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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!. 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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  1. Access for Pediatric CRRT Timothy E. Bunchman, Professor & Director VCU School of Medicine Founder PCRRT www.pcrrt.com

  2. The System is Down due to poor Access! Nephrologist or Intensivist

  3. My first choice is…. Nephrology nurse on call or PICU nurse at bedside

  4. 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.

  5. 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

  6. 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

  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 or • 10-12 ml/kg/min in neonates and infants • 5-10 ml/kg/min in children

  8. 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

  9. 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

  10. Femoral vs IJ catheter performance * p<0.001 ** p<0.007 Little et al: AJKD 36:1135-9, 2000

  11. 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

  12. Vascular Access Hackbarth R et al: IJAIO 30:1116-21, 2007

  13. Vascular Access “Location, location, location!” Options: • Femoral vein • Subclavian vein • Internal Jugular vein

  14. 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

  15. 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

  16. 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

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

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

  19. 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

  20. 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

  21. Vascular Access Note the relationship of the line tips.

  22. Do we need triple lumen access?

  23. (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)

  24. Citrate ~ running it Arterial access Venous access Citrate infusion via “y” adaptor

  25. CaCl infusion line/or TPN/or Med line Venous line “arterial” line

  26. 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

  27. 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?

  28. ..I’ll tell you where to stick this next drug… (PICU nurse)

  29. Suggested size and company

  30. So what have we learned?

  31. 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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