The “Touch Cannulation” Technique for Hemodialysis
Stuart Mott
Barbara F. Prowant
Q:
When I’m cannulating a “deep” access and cannot see the fistula or
graft, sometimes I can’t tell if the needle is above or alongside the
fistula or graft; therefore, I don’t know which way to re-direct the
needle to cannulate the vessel. Also, when I’m cannulating an
established buttonhole, I can’t always tell if the blunt needle is
sliding smoothly through the tunnel, or if it is damaging the “wall” of
the tunnel track.
A: Typically, nurses are taught to hold the “wings” of fistula needles for control of the needle as they cannulate
a fistula or graft to initiate hemodialysis (see Figure 1), and this
has become standard practice over the years. This Clinical Consult
column describes a relatively new technique we have dubbed “touch
cannulation.” When using this technique, the cannulator holds the
tubing behind the wings, rather than holding the wings themselves, and
gently pushes the needle forward through the skin and tissue into the
access (see Figure 2). This provides more sensitive pressure feedback
during cannulation, and most of the time it is possible to feel whether
the needle is above or to the right or left side of a synthetic graft.
Although the pressure feedback is not as sensitive for arteriovenous
fistulas, it is still greater than when cannulating by holding the
wings. This more precise feedback allows the cannulator to move the
needle slightly to the right or to the left or to center the needle
above the graft or fistula for insertion into the vessel. Another
advantage of this technique is that the fingers do not conceal the
blood flashback. If resistance is felt, the cannulator can slide the
thumb and index finger forward, just behind the wings (see Figure 3).
This allows the cannulator to increase the force slightly, yet still
retain greater sensitivity at the needle tip. This “touch cannulation”
technique has been used incenter, by patients on home hemodialysis, and
in both adult and pediatric dialysis units (A. Allsteadt, Texas
Children’s Hospital, personal communication, July, 2007).
Buttonhole Cannulation
The “touch cannulation” technique may be used for constant site
cannulation. Some centers use it to create “buttonholes,” and others
use it to cannulate established buttonhole tracks (Bregel, 2007). To
cannulate a buttonhole using this technique, the tubing is held with
the thumb and forefinger; the other fingers rest against the patient’s
arm providing stabilization. This provides consistency of the angle of
needle insertion, which is imperative in establishing the buttonhole
tunnel. A consistent angle also helps preserve established tunnels, as
it reduces the likelihood of cutting and damaging or enlarging the
tunnel track (Ball, 2006). The “touch cannulation” technique is
also used successfully by patients on home hemodialysis who
self-cannulate. Figure 4 shows a patient on home hemodialysis holding
the tubing behind the wings to cannulate an established buttonhole.
When the cannulator holds the wings of the fistula needle to cannulate
an established buttonhole track, this directs the needle’s path and is
more likely to cut a new or
larger tunnel track, and damage tissue along the established track
(even when using a “blunt” or “dull” needle). In contrast, when
cannulating an established buttonhole
with the “touch cannulation” technique, if resistance is met in the
tunnel track, the tubing can be rotated slightly while applying very
gentle forward pressure (see Figure 5). This allows the dull needle to
advance down the established track, but is not forceful enough to
damage or enlarge the tunnel track. This gentle twisting or rotation of
the tubing
has been used in several centers and is being taught by vascular access experts (Bregel, 2007; Brouwer, 2006).
 
Ball, L.K. (2006). The buttonhole technique for arteriovenous fistula cannulation. Nephrology Nursing Journal, 33(3), 299-304.
Bregel, K. (2007, February). Advances in buttonhole cannulation
technique. Paper presented at the Annual Conference onDialysis, Denver,
CO.
Brouwer, D. (Speaker). (2006). ANNA’s winter 2006 audio conference.
Fistula first breakthrough initiative: Focus on cannulation (CD-ROM
Recording No. P170_2). Pitman, NJ: American Nephrology Nurses’
Association.
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