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  • 1. Access in Pediatric CRRT Patrick D Brophy MD Pediatric Nephrology, Dialysis & Transplantation CS Mott Children’s Hospital University of Michigan
  • 2. From Gina
  • 3. The System is Down due to poor Access!
  • 4. My first choice is….
  • 5. 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.
  • 6. 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
  • 7. 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
  • 8.  
  • 9. 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
  • 10. Catheter Position
    • No Right or Wrong Choice of Placement
      • FACTORS
        • Clinical expertise
        • Body Habitus
        • Other catheters (Citrate anticoag-triple preferred)
        • Coagulopathy
        • Intra-abdominal distension
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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.
  • 17. 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.
  • 18. 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
  • 19. 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?
  • 20. 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!
  • 21. Thanks!
    • Stu Goldstein
    • Tim Bunchman
    • Theresa Mottes
    • Tim Kudelka
    • Betsy Adams
    • Tammy Kelly
    • Robin Nievaard