Summary Background and objectives Buttonhole needling is reported to be associated with less pain than standard needling. The purpose of this study was to compare patient perceived pain and fistula complications in buttonhole and standard needling. Design, setting, participants, & measurements In this study, 140 conventional hemodialysis patients were randomly assigned to buttonhole or standard needling. The primary outcome was patient perceived pain with needling at 8 weeks. Fistula complications of hematoma, bleeding postdialysis, and infection were tracked. Results Median pain score at 8 weeks using a visual analog scale from 0 to 10 cm was similar for standard and buttonhole needling (1.2 [0.4–2.4] versus 1.5 [0.5–3.4]; P=0.57). Rate of hematoma formation in standard needling was higher (436 versus 295 of 1000 hemodialysis sessions; P=0.03). Rate of no bleeding postdialysis was 23.6 and 28.3 per 1000 in standard and buttonhole needling, respectively (P=0.40). Rate of localized signs of infection in standard versus buttonhole needling was 22.4 versus 50 per 1000 (P=0.003). There was one episode of Staphylococcal aureus bacteremia during the 8 weeks with buttonhole needling and no episodes with standard needling (P=1.00). Within 12 months of follow-up, another two buttonhole needling episodes developed S. aureus bacteremia, and nine buttonhole needling episodes had needling site abscesses requiring intravenous antibiotics versus zero standard needling episodes (P=0.003). Conclusions Patients had no difference in pain between buttonhole and standard needling. Although fewer buttonhole needling patients developed a hematoma, there was an increased risk of bacteremia and localized signs of infection. Routine use of buttonhole needling is associated with increased infection risk.

On the basis of the current studies, buttonhole, when done in an in-center environment with many rotating staff nurses, is a complex and challenging technique. Buttonhole technique might be best utilized for difficult or limited fistula needling sites. An infection prevention education campaign along with regular audits regarding localized infections and bacteremias should be a critical part of any program which uses buttonhole cannulation. A randomized trial comparing buttonhole to rope ladder needling among home hemodialysis or self-needled patients should be the focus for future research.

No abstract