作者: 葉時孟醫師 ( Shih-Meng Yeh, MD )
前記: 久違的英文演說
因為診所病人的需求，於 5 年前和診所資深護理師一起到台南光明診所取經，觀摩學習扣眼式上針法。光明診所在這一塊的經驗非常多，李思遠醫師也給了很多實際執行面的解答和建議。
近期剛在部落格分享關於扣眼式打法的介紹，適逢台南成大醫院國際醫療中心執行衛福部肯亞醫衛合作案，辦理醫事人員來台交流訓練，預定於今日 ( 2025/10/16 ) 參訪光明診所，觀摩扣眼式上針。
李醫師來電邀請我用英文作一個介紹和簡短演說，對於久未上台，且要用非母語演說，心中開始有些忐忑。幸好現在有 chatgpt 可以幫忙潤稿，15 分鐘的演說也花了十 數小時的練習時間。
原本是「從從容容、游刃有餘的」，但可能昨晚在診所練習完，沒有關檔案拔除隨身碟，竟然早上在家中檢視演說檔案發現檔案毀損打不開。 幸好之前有寄給李醫師演說的 PDF 檔預定內容，才能「匆匆忙忙、連滾帶爬」的重新製作簡報和動畫，真的了解到一再確認是多麼重要的事。
演說完畢也和仁得診所的黃子豪醫師、肯亞來交流的護理人員作現況的交流，是獲益良多的一次經驗。
放上這次英文演說的內容，供外國來賓作為參考和記錄。
Introduction
Ladies and gentlemen, good afternoon , and welcome to Taiwan.
Let me begin by introducing myself. My name is Shih Meng Yeh, and I come from Kaohsiung, a city located even further south than Tainan.
I run a hemodialysis clinic in Kaohsiung, and in my spare time I write a blog where I share knowledge about dialysis and chronic kidney disease.
Like you, I once visited Guang Ming Clinic to learn about the buttonhole cannulation technique, with the hope of bringing its benefits to patients who truly need it.
Recently, I also shared an article on my blog about this very technique. Today, thanks to the kind invitation of Dr. Lee, I am honored to give a short presentation on this topic.
Connection since 5 years ago
Looking back, this connection goes back about five years, during the COVID-19 pandemic.
At that time, I had a young patient. She had a history of type 1 diabetes and chronic kidney disease , unfortunately, during her pregnancy her kidney function rapidly declined, and she had to start long-term dialysis.
Because she was young, she cared very much about cosmetic issues. She also had an older sister in Taipei, who was also on dialysis and had received the buttonhole cannulation technique. So she asked me if there was any way I could provide the same treatment for her.
With the support and coordination of Huajiang Medical Instruments Company, in 2020, three senior nursing staff and I , visited Guang Ming Clinic to learn the buttonhole technique. After that, we were able to apply it successfully for this patient, and she has been using it smoothly up until now.
回顧起來，緣分從 5 年前開始，在華江醫療儀器公司的引薦和幫忙下，在 2020 年，我和診所三位資深護理人員拜訪光明診所去觀摩學習扣眼式上針法。在之後可以將方法應用於診所的病人。
An accidental finding in 1972
The buttonhole cannulation technique was first discovered by accident in 1972, by Dr. Zbylut J. Twardowski, a Polish-born nephrologist.
At that time, Dr. Twardowski was caring for a dialysis patient with a very difficult vascular access. Because it was almost impossible to change the puncture site, the nurses had no choice but to repeatedly insert the needle in the exact same location.
Over time, they noticed something surprising: cannulation at this spot became easier and easier. The reason was that, in those days, needles were disinfected and reused. Through repeated use, the sharp needles gradually became blunt. This unintentionally reduced trauma to the tissue and allowed the needle to slide smoothly along the previously established track into the fistula.
This accidental finding inspired what we now call the buttonhole technique. In the early days, it was sometimes referred to as constant-site cannulation, because the puncture was always made at the same location.
扣眼式上針法是在 1972 年由波蘭裔醫師 Zbylut J. Twardowski 和他的醫療團隊意外發現的。
當時， Twardowski 醫師有一位瘻管相當困難上針的病人，僅有一小處打打，因為幾乎不可能改變穿刺位置，護理師別無選擇，僅能反覆的在同一點穿刺上針，執行透析治療。
但隨著時間過去，他們發現某件意料之外的事，即是從該部位上針變得越來越好打。原因是因為，在當時的時空，針具都是消毒後再利用，隨著再利用穿刺的次數增加，原本的針具變得越來越鈍。
而這反而減少了組織的損傷，而使變鈍的針能順著原先反覆穿刺形成的通道進入瘻管。
Botton hole and ear piercing
The name “buttonhole” comes from the idea of a button passing through a buttonhole on clothing.
When I explain this technique to patients, however, I often find that the example of ear piercing is even easier for them to understand. Just like an earring slides through the same hole every time, the dialysis needle follows the same established track into the fistula.
「扣眼式上針」的名稱源於上針的過程猶如鈕扣穿過已存在衣服上的「扣眼」。
但當我向病人解釋這項技術時，發現穿耳洞的比方更容易使病人了解。就像耳洞建立完成後，耳環由同一個洞穿過，當扣眼式上針的通道建立後，透析用針也由建立好的通道進入瘻管。
Keys steps in performing buttonhole cannulation
Now let’s talk about the key steps in performing buttonhole cannulation.
First, we need to establish at least two tracts. Traditionally, this was done by experienced nurses, who would use sharp needles to cannulate the same site, at the same angle and direction each time. However, since people are not machines, it is easy to deviate slightly, which often leads to multiple, inconsistent pathways.
Thus there comes the modified method with the Bio-hole. Nowadays, we use a sterile plug, called the Bio-hole. After the very first successful cannulation, this plug is inserted to prevent the tract from closing.
During the next two to four weeks, the plug is replaced at every dialysis session, which helps the tract mature properly.
Once the tract is matured, cannulation must be carried out under strict aseptic technique. A blunt needle is used, and it should glide gently along the established tract, without applying extra force.
Finally, after cannulation. We must continue to maintain aseptic handling and always focus on infection prevention.
扣眼式穿刺法（Buttonhole Cannulation）的主要步驟
建立穿刺通道（Establishing Tracts）
第一個步驟是建立至少兩個穿刺通道。傳統上，這個階段是由經驗豐富的護理人員執行，他們會使用銳針（sharp needle）在相同的位置、相同的角度與方向進行穿刺。
然而，由於人手操作難免存在微小差異，因此很容易產生偏移，導致形成多條不一致的通道。
導入 Bio-hole 改良法（Introducing the Bio-hole Method）
為了改善這個問題，後來發展出一種改良式 Bio-hole 技術。在第一次成功穿刺之後，會將一個無菌的塞子（Bio-hole plug）插入穿刺口，以防止通道在治療間期閉合。
通道成熟期（Tract Maturation Phase）
接下來約 2 至 4 週 的時間內，每次透析後都要更換 Bio-hole 塞子。這段期間能讓通道逐漸成熟（mature），形成一條平滑且穩定的穿刺路徑，為日後的固定穿刺做準備。
使用鈍針穿刺（Using Blunt Needles）
當通道成熟後，穿刺時必須嚴格遵守無菌操作原則（aseptic technique）。此時應使用鈍針（blunt needle），並讓針頭順著既有通道輕滑進入，不可施加過多力量，以免損傷通道組織。
穿刺後的護理（Post-Cannulation Care）
穿刺完成後，仍須持續維持無菌操作。
包括適當的清潔、消毒與固定方式，皆是預防感染與維護通道完整性的重要步驟。
The operation of the biohole plug
Now, let me explain the operation of the Bio-hole sterile plug as shown in the illustration.
At the tail end of the plug, there is a small handle for gripping.
After needle withdrawal and hemostasis, or when replacing the plug, the handle should be held firmly by hand to carefully insert the plug into the tract.
Next, using a sterile-gloved hand or sterile forceps, press the plug in place.
Then, detach the handle from the plug. secure the plug to ensure it stays properly in position.
Operation of the Bio-hole Sterile Plug
Bio-hole 無菌塞的操作步驟
在塞子的尾端，有一個小型握柄（handle），方便手持操作。
在拔針並止血完成後，或在更換塞子時，應以手穩固握住握柄，將塞子小心地插入穿刺通道（tract）中。
接著，使用戴無菌手套的手或無菌鑷子，將塞子輕壓固定於適當位置。
然後，將握柄從塞子上分離，確認塞子牢固貼合、位置正確，不會鬆脫。
Aseptic preparation and cannulation
Next, let’s talk about the practical aseptic preparation.
First, the patient should thoroughly wash the fistula site with soap.
The cannulating staff must then perform proper hand hygiene, put on sterile gloves, and disinfect the tract site with either 2% chlorhexidine or povidone-iodine.
It is important to allow the disinfectant to dry completely. Chlorhexidine dries more quickly, in about 30 seconds, while povidone-iodine requires a longer time, usually at least two to three minutes.
Some guidelines recommend softening the scab before removal. However, others suggest this may cause the scab to break into small fragments, which makes complete removal more difficult and increases the risk of contamination.
Once the scab is removed, the site must be disinfected again and allowed to dry.
Finally, a blunt needle should be used to gently slide along the tract, without applying extra force.
實際的無菌準備步驟
首先，病人需以肥皂徹底清洗瘻管部位，確保表面潔淨。
接著，穿刺人員應確實執行手部衛生，戴上無菌手套，並使用 2% chlorhexidine 或優碘（povidone-iodine）對穿刺通道部位進行消毒。
必須讓消毒劑完全乾燥，chlorhexidine 較快，約需 30 秒；而優碘則需較長時間，通常至少 2 至 3 分鐘 才能完全乾。
有些指引建議在去除痂皮（scab）前先使其軟化；但另一些研究指出，這樣可能使痂皮碎裂成小片，反而難以完全移除，並增加污染風險。
當痂皮移除後，應再次消毒該部位，並等待其完全乾燥。
最後，使用鈍針（blunt needle），順著既有通道輕滑進入，不可施力過大，以避免損傷通道或導致出血。
Infection prevention after decannulation
First, the staff should perform proper hand hygiene.
After needle withdrawal and hemostasis, it is recommended to apply the antibiotic ointment Mupirocin directly on the site and allow it to air-dry naturally.
At the end of the procedure, the staff should once again wash their hands thoroughly.
拔針後的感染預防
首先，醫護人員應確實執行手部衛生，以維持無菌操作。
在拔針並完成止血後，建議直接在穿刺口塗抹抗生素藥膏 Mupirocin，並讓其自然風乾，以降低局部感染風險。
最後，程序結束時，醫護人員應再次徹底洗手，確保整體感染控制的完整性。
Advantages of the botoonhole cannuation technique
Now, let me highlight the advantages of the buttonhole cannulation technique.
First, it helps to reduce pain. This is particularly beneficial for patients who previously experienced difficult cannulation, as the established tract allows the needle to follow the pathway smoothly each time. However, even with a blunt needle, patients may still feel some sensation as it passes through the subcutaneous tract.
Second, it lowers the risk of cannulation failure or subcutaneous hematoma caused by blood leakage.
Third, it reduces the risk of aneurysms formation.
And fourth, it decreases the likelihood of vascular stenosis and occlusion, which are often the result of improper or repeated sharp-needle cannulations.
扣眼式穿刺法的優點
首先，它能減輕穿刺疼痛。這對於過去穿刺困難的病人特別有幫助，因為固定的通道能讓針頭每次都順著相同路徑滑入，減少重複刺入造成的不適。
不過，即使使用鈍針，病人在針頭滑過皮下通道時仍可能感到些微觸感，這是正常現象。
第二，它可降低穿刺失敗或因血液滲漏導致皮下血腫的風險。穩定的通道讓針頭進入更精準，可避免反覆嘗試或誤入血管外造成的損傷。
第三，它可減少血管瘤形成的風險。因為穿刺點集中且固定，能有效延長瘻管的使用壽命。
第四，它可降低血管狹窄與阻塞的發生率。這些問題往往與不當或反覆使用銳針有關，而扣眼式技術能有效減少這類長期損傷。
Limitations and drawbacks
let’s talk about the limitations and drawbacks of the buttonhole technique.
First, it cannot be used with synthetic grafts.
Second, on average, the infection rate is relatively higher compared with the gold standard rope ladder cannulation technique.
However, this risk can be minimized. With careful patient selection, and through strict aseptic awareness and proper cooperation between both the patient and the healthcare team, the likelihood of infection can be reduced to the lowest possible level.
扣眼式穿刺法的限制與缺點
第一，扣眼式穿刺法無法應用於人工血管。這項技術僅適用於自體動靜脈瘻管，因為人工血管材質不同，難以形成穩定且可重複使用的通道。
第二，平均而言，其感染率相較於被視為黃金標準的「繩梯式穿刺法」要略高。這主要是因為通道的重複使用及局部皮膚反覆接觸，使得細菌在不當操作下更容易入侵。
然而，這項風險是可以大幅降低的。透過仔細篩選合適的病人，並確保醫護團隊與病人雙方都具備良好的無菌觀念與確實配合操作，即可將感染風險降至最低可控程度
Rewiew of Rope ladder cannulation
Let’s review other cannulation techniques
Rope Ladder Cannulation is a technique where each treatment session involves puncturing a new site along the entire length of the arteriovenous fistula.
Theres are some key points
Rotate sites systematically: A different puncture site is chosen each time.
Spacing: Sites are usually placed 0.5–1 cm apart.
Full vessel use: The whole length of the fistula is utilized to distribute wear evenly.
繩梯式穿刺法（Rope Ladder Cannulation）回顧
讓我們來回顧另一種常見的穿刺技術。
「繩梯式穿刺法」是一種在每次透析治療時，於整條動靜脈瘻管上選擇新的穿刺點進行穿刺的技術。
這種方式可使血管的不同部位輪流使用，避免單一區域過度損耗。
重點原則:
系統性輪替穿刺點：
每次治療時都應更換不同的穿刺位置，確保血管各段均衡使用。
穿刺間距：
每個穿刺點之間應保持約 0.5 – 1 公分的間距，避免穿刺點過於密集導致血管壁受損。
全段血管利用：
應盡可能利用整條瘻管的可穿刺範圍，讓血管磨損分散，延長瘻管壽命。
Rope ladder cannulation advantages and drawbacks
As the gold standard of cannulation，rope-ladder cannulation offers several key advantages.
Lowest infection risk: No repeated use of the same hole reduces bacterial colonization.
Prevents aneurysm formation: Less localized vessel damage compared to area cannulation.
Prolongs access life: Stress is spread evenly across the vessel.
However, the drawbacks are that this technique is highly dependent on the experience and skill of the staff. It requires careful observation of the fistula’s anatomy and pathway.
In addition, it also relies on the patient’s cooperation. When new sites need to be cannulated, the procedure can be more painful.
繩梯式穿刺法的優點與缺點
作為目前被視為穿刺黃金標準的技術，繩梯式穿刺法具有以下幾項主要優點：
優點:
感染風險最低
由於不重複使用相同穿刺孔，可有效降低細菌定植的可能性，感染風險最小。
可預防血管瘤形成
相較於區域式穿刺法，繩梯式方法能避免在單一區域重複損傷血管，減少局部血管壁薄弱與血管瘤產生。
延長血管通路壽命
因為穿刺壓力平均分布於整段瘻管，可有效延長血管的使用年限。
缺點:
高度依賴技術與經驗
這項方法需要穿刺人員具備良好的經驗與技巧，能夠準確辨識瘻管的走向與深度，否則容易導致穿刺困難或失敗。
需病人配合度高
當需要開發新的穿刺點時，病人可能會感到更明顯的疼痛或不適，因此需病人理解與配合。
Area/regional cannulation : introduction
Area or regional cannulation is characterized by concentrating puncture sites within a small region of the fistula, usually no more than five centimeters in length.
In practice, the cannulation sites are often chosen close to previous successful sites, and both the central portion and the edges of the fistula may be used.
Because site selection is based on nearby previous points, and does not follow a planned rotation along the whole length of the fistula, the procedure tends to be easier and more straightforward for staff to perform.
區域式穿刺法介紹
區域式穿刺法的特徵是：穿刺點集中在瘻管的一小段區域內，通常範圍不超過五公分。這意味著同一小區段的瘻管會被反覆使用。
在實際操作中，穿刺點常選擇在前一次成功穿刺位置的附近，可能包括瘻管的中央區段或邊緣部位。這種方式強調「就近原則」，方便人員找到可行的進針點。
由於穿刺點的選擇是依照前次穿刺位置附近決定，而並非沿整條瘻管進行規劃性輪替，因此這種方法對醫護人員來說相對簡單、直觀，不需記錄複雜的穿刺順序。
Area/regional cannulation : drawbacks
However, this lack of systematic planning can lead to repeated use of the same localized area.
Over time, this increases the risk of vessel wall damage and aneurysm formation.
Furthermore, tissue damage leads to fistula fibrosis and narrowing , eventually shortens fistula life span.
We all know that the Area Cannulation method should generally be avoided.
However, in real clinical practice, this situation sometimes occurs unintentionally.
For example, when dialysis staff rotate frequently, or when the vascular access has limited usable length, only a very short segment of the fistula may be used or available for puncture.
In such cases, the intended rope-ladder technique can gradually shift into an area cannulation pattern without being noticed.
區域式穿刺法的缺點
然而，缺乏系統性規劃會導致同一區域被反覆穿刺使用。隨著時間推移，這將增加血管壁損傷與血管瘤形成的風險。
此外，組織反覆受損會造成瘻管纖維化與狹窄，最終縮短瘻管的使用壽命。
我們都知道，區域式穿刺法原則上應該避免使用，然而，在臨床實務中，這種情況有時會不自覺地發生。
例如，當透析人員頻繁輪替、或血管通路可使用的長度有限時，可能只剩短小的一段瘻管能夠被使用或安全穿刺。
在這些情況下，原本設計為繩梯式穿刺的操作，可能在不知不覺中演變成區域式穿刺，而未被即時發現。
Key points of bottonhole cannulation technique
Let’s summarize the key points of the Buttonhole Cannulation technique.
To perform this method, at least two tracks need to be established. Whenever possible, the use of the Bio-hole device is recommended, as it helps the tunnel mature more consistently.
Strict aseptic preparation is essential, along with the correct use of blunt needles. After cannulation, preventing infection and site care is also a critical step.
The advantages of buttonhole cannulation include reduced pain, lower risk of subcutaneous hematoma, and less chance of aneurysm formation. For these reasons, it is often considered a useful alternative to the rope-ladder technique.
This method is especially suitable for patients with fistulas that are short in usable length, for those who are particularly concerned about needle pain and the cosmetic appearance of their fistula, and for patients performing home hemodialysis who need to self-cannulate.
扣眼式穿刺法重點摘要
在執行此方法時，需建立至少兩條穿刺通道。在條件允許下，建議使用 無菌塞裝置，可使通道的成熟過程更穩定、更一致。
嚴格的無菌準備是成功的關鍵，並且必須正確使用鈍針。穿刺完成後，感染預防與穿刺點護理同樣是不可忽視的重要步驟。
扣眼式穿刺法的優點包括：減少穿刺疼痛、降低皮下血腫發生率、減少血管瘤形成
因此，它常被視為繩梯式穿刺法的有效替代方案。
此方法特別適用於以下類型的病人： 可使用瘻管長度較短者、對穿刺疼痛或瘻管外觀特別在意者，居家透析、需自行上針的病人。
