Dialysis Buttons for your Buttonholes

In my last post I mentioned that it is becoming more common for units to get people started with buttonholing by inserting a plug into each needle hole for a couple of weeks, so that buttonhole and tunnel formation are accelerated.  I met with Anna Flynn, a very experienced practitioner of this technique last week to get the whole story.

As you know, I am a big proponent of buttonholing (using the same needle holes for each dialysis session) for several reasons.  On a day-to-day basis, you get less pain when the needles go in, less lumps and bumps develop on your arm and bleeding times is reduced to a few minutes once the needles have been removed.  In the longer term, it is pretty clear that fistulas last and stay functional for a longer time.

Just a quick recap on what buttonholing is:

  • Using the same hole, inserting at the same angle and depth eventually creates a tunnel down to the fistula vessel for each needle.
  • At the start of the next session, each site is cleaned and sanitised, the scab that forms after the last session is lifted off, the sites are cleaned again and the needles inserted to puncture the fistula at the same place each time
  • After a few weeks of this, a tunnel forms to guide each needle and a flap or “trap door” is created in the fistula wall
  • At this point, you can switch to blunt needles, since there is no longer much resistance when the needle is inserted: it flows down the tunnel, opens the flap, and Robert’s your father’s brother!
  • When you remove the needle, the flap closes over and the after a few minutes pressure, the bleeding stops, you put on a light dressing and go home.

That’s buttonholing.

Now, about the plugs.  Called Bioholes® (manufactured only by Nipro in Japan) they are very small, sterile, polycarbonate, thumbtack-shaped pegs, used to prop the needle tracks open between cannulations.

This is Biohole® plug. The shaft is about as thick as a BigD needle.

Once inserted, scar tissue forms quickly around the peg as the body tries to heal itself in just the same that a newly pierced ear does, when a sleeper stud is left in place to preserve the new hole.  This scar tissue helps form the tunnel track and can be felt as a small lump over the needle site as the track develops.  Typically you need only 6 or 7 sessions to create fully developed buttonhole.

Here's what Biohole® plugs look like in place.

Bioholes® were developed in Japan in 2003 (yes, things move slowly in medical world), to speed the buttonhole development cycle and the enable the buttonholing to be introduced to dialysis units on a large scale.  The problem with the buttonhole approach is that it requires that the same person to insert the needle each time.  This is not possible in most dialysis units with many staff on various rosters.  Using these plugs and a customised protocol, these problems can be minimised.  Bioholes® are being trialled in Europe (see this paper); they  used Asia and the pacific (including Australia) now, and are probably coming to a BigD unit near you sooner rather than later.

Here’s how it’s done:

1.       At the end of dialysis, remove the needles as usual, and apply pressure to stop bleeding the needle sites.

Inserting a Biohole® plug after the needle has been removed

Closeup of Biohole® inserting

2.       Once bleeding has stopped, ideally wait for five minutes, then insert the Biohole pegs can be inserted into the holes, using an aseptic technique.

3.       Cover the pegs with at least two plasters to avoid the accidental dislodgement.  Keep them in place until the next dialysis session.

The hole that's left after the Biohole® is removed. Thanks to Nipro for the photo.

4.       At the next dialysis session, the nurse and or the patient removes the pegs.

5.       After the patient has washed their hands and fistula arm with antibacterial soap and water, sharp needles are inserted as normal into the sites recently vacated by the Biohole peg.

While we are on buttonholing, there are a couple tricks to know:

  • Getting the scab off before inserting the blunt needle: I use a sharp needle, so I can get under the scab and lift it off.  Most use blunt Drawing-Up needles.  Both are effective; the sharp are quicker, but you can do a bit of damage if you are not careful (especially if like me, your eyesight is a bit iffy).
  • If you are having trouble getting the scab off, put some saline or skin disinfectant on some gauze for 5 minutes, to soften it up.
  • Recent finding indicate the buttonholing can increase the potential for infection, so swab before and after removing the scab and if you need to fully withdraw the needle while you are hunting for the flap, start again with a new needle.
  • Sometimes, with the best technique, the needle can’t find the entry flap (my fistula seems to be always on the move, and the entry point seems to wander).  Don’t force it: you can tear and scrape tissue which is both painful and ineffective.
  • Insert the blunt needle by holding the tubing part of the needle just behind the wings and with a gentle twisting and rotating motion, allow it to seek out the tunnel.  It can be helped along by gently stretching the skin to open the tunnel.

For more details, check out Anna’s presentation:

Many thanks to Anna Flynn for the pics and the extensive advice.

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10 thoughts on “Dialysis Buttons for your Buttonholes

  1. The nurses/technicians at my unit are alright but then the other ones that insert the needles do not insert them correctly as “much less! than halfway through my treatment I start to bleed profusely through my site and my arm is totally numb for hours after I’m already home. The nursed stop short my treatment by” more”! then an a complete hour and send me home which upsets me as I have extra fluid that needs to come off and I get extra treatments that my doc ordered for half my regular 4 hour treat. time which is 2 hours, so what’s the use if they cou me short 2-3 times a week! And I only go 3 times a week unless I’m scheduled for those extra treatments, so what’s the use of extra treatments if what’s going on, defeats the purpose???? Please help and advised. Thank you very much. 347 697 8539 my tel# if you need it.

    • Hi Elise, thanks for your comment. In the early days of my BigD time, I had a similar experience with an inept needler, and had to shorten my run. But I made such a fuss that the Unit Manager fired the person and it has not happened since (it was also one of the reasons why I decided to do the needling myself). You are right that it is no good at all to shorten your treatment, especially when you need to get rid of fluid.

      If I were you, I would not let that person needle me again. The way to get action is to make a formal complaint. Most units have things called Incident Reports, which are the way unit administration is informed that something like this has happened and they must respond formally, to ensure it doesn’t happen again. Ask to make an Incident Report regarding both the poor needling and the reduced run time, which if it happens often, can be life threatening.

      Let me know what happens. I am happy to help where I can. Greg

  2. I don’t know if this is a dialysis problem but it all started after dialysis and now I’m almost turning an invalid! Here goes: I use a portable oxygen tank when I go for my treatments and all of a sudden I can’t make it from my bedroom to the bathroom with feeling like I ran around the block 3 times!and to make it worse I have to sit down somewhere after taking less than 10 stepts I’m gasping for air with the oxygen on the highest level. This continues throughout the entire time when trying to get outside to the ambulette taking me to the dialysis treatment center. I have to stop and sit down every 10 steps for intervals of 7 minutes gasping for air w/oxygen.etc. Its terrible and I have to repeat this until I get into the Ambulette. I don’t understand this cause when I am sitting down its totally the opposite. And everone thinks its extra fluid but its not as I have had extra treatments for this! My old kidney doctor was very unprofessional. And I fired him for leaving a lot of fluid on me for months and doing nothing to schedule extra treatments to take it off and I switched docs and the new one is trying to help and told me a lot! Of fluid is in my tissues as my legs were hard as concrete and I can’t even bend them at all! Please try and help me solve this breathing problem as I am going to die if this goes on as its unbelievable!

  3. Hi Elise. I don’t think I answered you question properly last time. I don’t know why – maybe I was a little spaced out after dialysis! Anyway, from what you say, it does sound very much like extra fluid. Once your lungs fill with excess fluid, it becomes very hard to breathe. It also puts great strain on your heart and circulation suffers – legs fill up and become hard and inflexible. I know its very uncomfortable, and very dangerous.
    The best approach is to act at both ends of the problem: try and get more dialysis over a long term – weeks, not just a few sessions, and try to limit what you drink. If you can do this, you will see a big improvement in a couple of weeks. But it is important to keep the fluid off. Its a long-term effort to stay healthy. Don’t rely on the machine.
    How are things now? Greg

  4. Reblogged this on THE NONO SLEEVE and commented:
    This is the first I have heard about the plugs. I wonder if the infection rate is higher using these since the sites are open all the time.

    I use the blunts for removing my scabs because they have a removal tool covering the needle itself. I don’t particularly like them because of the sharpness causes difficulty in lifting the scab out completely, but would never be able to use a sharp to do the job. My hat is off to you for that feat. Good health to you and yours and stay positive always.

  5. Interesting. I don’t think anybody has every talked to my husband about buttonholing at his dialysis center. Is it better than being poked at a different place each time? If there is increased risk of infection with buttonholing, why would people choose it over getting poked at a different place each time? I am confused.

    • Hi Holly. There are many additional benefits from buttonholing, including a longer lasting fistula, reduced bleeding when the needles are removed, ease of needling and usually, less pain. While there is statistically an increased infection risk, as long as you take the usual infection precautions, that risk is still quite low.
      One difficulty with buttonholing is that the needles must be inserted at the same angle every time, so it should be done by the same person each time. This can be impractical in a large unit, so the best alternative is for your husband to learn to needle himself. It is a bit scary at first, but only takes a few days to learn and it will give him total control over the process.
      Regards, Greg

      • I’m not sure they allow people to needle themselves at his unit. I’ll have to ask him or have him ask them. I know one of his big gripes is techs who don’t seem to know what they’re doing when they stick him. But thanks for the info!

  6. I just discovered your site and am thrilled. I’m going to be sticking myself starting next week. So far my button holes have been going great! No more anxiety about inept techs sticking me!

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