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      Nursing approach to the use of buttonhole and rope ladder cannulation of arteriovenous fistula based on a survey in Nigeria


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          The main purpose of this study is to examine the nursing aspect of two types of cannulation techniques and to investigate the outcomes of using cannulations on an arteriovenous fistula, as well as analysing their impact on outcome.

          Materials and methods

          Data were collected using a self-developed questionnaire. Data were obtained from haemodialysis (HD) patients in Rivon Dialysis Centre in the city of Rivers State named Port Harcourt with over 60 HD patients and with over 15 HD nurses. Only 50 patients met the inclusive criteria after answering the questionnaire, 25 for rope ladder (RL) and 25 for buttonhole (BH) and 10 nurses chosen answered the questionnaire.


          This study revealed that patients who are using the BH cannulation technique reported a better outcome than the RL group patients. Patients reported lower occurrence of complication, for instance, out of 25 patients, 8 of them using the BH and 15 of them using the RL reported to have infection.


          Based on the results, it is possible to conclude that the patients who are cannulated with the RL cannulation technique have a higher risk of experiencing complications than the patients using the BH site cannulation technique.

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          Most cited references14

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          Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

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            Cannulation technique influences arteriovenous fistula and graft survival

            Hemodialysis patient survival is dependent on the availability of a reliable vascular access. In clinical practice, procedures for vascular access cannulation vary from clinic to clinic. We investigated the impact of cannulation technique on arteriovenous fistula and graft survival. Based on an April 2009 cross-sectional survey of vascular access cannulation practices in 171 dialysis units, a cohort of patients with corresponding vascular access survival information was selected for follow-up ending March 2012. Of the 10,807 patients enrolled in the original survey, access survival data were available for 7058 patients from nine countries. Of these, 90.6% had an arteriovenous fistula and 9.4% arteriovenous graft. Access needling was by area technique for 65.8%, rope-ladder for 28.2%, and buttonhole for 6%. The most common direction of puncture was antegrade with bevel up (43.1%). A Cox regression model was applied, adjusted for within-country effects, and defining as events the need for creation of a new vascular access. Area cannulation was associated with a significantly higher risk of access failure than rope-ladder or buttonhole. Retrograde direction of the arterial needle with bevel down was also associated with an increased failure risk. Patient application of pressure during cannulation appeared more favorable for vascular access longevity than not applying pressure or using a tourniquet. The higher risk of failure associated with venous pressures under 100 or over 150 mm Hg should open a discussion on limits currently considered acceptable.
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              Cannulating in haemodialysis: rope-ladder or buttonhole technique?

              The standard technique for fistula cannulation, the rope-ladder technique, is problematic for patients with short fistula lengths and for patients in whom the fistula is difficult to cannulate. The buttonhole technique, cannulation of exactly the same site, offers the advantage of an easy cannulation procedure. However, it can be used only in native fistulas and cannulation is preferably executed by a 'single-sticker'. This study was conducted to compare these cannulation techniques using objective parameters. We introduced the buttonhole technique for self-cannulating home haemodialysis patients and compared it with baseline data obtained with the rope-ladder technique. Thirty-three patients with a native arteriovenous fistula were observed prospectively during 18 months on the following parameters: cannulating ease, number of bad sticks, pain, time of compression after cannula removal, bleeding, infectious complications and aneurysm formation. With the buttonhole method, cannulating ease improved distinctly, which was especially favourable in patients with a short fistula vein. Reported cannulation pain did not change significantly. The incidence of bad sticks decreased significantly, as well as time of compression after cannula removal, without increased incidence of bleeding. Three patients developed a local skin infection of their buttonhole during the study, after which the disinfection routine prior to cannulation was changed. Compared with the rope-ladder technique, the buttonhole method offers the advantage of an easier cannulation procedure with less bad sticks, which has a special benefit for patients with limited access cannulation sites or with a fistula which is difficult to cannulate. Prolonged compression times or re-bleeding episodes did not occur, but precautions have to be taken in order to prevent infectious complications. The buttonhole method can contribute considerably to the cannulating ease of self-cannulating patients, thus providing a better quality of life.

                Author and article information

                Developments in Health Sciences
                Akadémiai Kiadó (Budapest )
                04 October 2019
                September 2019
                : 2
                : 2
                : 51-57
                [ 1 ] Diaverum Dialysis Centre , Budapest, Hungary
                [ 2 ]Department of Nursing, Faculty of Health Sciences, Semmelweis University , Budapest, Hungary
                Author notes
                [* ]Corresponding author: Jared Merit; Diaverum Dialysis Centre, H-1118 Dayka Gábor utca 30, Budapest, Hungary; Phone: +36 20 503 5659; E-mail: meritjared@ 123456gmail.com
                © 2019 The Author(s)

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited, a link to the CC License is provided, and changes – if any – are indicated.

                : 21 December 2017
                : 03 June 2019
                : 03 September 2019
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 16, Pages: 7
                ORIGINAL ARTICLE

                Medicine,Immunology,Health & Social care,Microbiology & Virology,Infectious disease & Microbiology
                rope ladder cannulation techniques,arteriovenous fistula,nursing,buttonhole cannulation techniques,haemodialysis


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