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    Access Access Presentation Transcript

    • 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.
      • This is the most important aspect of CVVH therapy.
          • Adequacy.
          • Filter life.
          • Increased blood loss.
          • Staff satisfaction.
    • 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
    • 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/1.73m 2 or
        • 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
      • One dual- or triple-lumen or two single lumen uncuffed catheters
      • Sites
        • femoral
        • internal jugular
        • avoid sub-clavian vein if possible
    • Catheter Position
      • No Right or Wrong Choice of Placement
        • FACTORS
          • Clinical expertise
          • Body Habitus
          • Other catheters (Citrate anticoag-triple preferred)
          • Coagulopathy
          • Intra-abdominal distension
    • 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
      • 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
      PROS CONS
    • Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site
      • 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
      PROS CONS
    • 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
    • Femoral versus IJ catheter performance Little et al: AJKD 36:1135-9, 2000 * p<0.001 ** p<0.007 -0.1 to 1.0 0.4* 226.4 13 Jugular 17.1 to 35.5 26.3** 247.5 7 < 20cm 2.9 to 13.7 8.5** 233.3 19 > 20cm 7.6 to 18.6 13.1* 237.1 26 Femoral 95% CI Recirculation(%) Qb (ml/min) Number Type
    • Troubleshooting Access
      • 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.
    • 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.
    • 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
    • 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?
    • 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!
    • Thanks!
      • Stu Goldstein
      • Tim Bunchman
      • Theresa Mottes
      • Tim Kudelka
      • Betsy Adams
      • Tammy Kelly
      • Robin Nievaard