CLEAN BUTTONHOLE PUNCTURE PREVENTS INFECTION

Abstract BACKGROUND AND AIMS The buttonhole (BH) puncture has been criticized for the problem of infection. We considered that at least one of the causes for the higher infection rate in the BH technique might be insufficient removal of scabs. The scab pushed into the BH by a dull needle provides optimal temperature, moisture and nutrition for the germs, and protects them from immune system attack. We considered that the infection would be established if enough bacteria were inside when the scab was dissolved. Usually, scabs covering the BH entry site are removed with needles or forceps, and this procedure tends to injure the entry site so that scabs stick more firmly to the site after that. We reported the effect of the moist wound healing procedure on the BH entry site to solve this problem from the 49th ERA-EDTA congress. Since that time, we have continued this method to the BH entry site in Yokohama Minami Clinic. After transferring to the Toshin Clinic in 2019, we faced the problem of difficulty in performing the BH method because nurses were not familiar with removing the scab. For this reason, we had to ask patients who wanted the BH procedure to soak the scabs in the bathtub and wash it with a nylon towel until the scab was gone. METHOD This study was conducted at Toshin Clinic from April 2021 to November 2021. In most patients, fistula vessels were punctured by either the BH or the rope-ladder method. But, in some patients, however, fistula vessels were punctured by both methods. For the BH method, supercath clump cath P painless needles were used. After hemostasis was achieved, we put a small amount of white petroleum jelly. We instructed patients to wash the puncture site at home, especially when they took a bath, using a nylon towel until the blistered scabs were gone. Patients were also instructed to apply the white petrolatum on the site after washing the site. Thanks to this method, in many patients, scabs could be wiped off easily. RESULTS At the end of November 2021 119 patients were punctured by the rope ladder method (79 males/40 females, 70.2 years old, 107 months on dialysis) and 35 patients by the BH method (29/6, 68.9 years old, 93.3 months). We have punctured 66 925 times by the rope-ladder method and 8011 by the BH method. One local infection requiring hospitalization debridement occurred in the rope-ladder group and one local infection occurred in the BH group. There was no significant difference between the two groups (P = 1.0, Pearson's chi-squared test). CONCLUSION Infection can be prevented by continued moist treatment of the BH and vigorous self-cleaning. I would like to call this method the "clean buttonhole method" because it keeps the BH clean in appearance, unlike the conventional dirty BH method where the scabs are dried and have to be plucked off.