Disclosures: Hallan reports no relevant financial disclosures.
December 29, 2021
2 min read
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Patients report marking buttonhole cannulation on skin makes procedure less painful

Disclosures: Hallan reports no relevant financial disclosures.
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Skin markings identifying the direction and angle of buttonhole cannulations can make the procedure less painful and anxiety-inducing for patients, according to data published in Kidney Medicine.

Further, a less traumatic cannulation may reduce buttonhole-related infections.

Doctor with a black patient

Source: Adobe Stock

“The overall goal for patients and caregivers is a healthy and minimally traumatized access with longevity, few complications, and minimal pain and discomfort for the patient. Cannulation technique is one of the major determinants for achieving this goal, but our knowledge on this topic is weak,” Stein Hallan, MD, PhD, professor in the department of nephrology at St. Olav University Hospital, Norway, and colleagues wrote. “The aim of this randomized clinical trial was therefore to study if patient-specific skin markings of buttonhole cannulation direction and angle could facilitate a gentler needle placement as measured by improved success rates and reduced patient discomfort.”

In an 8-week, prospective, open label, randomized, controlled trial, researchers evaluated 83 hemodialysis patients (mean age 66 years; 70% men) with buttonhole tracts for arteriovenous fistula cannulation at seven dialysis centers in Norway.

Using block randomization, patients were randomized 1:1 to the intervention group (43 patients, 658 cannulations) or control group (40 patients, 611 cannulations) with a variable block size of six, eight or 10 patients. Those in the intervention group had the direction and angle of the buttonhole tract marked on their forearm skin, whereas those in the control group had no structured cannulation information system.

The nurses had the first 2 weeks of the study to get familiar with the cannulations. Analyses began in the following 6 weeks. The primary outcome of the study was successful cannulation.

Patients were also asked to measure their pain and anxiety levels regarding the cannulation.

Among the 83 patients enrolled in the study, two patients from each group dropped out. In the 6 weeks following the training period, researchers analyzed 1,269 cannulations. The two groups had similar success rates for cannulations on the first attempt (74.8% in the control vs. 73.9% in the intervention group). Analyses revealed no significant difference between the groups.

However, patients in the intervention group reported feeling less pain and anxiety than those in the control group. One patient from each group showed signs of a minor infection around the buttonhole tract.

“In conclusion, skin markings of direction and angle did not improve overall buttonhole cannulation success rate. However, patients reported less cannulation difficulties and less pain with the new technique,” Hallan and colleagues wrote. “Less traumatic cannulation with less damage to the epithelial lining of the buttonhole track could potentially reduce infection risk, but this hypothesis needs to be tested in a larger trial with longer follow-up. Currently, the clinical importance of the intervention is to reduce the patients’ daily procedure-related discomfort.”