Access for pediatric crrt
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Access for Pediatric CRRT. Timothy E. Bunchman, Professor & Director VCU School of Medicine Founder PCRRT www.pcrrt.com. The System is Down due to poor Access!. Nephrologist or Intensivist. My first choice is…. Nephrology nurse on call or PICU nurse at bedside. Access.

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Access for Pediatric CRRT

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Access for pediatric crrt

Access for Pediatric CRRT

Timothy E. Bunchman,

Professor & Director

VCU School of Medicine

Founder PCRRT

www.pcrrt.com


The system is down due to poor access

The System is Down due to poor Access!

Nephrologist or

Intensivist


My first choice is

My first choice is….

Nephrology nurse on call or PICU nurse at bedside


Access

Access

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

  • This is the most important aspect of CRRT therapy.

    • Adequacy.

    • Filter life.

    • Increased blood loss.

    • Staff satisfaction.


Vascular access

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


Vascular access for crrt

Vascular 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


Pediatric crrt vascular access performance blood flow

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 or

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

    • 5-10 ml/kg/min in children


Access for pediatric crrt

Comparison of upper vs. lower body location line placement(Kendall 8 Fr 9 and 12 cmn = 20; 120 Treatments)

P value NS NS NS NS

Gardner et al, CRRT San Diego 1998


Femoral vs ij catheter performance

Femoral vs 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


Femoral vs ij catheter performance1

Femoral vs IJ catheter performance

* p<0.001

** p<0.007

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


Vascular access1

Vascular Access

ppCRRT Registry Access Study

  • 13 Pediatric Institutions

  • 376 patients

  • 1574 circuits

  • Circuit survival by Catheter size, site, and modality

Hackbarth R et al: IJAIO 30:1116-21, 2007


Vascular access2

Vascular Access

Hackbarth R et al: IJAIO 30:1116-21, 2007


Vascular access3

Vascular Access

“Location, location, location!”

Options:

  • Femoral vein

  • Subclavian vein

  • Internal Jugular vein


Vascular access4

Vascular Access

“Location, location, location!”

Femoral Vein

Pros:

  • Accessible under almost any conditions

  • Easier to maintain hemostasis

    Cons:

  • Potential for kinking

  • More recirculation

  • Thrombosis

  • Problematic flow with increased abdominal pressures


Vascular access5

Vascular Access

“Location, location, location!”

Subclavian Vein

Pros:

  • Shorter catheter/better flow

  • Less recirculation

    Cons:

  • Potential for kinking

  • Difficult hemostasis

  • Potential for venous narrowing

  • Less accessible with cervical trauma


Vascular access6

Vascular Access

“Location, location, location!”

Internal Jugular Vein

Pros:

  • Shorter catheter/better flow

  • Less recirculation

    Cons:

  • Difficult hemostasis

  • Less accessible with cervical trauma

  • Catheter length problematic in small infants


Access for pediatric crrt

Hackbarth R et al: IJAIO 30:1116-21, 2007


Access for pediatric crrt

Hackbarth R et al: IJAIO 30:1116-21, 2007


Vascular access7

Vascular Access

1st 72 hrs of circuit

life only

Shorter life span

for 7 and 9 French

catheters (p< 0.002)

Hackbarth R et al: IJAIO 30:1116-21, 2007


Vascular access8

Vascular Access

Recirculation

  • More of an issue in femoral catheters especially shorter than 20 cm

  • Is this really a practical concern with 24/7 clearance?

  • Catheter proximity may be a bigger issue


Vascular access9

Vascular Access

Note the relationship of the line tips.


Do we need triple lumen access

Do we need triple lumen access?


Access for pediatric crrt

(Ca = 0.4 x citrate rate

60 mls/hr)

(Citrate = 1.5 x BFR

150 mls/hr)

Pediatr Neph 2002,

17:150-154

(BFR = 100 mls/min)

Normal Saline Replacement Fluid

Calcium can be infused in 3rd lumen of triple lumen access if available.

Normocarb Dialysate

  • ACD-A/Normocarb Wt range 2.8 kg – 115 kg

  • Average life of circuit on citrate 72 hrs (range 24-143 hrs)


Access for pediatric crrt

Citrate ~ running it

Arterial access

Venous access

Citrate infusion via “y” adaptor


Access for pediatric crrt

CaCl infusion line/or TPN/or Med line

Venous line

“arterial” line


Vascular access for pediatric crrt hackbarth et al crrt 2005

Vascular Access for Pediatric CRRT(Hackbarth et al, CRRT 2005)

  • 7 Fr dual lumen with clot in 50%

    • Avg BFR 27 mls/min

  • 8 Fr dual lumen with clot in 20%

    • Avg BFR 73 mls/min

  • 12 Fr triple lumen with no clot in any

    • Avg BFR 127 mls/min

    • This was used in in all children > 35 kg


Triple vs dual in peds rrt

Triple vs Dual in Peds RRT

  • 5 year experience with Pediatric CRRT using the “pigtail” as the CaCL replacement

  • If not for citrate CRRT also serves as an added central line for other med/TPN infusion

  • What staff at bedside ever has sufficient central access?


I ll tell you where to stick this next drug

..I’ll tell you where to stick this next drug…

(PICU nurse)


Access for pediatric crrt

Suggested size and company


Access for pediatric crrt

So what have we learned?


Access summary

Access Summary

  • In children > 35 kg the Triple lumen 12 Fr access serves as the mainstay of Pediatric CRRT access

  • In smaller children on CRRT more central lines are needed for their care with increase risk of clotting, infections

  • IJ superior to other locations


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