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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. If you don’t have it you might as well go home.

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Access in Pediatric CRRT

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Access in pediatric crrt l.jpg

Access in Pediatric CRRT

Patrick D Brophy MD

Pediatric Nephrology, Dialysis & Transplantation

CS Mott Children’s Hospital

University of Michigan


From gina l.jpg

From Gina


The system is down due to poor access l.jpg

The System is Down due to poor Access!


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My first choice is….


Access l.jpg

Access

  • If you don’t have it you might as well go home.

  • This is the most important aspect of CVVH therapy.

    • Adequacy.

    • Filter life.

    • Increased blood loss.

    • Staff satisfaction.


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Vascular Access

  • Ideal Catheter Characteristics

    • Easy Insertion

    • Permits Adequate Blood Flow without Vessel Damage

    • Minimal Technical Flaws

      • High Recirculation Rate

      • Kinking

  • Shorter and Larger Catheters

    SIZE DOES MATTER

    • Lower Resistance

    • Improved Bloodflow


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Pediatric CRRT Vascular Access:Performance = Blood Flow

  • Minimum 30 to 50 ml/min to minimize access and filter clotting

  • Maximum rate of 400 ml/min/1.73m2 or

    • 10-12 ml/kg/min in neonates and infants

    • 4-6 ml/kg/min in children

    • 2-4 ml/kg/min in adolescents


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Venous Access for CRRT

  • Match catheter size to patient size and anatomical site

  • One dual- or triple-lumen or two single lumen uncuffed catheters

  • Sites

    • femoral

    • internal jugular

    • avoid sub-clavian vein if possible


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Catheter Position

  • No Right or Wrong Choice of Placement

    • FACTORS

      • Clinical expertise

      • Body Habitus

      • Other catheters (Citrate anticoag-triple preferred)

      • Coagulopathy

      • Intra-abdominal distension


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Catheter Position

  • Internal Jugular-Right- aim for RA to secure adequate BFR

  • Subclavian-Patient mobility? Most frequent site of inadequate performance -catheter curves and abutts against SVC-Vein collapses against catheter due to positional/volume change

  • Femoral- optimal position in tip of IVC


Vascular access for pediatric crrt pros and cons of femoral site l.jpg

Relatively larger vessel may allow for

larger catheter

higher flows

Ease of placement

No risk of pneumothorax

Preserve potential future vessels for chronic HD

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 Femoral Site

PROS

CONS


Vascular access for pediatric crrt pros and cons of ij scv site l.jpg

Tip placement in right atrium decreases recirculation

Not affected by ascites

Preserve potential vein needed for transplant

SCV stenosis (SCV)

Superior vena cava syndrome

Risk of pneumothorax in patients with high PEEP

Trauma to veins needed potentially for future HD access

Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site

PROS

CONS


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Femoral versus IJ catheter performance

  • 26 femoral

    • 19 > 20 cm

    • 7 < 20cm

  • 13 IJ

  • Qb 250 ml/min (ultrasound dilution)

  • Recirculation measurement by ultrasound dilution method

Little et al: AJKD 36:1135-9, 2000


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Femoral versus IJ catheter performance

* p<0.001

** p<0.007

Little et al: AJKD 36:1135-9, 2000


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How can you tell if you have a problem before starting?

Check placement first, then use syringe to test resistance and blood return.

What if you have problems during treatment?

Check line for kink, then assess patients position or need for sedation.

Troubleshooting Access


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Access

  • Clotting or sluggish catheter.

    • tPA (tissue plasminogen activator).

      (Spry et al., Dialysis&Transplantation. Jan. 2001).

    • Normal saline flush.

  • Reason to replace catheter.

    • Clotted catheter with no response to tPA.

    • Exit site blood leakage with no response to pressure dressing.

    • Severe kinked catheter.

    • Bad re-circulation issues.


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    Pressures

    • Arterial or outflow pressures

      • 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

    • Moderate to high positive pressure + high arterial pressure = filter problem.

    • High return pressure + moderate arterial pressure = access


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    Vascular Access for Pediatric CRRT:Some Final Thoughts

    • Catheters with poor function will function poorly… over and over and over and over

    • Balance between surgical/ICU expertise (preference?) and the necessary evils dictated by the patient

      • high PEEP… femoral catheter?

      • massive ascites… IJ catheter?

      • available sites… are there any?

    • Which vessel are you willing to traumatize?


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    Conclusions

    • Poor Access-- May as well stop

    • Choice- patient size and optimal flows

    • Site- IJ/Femoral -recommended

    • Care- Local standard + Lock issues- heparin

    • Troubleshooting- anticipate, what is the machine saying?

    • Happy Hemofiltering!


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    Thanks!

    • Stu Goldstein

    • Tim Bunchman

    • Theresa Mottes

    • Tim Kudelka

    • Betsy Adams

    • Tammy Kelly

    • Robin Nievaard


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