This document discusses vascular access options for hemodialysis in children, including peritoneal dialysis, arteriovenous fistulas, synthetic grafts, and central venous catheters. Peritoneal dialysis is generally preferred for neonates and small children due to its simplicity compared to hemodialysis. Arteriovenous fistulas are the best long-term option but have a slow maturation process and risk of failure. Synthetic grafts have increased infection risks and expected lifespan of only 3-5 years. Central venous catheters are used for acute cases but carry risks of infection and thrombosis. Patient size, vascular anatomy, and dialysis needs must all be considered to determine the most appropriate access.

1. P R E S E N T E R : N U M A N S H A H
M O D E R A T O R : L E C T U R E R S I R Y O U S A F K H A N
I P M S - K M U
P E S H A W A R
Specialized Dialysis & Vascular
Access In Children

2. Introduction
 Generally peritoneal dialysis is considered the preferred
method for dialysis in neonates and small children.
 PD is a very simple technique when compared to
hemodialysis.
 Set a program :
 needs
 a doctor
 a dialysis staff
 a nurse
 a patient
 Assure a successful one :well- planned

3. Some absolute and relative indications to PD
Absolute indications:
 Poor cardiac function
 Peripheral vascular disease
Relative indications:
 Free life style
 Want to take care themselves
 Long distance to hemodialysis center

4. Teaching plans and materials
 Demonstration is essential :
 _by a dialysis staff and nurse
 _by an experienced patient
 _via video
 Practice on a mannequin
 Practice on himself/herself
 Recheck the procedure
 Update for new knowledge

5. Equipment requirement in PD training
 Comfortable chair
 Water sink
 Weighing scales
 Drip stand/hook
 Books, booklets ,charts ,posters
 Television and video/VCD/DVD
 Automate PD machine
 Shelving for consumable

6. Multi-discipline care team
The team typically includes :
 Doctors
 Dialysis staff
 Nurses
 Dietitians
 Social workers
 Often include a surgeon, a cardiologist, a
psychologist, a psychiatrist, a physiotherapist etc.

7. Advances of PD as Initial Modality
 1.Preserves residual renal function better
 2. May allow better blood pressure and volume
control with cardiovascular benefits
 3. May give better quality of life
 4. Has less anemia and lower EPO doses
 5. Lower risk of Hepatitis C
 6. Equal or better survival in early years
 7. Cost advantages - in many countries

8. Vascular Access
 The ideal vascular access delivers an adequate flow
rate for the dialysis prescription, has a long use-
life, and has a low rate of complications (e.g.
infection, stenosis, thrombosis, aneurysm, and
limb ischemia)”.
 The arteriovenous fistula (AVF) is the best
approximates definition, however
 - Not useful in acute cases.

9. Venous access in small children
Why difficult?
 Vessels are small-sized.
 Technically more difficult to approach more risk of
injury.
 Small patients require small catheters.
 Difficulty in maintaining access.
 Shorter life, repeat access, site exhaustion.
 Radiographic tools may be utilized to plan and guide
vascular access.
 Needs general anaesthesia.

10. Types of Acute Hemodialysis Access
 At times, vascular access for hemodialysis is required
immediately in children with AKI and in those with
ESRD.
 Central venous catheters:
 Uncuffed ‘intermediate term’ Polyurethane catheters
 Cuffed tunneled ‘long-term’ Silicone catheters
 Access through :
1. Internal jugular vein.
2. Subclavian vein.
3. Femoral vein.

11. Acute Hemodialysis Access
 Various catheters sizes according to weight of the
child:
Size of the child Catheter size
Neonates 5 French
3-6 kg 7 French
6-12kg 8 French

12. Acute Hemodialysis Access
 In small infants, single-lumen catheters may
occasionally be used.
 The size of catheter used must be individualized to
each patient.
 Large catheters are more effective for dialysis, but
carry a higher risk of thrombosis, vessel damage, and
stenosis.
 Small catheter that will provide adequate dialysis
(a flow rate of 3 to 5 mL/kg/minute is acceptable in
most patients).

13. Location Advantage Disadvant
age
Internal jugular vein •Bleeding can be
recognized & controlled
•Malposition is rare
•Less risk of
pneumothorax
•Risk of carotid artery
puncture
•Pneumothorax is
possible
Subclavian vein •Most comfortable for
conscious patients
•High risk of bleeding
•Bleeding is difficult to
be controlled
•High risk of
pneumothorax
Femoral vein •Technically easier
•No risk of
pneumothorax
•Preferred site for
emergencies
•Highest risk of infection
•Risk of DVT
•Not good in ambulatory
patients

14. General principles in catheter insertion
 Decide if the line is really necessary
 Know your anatomy
 Be familiar with the equipment
 Obtain patient positioning
 Take your time
 Use sterile technique
 Always have a hand on your guide wire
 Always aspirate as you advance as you withdraw the
needle slowly

16. Incidence of Complications During Acute Catheter
Insertion
Complication Incidence
Arterial Puncture 4.4%
Local Bleeding 4.0%
Pneumo/ hemothorax 2.0%
Air embolism 0.6%
Retroperitoneal bleeding 0.6%

17. Chronic Hemodialysis Access
 In children, as in adults, vascular access for long-
term hemodialysis may be provided by creation of a
native arteriovenous fistula (AVF), creation of an
AVF with synthetic graft (AVG), or placement of a
cuffed central venous catheter.

18. Fistula
 Primary Arteriovenous Fistula
 The first subcutaneous AVF was described by
Brescia and Cimino in 1966, and involved the
anastomosis of the radial artery to the largest
available vein at the wrist
 Arteriovenous fistula consist of surgical anastomosis
of an adjoining artery and vein.

19. Fistula
Anastomosis :
 End of the vein to side of the artery
 End of the vein to end of the artery
 Side of the vein to side of the artery

21. Fistula
 Long term potency, Low complication rates
 Low morbidity and improved performance with time in
fistulae rather than graft
 Choice of location for AVF
1. Radiocephalic (wrist)
2. Brachiobasailic fistula
3. Brachiocephalic (elbow)
4. Brachiocephalic transposition ( involves freeing and
transposition of basilic vein at time of AVF formation.
 Then forearm prosthetic graft, thigh fistulae and thigh
graft and axillo-axillary graft

22. Synthetic graft
 Should not be first choice for permanent access. Usually made
from Polytetrafluoroethylene (PTFE).
 The material is porous allowing in growth of fibroblasts and
incorporation of the graft into the subcutaneous tissues.
 The most common approach uses a forearm loop between the
brachial artery and cephalic vein, extending 10 cm down the
forearm.
 Linear radiocephalic forearm graft upper arm loop grafts and
upper thigh femoral loops are also placed.
 Short grafts can deteriorate from repeated puncture at a
limited number of sites
 Long graft have increased pressure, reduce flow and increase
thrombosis risk.

24. Disadvantages of AVF
 Slow maturation
 Failure of maturation
 More difficult to needle
 Increase in size with age
 Increase aneurysm formation
 Cosmetic appearance of dilated veins

25. Disadvantage of graft
 More extensive surgery
 Substantially increased infection risk
 Increase thrombosis risk
 Stenosis at anastomosis
 Expected life of only 3-5 year
 Difficult to remove
 Skin erosion