nursing experience of intimal hyperplasia at buttonhole puncture site in a patient with autogenous arteriovenous fistula was reported.The key points of nursing:to formulate a scientific and reasonable internal fistula puncture plan,to establish and maintain the buttonhole tunnel,to regularly monitor the use of arteriovenous fistula,to replace the traditional internal fistula steel needle(hereinafter referred to as the steel needle)with the hemodialysis trocar needle(hereinafter referred to as the trocar needle)for buttonhole puncture,to treat with far infrared ray during each dialysis,and to guide the patient to apply hirudoid cream on the arm of the fistula side.After careful nursing,the intimal hyperplasia at the buttonhole puncture site disappeared,and there was no recurrence after 6 months of follow-up.

Formation of abnormal fistula on arteriovenous fistula in a patient with buttonhole cannulation: a case report.

Buttonhole cannulation has been suggested as a technique that may lead to a reduction in many complications when compared with other techniques such as rope-ladder cannulation. Despite all above, some complications still continue, which may lead to a dysfunction of the arteriovenous fistula (AVF) and inadequate dialysis, having an impact on the quality of life of the patients or eventually making the vascular access unusable. We report a 47-year-old Chinese male with end-stage renal disease who had maintenance hemodialysis three times a week for 5 years. The AVF on the left wrist was operated 5 years ago and proved to be functionally effective with some monitoring and surveillance measures in the fourth year of hemodialysis. Two months later, the buttonhole cannulation technique was applied due to fistula punctuation difficulty by previous aneurysmal dilatation. After 10 times of buttonhole cannulation, the edema on the left forearm of the patient indicated a dysfunction of the AVF. This was further confirmed by the HD02 hemodialysis monitor and a vascular ultrasound, revealing a recirculation of 87%, an abnormal fistula between the AVF and the vein together with thrombus, and aneurysmal dilatation near the anastomosis. The site of cannulation was changed to avoid heavy recirculation (reduced to 25%), and a new AVF on the left wrist was successfully operated. Abnormal fistula on the AVF and vein during buttonhole cannulation is rarely reported, which reminds us that vascular access surveillance should be done regularly before and during the process of construction to find a possible dysfunction of the AVF in patients undergoing buttonhole cannulation.

The care and keeping of vascular access for home hemodialysis patients.

Creating and maintaining a healthy vascular access is a critical factor in successful home hemodialysis (HD). This article aims to serve as a "how-to manual" regarding vascular access issues for both patients and health-care providers in a home HD program. This document outlines cannulation options for patients with arteriovenous access and describes troubleshooting techniques for potential complications; strategies are suggested to help patients overcome fear of cannulation and address problems associated with difficult cannulation. Technical aspects of central venous catheter care, as well as a guide to troubleshooting catheter complications, are covered in detail. Monitoring for access-related complications of stenosis, infection, and thrombosis is a key part of every home HD program. Key performance and quality indicators are important mechanisms to ensure patient safety in home HD and should be used during routine clinic visits.

Developing renal nurses' buttonhole cannulation skills using e-learning.

BACKGROUND: It has previously been shown that nurses can learn clinical nursing skills by e-learning (online), and that many variables will influence how well nurses adopt learned clinical skills using distance education. OBJECTIVES: This study aimed to identify and measure the strength of those factors which would simultaneously influence registered nurses' (RNs') beliefs about their own learning about buttonhole cannulation, using e-learning. DESIGN: An online Likert style survey consisting of a list of statements related to knowledge and skill domains considered crucial in the area of buttonhole cannulation was distributed to 101 RNs before and after completing an e-learning programme. Participants were required to identify their current level of self-confidence in relationship to each of the statements. MEASUREMENTS: Measures of RNs' self-rated abilities to assess and implement buttonhole cannulation after completing a related e-learning program were tested using a Partial Least Squares Analysis (PLS-PATH) programme. RESULTS: The study's results strongly identify that the nurses' ability to meet both clinical and educational outcomes of the renal e-learning module can be predicted by six variables, none of which are directly related to the participants' demographic or clinical backgrounds. CONCLUSION: These findings support the use of e-learning to teach clinical skills to RNs, and demonstrate the value of Partial Least Squares Analysis in determining influential learning factors.

Clinical Experience with Buttonhole Needling in a Single Hemodialysis Center / 대한내과학회지

BACKGROUND/AIMS: The buttonhole technique, in which needle insertion during cannulation is always into the same site, confers advantages including ease of cannulation, ease of achieving hemostasis, and reduced pain compared with rope-ladder needling. We introduced the buttonhole technique in hemodialysis patients experiencing pain during needling. None of the disadvantages associated with the buttonhole technique, such as infection or access events, were observed, due to the short duration of the study. METHODS: Patients undergoing buttonhole needling were observed prospectively. Data were collected on the following parameters: infectious complications, hospitalizations and access events. We compared buttonhole and rope-ladder needling using baseline data. RESULTS: A total of 48 patients (34 males; mean age = 49.4 +/- 13.8 years) were enrolled. Seven patients were excluded: in three patients, the buttonhole technique failed to form a tract, three others underwent kidney transplantation, and one was lost to follow-up. The remaining 41 patients were followed for 15.7 +/- 4.7 months. Thirteen patients suffered infections, as follows: local infections (n = 5), pneumonia (n = 3), bacteremia (n = 2), cellulitis (n = 1), osteomyelitis (n = 1), and liver abscess (n = 1). There were no significant differences between the rope-ladder and buttonhole needling techniques in rates of infection, hospitalization or vascular access events. CONCLUSIONS: The infection rate and access event frequency associated with buttonhole needling did not differ in relation to that of rope-ladder needling.

Clinical Experience with Buttonhole Needling in a Single Hemodialysis Center / 대한내과학회지

BACKGROUND/AIMS: The buttonhole technique, in which needle insertion during cannulation is always into the same site, confers advantages including ease of cannulation, ease of achieving hemostasis, and reduced pain compared with rope-ladder needling. We introduced the buttonhole technique in hemodialysis patients experiencing pain during needling. None of the disadvantages associated with the buttonhole technique, such as infection or access events, were observed, due to the short duration of the study. METHODS: Patients undergoing buttonhole needling were observed prospectively. Data were collected on the following parameters: infectious complications, hospitalizations and access events. We compared buttonhole and rope-ladder needling using baseline data. RESULTS: A total of 48 patients (34 males; mean age = 49.4 +/- 13.8 years) were enrolled. Seven patients were excluded: in three patients, the buttonhole technique failed to form a tract, three others underwent kidney transplantation, and one was lost to follow-up. The remaining 41 patients were followed for 15.7 +/- 4.7 months. Thirteen patients suffered infections, as follows: local infections (n = 5), pneumonia (n = 3), bacteremia (n = 2), cellulitis (n = 1), osteomyelitis (n = 1), and liver abscess (n = 1). There were no significant differences between the rope-ladder and buttonhole needling techniques in rates of infection, hospitalization or vascular access events. CONCLUSIONS: The infection rate and access event frequency associated with buttonhole needling did not differ in relation to that of rope-ladder needling.