In our center we proposed the possibility of applying the Button-Hole technique or the cheek technique when starting the HDD technique to facilitate the patient performing the puncture at home minimizing complications.
The technique consists of creating a subcutaneous tunnel as a permanent and invariable access to the AVF, through which it will be punctured with a blunt needle once formed.
The first puncture must be performed with a conventional needle, choosing the area bearing in mind that the separation between the two punctures must be at least 6 cm and not performed in the aneurysmal area.
After the hemodialysis session, both needles were extracted coagulating without any type of dressing.
Once the patient has coagulated, the area is disinfected with chlorhexidine and action is allowed before applying Kit to stabilize the tunnel.
The stabilisation kit shall be placed with sterile technique (Imagen 1).
It will be implanted until the next session, covering with a transparent dressing.
In the following session, the transparent dressing is removed without removing Kit, disinfected with chlorhexidine and then removed Kit with sterile technique with the help of two forceps (Imagen).
The tunnel will be visible (Imagen 3).
Vascular access should be channelled with blunt needle.
We must apply the stabilization Kit for 5 or 6 sessions, always with the same technique and by the same nurse, previously trained.
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Image 2
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Image 3
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Once the tunnel is stabilised, the blunt needle will be punctured, removing previously the crust that forms at the orifice after the orifice, using a clean technique, disinfecting the area before and after the rib.
Coagulation shall always be manual and without the application of any type of anaesthesia to minimise the risk of infection and the possibility of the tunnel being covered by the visa stick.
In the case of our patient on home hemodialysis, it took 5 days, with daily hemodialysis, for the complete formation of the two subcutaneous tunnels.
After another five days of puncture (always by the same nurse), self-puncture training began, and in 5 days more the patient self-puncture was uneventful.
One week later, the patient started hemodialysis at home.
Nearly years after his first home hemodialysis, he has not presented any puncture or AVF-related problems, so we have extended the technique to patients undergoing hospital hemodialysis in a chronic ward.
The unit's approach is to extend the technique to all patients who may benefit from it, since in all patients in whom no visible episode has been practiced, the pain to puncture has been repeatedly reduced and the puncture has not failed.
In the case of our patient on HDD, there was no infection, no episode of extravasation and no failed puncture.
The small aneurysms presented previously have not increased in size, and the blood flows achieved are the same.
Blood pressure and venous pressure values remained in the same range as with staggered puncture.
The patient reports that the Button-hole technique has greatly facilitated self-puncture, since it has eliminated pain and gives him great security knowing that it is not possible to fail to puncture or produce vascular access.
