Access in Pediatric CRRT Patrick D Brophy MD Pediatric Nephrology, Dialysis & Transplantation CS Mott Children’s Hospital University of Michigan
From Gina
The System is Down due to poor Access!
My first choice is….
Access n If you don’t have it you might as well go home. n This is the most important aspect of CVVH therapy. n Adequacy. n Filter life. n Increased blood loss. n Staff satisfaction.
Vascular Access n Ideal Catheter Characteristics n n Easy Insertion Permits Adequate Blood Flow without Vessel Damage Minimal Technical Flaws n High Recirculation Rate n Kinking Shorter and Larger Catheters SIZE DOES MATTER n n Lower Resistance Improved Bloodflow
Pediatric CRRT Vascular Access: Performance = Blood Flow n n Minimum 30 to 50 ml/min to minimize access and filter clotting Maximum rate of 400 ml/min/1. 73 m 2 or n n n 10 -12 ml/kg/min in neonates and infants 4 -6 ml/kg/min in children 2 -4 ml/kg/min in adolescents
Venous Access for CRRT Match catheter size to patient size and anatomical site n One dual- or triple-lumen or two single lumen uncuffed catheters n Sites n femoral n internal jugular n avoid sub-clavian vein if possible n
Catheter Position n No Right or Wrong Choice of Placement n FACTORS n Clinical expertise n Body Habitus n Other catheters (Citrate anticoag-triple preferred) n Coagulopathy n Intra-abdominal distension
Catheter Position Internal Jugular-Right- aim for RA to secure adequate BFR n Subclavian-Patient mobility? Most frequent site of inadequate performance -catheter curves and abutts against SVC-Vein collapses against catheter due to positional/volume change n Femoral- optimal position in tip of IVC n
Vascular Access for Pediatric CRRT: Pros and Cons of Femoral Site PROS n Relatively larger vessel may allow for n n n larger catheter higher flows Ease of placement No risk of pneumothorax Preserve potential future vessels for chronic HD CONS n n n Shorter femoral catheters with increased % recirculation Poor performance in patients with ascites/increased abdominal pressure Trauma to venous anastamosis site for future transplant
Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site PROS n n n Tip placement in right atrium decreases recirculation Not affected by ascites Preserve potential vein needed for transplant CONS n n SCV stenosis (SCV) Superior vena cava syndrome Risk of pneumothorax in patients with high PEEP Trauma to veins needed potentially for future HD access
Femoral versus IJ catheter performance n 26 femoral 19 > 20 cm n 7 < 20 cm n 13 IJ n Qb 250 ml/min (ultrasound dilution) n Recirculation measurement by ultrasound dilution method n Little et al: AJKD 36: 1135 -9, 2000
Femoral versus IJ catheter performance Type Femoral Number Qb (ml/min) Recirculation(%) 95% CI 26 237. 1 13. 1* 7. 6 to 18. 6 > 20 cm 19 233. 3 8. 5** 2. 9 to 13. 7 < 20 cm 7 247. 5 26. 3** 17. 1 to 35. 5 13 226. 4 0. 4* -0. 1 to 1. 0 Jugular * p<0. 001 ** p<0. 007 Little et al: AJKD 36: 1135 -9, 2000
Troubleshooting Access n How can you tell if you have a problem before starting? n What if you have problems during treatment? n Check placement first, then use syringe to test resistance and blood return. n Check line for kink, then assess patients position or need for sedation.
Access n Clotting or sluggish catheter. n t. PA (tissue plasminogen activator). (Spry et al. , Dialysis&Transplantation. Jan. 2001). n n Normal saline flush. Reason to replace catheter. n n Clotted catheter with no response to t. PA. Exit site blood leakage with no response to pressure dressing. Severe kinked catheter. Bad re-circulation issues.
Pressures n Arterial or outflow pressures n n High negative pressure = access problem. High positive pressure = filter problem. Moderate to high positive pressure + high return (venous) pressure = access problem. Venous or return pressures n n Moderate to high positive pressure + high arterial pressure = filter problem. High return pressure + moderate arterial pressure = access
Vascular Access for Pediatric CRRT: Some Final Thoughts n n n Catheters with poor function will function poorly… over and over Balance between surgical/ICU expertise (preference? ) and the necessary evils dictated by the patient n high PEEP… femoral catheter? n massive ascites… IJ catheter? n available sites… are there any? Which vessel are you willing to traumatize?
Conclusions Poor Access-- May as well stop n Choice- patient size and optimal flows n Site- IJ/Femoral -recommended n Care- Local standard + Lock issues- heparin n Troubleshooting- anticipate, what is the machine saying? n Happy Hemofiltering! n
Thanks! Stu Goldstein n Tim Bunchman n Theresa Mottes n Tim Kudelka n Betsy Adams n Tammy Kelly n Robin Nievaard n
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