Access in Access in Pediatric CRRTPediatric CRRT

Patrick D Brophy MDPatrick D Brophy MDPediatric Nephrology, Dialysis & Pediatric Nephrology, Dialysis &

TransplantationTransplantationCS Mott Children’s Hospital CS Mott Children’s Hospital

University of MichiganUniversity of Michigan

From GinaFrom Gina

The System is Down The System is Down due to poor Access!due to poor Access!

My first choice is….My first choice is….

AccessAccess If you don’t have it you might as If you don’t have it you might as

well go home.well go home.

This is the most important aspect This is the most important aspect of CVVH therapy.of CVVH therapy.

Adequacy.Adequacy. Filter life.Filter life. Increased blood loss.Increased blood loss. Staff satisfaction.Staff satisfaction.

Vascular AccessVascular Access

Ideal Catheter CharacteristicsIdeal Catheter Characteristics Easy InsertionEasy Insertion Permits Adequate Blood Flow without Vessel Permits Adequate Blood Flow without Vessel

Damage Damage Minimal Technical FlawsMinimal Technical Flaws

High Recirculation RateHigh Recirculation Rate KinkingKinking

Shorter and Larger CathetersShorter and Larger Catheters SIZE DOES MATTERSIZE DOES MATTER Lower Resistance Lower Resistance Improved BloodflowImproved Bloodflow

Pediatric CRRT Vascular Pediatric CRRT Vascular Access:Access:

Performance = Blood FlowPerformance = Blood Flow

Minimum 30 to 50 ml/min to minimize Minimum 30 to 50 ml/min to minimize access and filter clottingaccess and filter clotting

Maximum rate of 400 ml/min/1.73mMaximum rate of 400 ml/min/1.73m2 2 oror 10-12 ml/kg/min in neonates and infants10-12 ml/kg/min in neonates and infants 4-6 ml/kg/min in children4-6 ml/kg/min in children 2-4 ml/kg/min in adolescents2-4 ml/kg/min in adolescents

PATIENT SIZE CATHETER SIZE &

SOURCE

SITE OF INSERTION

NEONATE Single-lumen 5 Fr (COOK) Femoral artery or vein

Dual-Lumen 7.0 French

(COOK/MEDCOMP)

Femoral vein

3-6 KG Dual-Lumen 7.0 French

(COOK/MEDCOMP)

Internal/External-Jugular,

Subclavian or Femoral vein

Triple-Lumen 7.0 Fr

(MEDCOMP)

Internal/External-Jugular,

Subclavian or Femoral vein

6-30 KG Dual-Lumen 8.0 French

(KENDALL, ARROW)

Internal/External-Jugular,

Subclavian or Femoral vein

>15-KG Dual-Lumen 9.0 French

(MEDCOMP)

Internal/External-Jugular,

Subclavian or Femoral vein

>30 KG Dual-Lumen 10.0 French

(ARROW, KENDALL)

Internal/External-Jugular,

Subclavian or Femoral vein

>30 KG Triple-Lumen 12.5 French

(ARROW, KENDALL)

Internal/External-Jugular,

Subclavian or Femoral vein

Venous Access for CRRTVenous Access for CRRT

Match catheter size to patient size Match catheter size to patient size and anatomical siteand anatomical site

One dual- or triple-lumen or two One dual- or triple-lumen or two single lumen uncuffed catheterssingle lumen uncuffed catheters

SitesSites femoralfemoral internal jugularinternal jugular avoid sub-clavian vein if possibleavoid sub-clavian vein if possible

Catheter PositionCatheter Position

No Right or Wrong Choice of No Right or Wrong Choice of PlacementPlacement FACTORSFACTORS

Clinical expertiseClinical expertise Body HabitusBody Habitus Other catheters (Citrate anticoag-triple Other catheters (Citrate anticoag-triple

preferred)preferred) CoagulopathyCoagulopathy Intra-abdominal distensionIntra-abdominal distension

Catheter PositionCatheter Position

Internal Jugular-Right- aim for RA to Internal Jugular-Right- aim for RA to secure adequate BFRsecure adequate BFR

Subclavian-Patient mobility? Most Subclavian-Patient mobility? Most frequent site of inadequate frequent site of inadequate performance -catheter curves and performance -catheter curves and abutts against SVC-Vein collapses abutts against SVC-Vein collapses against catheter due to against catheter due to positional/volume changepositional/volume change

Femoral- optimal position in tip of IVCFemoral- optimal position in tip of IVC

Vascular Access for Pediatric Vascular Access for Pediatric CRRT: Pros and Cons of CRRT: Pros and Cons of

Femoral SiteFemoral Site

Relatively larger vessel Relatively larger vessel may allow formay allow for larger catheterlarger catheter higher flowshigher flows

Ease of placementEase of placement No risk of No risk of

pneumothoraxpneumothorax Preserve potential Preserve potential

future vessels for future vessels for chronic HDchronic HD

Shorter femoral Shorter femoral catheters with increased catheters with increased % recirculation% recirculation

Poor performance in Poor performance in patients with patients with ascites/increased ascites/increased abdominal pressureabdominal pressure

Trauma to venous Trauma to venous anastamosis site for anastamosis site for future transplantfuture transplant

PROS CONS

Vascular Access for Pediatric Vascular Access for Pediatric CRRT: Pros and Cons of CRRT: Pros and Cons of

IJ/SCV SiteIJ/SCV Site

Tip placement in right Tip placement in right atrium decreases atrium decreases recirculationrecirculation

Not affected by ascitesNot affected by ascites Preserve potential vein Preserve potential vein

needed for transplantneeded for transplant

SCV stenosis (SCV)SCV stenosis (SCV) Superior vena cava Superior vena cava

syndromesyndrome Risk of pneumothorax Risk of pneumothorax

in patients with high in patients with high PEEPPEEP

Trauma to veins needed Trauma to veins needed potentially for future potentially for future HD accessHD access

PROS CONS

Femoral versus IJ catheter performanceFemoral versus IJ catheter performance

26 femoral26 femoral 19 > 20 cm19 > 20 cm 7 < 20cm7 < 20cm

13 IJ13 IJ Qb 250 ml/min (ultrasound dilution)Qb 250 ml/min (ultrasound dilution) Recirculation measurement by Recirculation measurement by

ultrasound dilution methodultrasound dilution method

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

Femoral versus IJ catheter Femoral versus IJ catheter performanceperformance

TypeType NumberNumber Qb Qb (ml/min)(ml/min)

RecirculationRecirculation(%)(%) 95% CI95% CI

FemoralFemoral 2626 237.1237.1 13.1*13.1* 7.6 to 7.6 to 18.618.6

> > 20cm20cm

1919 233.3233.3 8.5**8.5** 2.9 to 2.9 to 13.713.7

< < 20cm20cm

77 247.5247.5 26.3**26.3** 17.1 to 17.1 to 35.535.5

JugularJugular 1313 226.4226.4 0.4*0.4* -0.1 to 1.0-0.1 to 1.0

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

* p<0.001** p<0.007

Troubleshooting AccessTroubleshooting Access

How can you tell if How can you tell if you have a you have a problem before problem before starting?starting?

Check placement Check placement first, then use first, then use syringe to test syringe to test resistance and resistance and blood return.blood return.

What if you have What if you have problems during problems during treatment?treatment?

Check line for Check line for kink, then assess kink, then assess patients position or patients position or need for sedation.need for sedation.

AccessAccess Clotting or sluggish catheter.Clotting or sluggish catheter.

tPA (tissue plasminogen activator).tPA (tissue plasminogen activator). (Spry et al., Dialysis&Transplantation. Jan. 2001).(Spry et al., Dialysis&Transplantation. Jan. 2001).

Normal saline flush.Normal saline flush.

Reason to replace catheter.Reason to replace catheter. Clotted catheter with no response to tPA.Clotted catheter with no response to tPA. Exit site blood leakage with no response to Exit site blood leakage with no response to

pressure dressing.pressure dressing. Severe kinked catheter.Severe kinked catheter. Bad re-circulation issues.Bad re-circulation issues.

PressuresPressures Arterial or outflow pressuresArterial or outflow pressures

High negative pressure = access problem.High negative pressure = access problem. High positive pressure = filter problem.High positive pressure = filter problem. Moderate to high positive pressure + high return Moderate to high positive pressure + high return

(venous) pressure = access problem.(venous) pressure = access problem.

Venous or return pressuresVenous or return pressures Moderate to high positive pressure + high arterial Moderate to high positive pressure + high arterial

pressure = filter problem.pressure = filter problem. High return pressure + moderate arterial pressure = High return pressure + moderate arterial pressure =

accessaccess

Vascular Access for Pediatric Vascular Access for Pediatric CRRT:CRRT:

Some Final ThoughtsSome Final Thoughts

Catheters with poor function will function Catheters with poor function will function poorly… over and over and over and overpoorly… over and over and over and over

Balance between surgical/ICU expertise Balance between surgical/ICU expertise (preference?) and the necessary evils (preference?) and the necessary evils dictated by the patientdictated by the patient high PEEP… femoral catheter?high PEEP… femoral catheter? massive ascites… IJ catheter?massive ascites… IJ catheter? available sites… are there any?available sites… are there any?

Which vessel are you willing to traumatize?Which vessel are you willing to traumatize?

ConclusionsConclusions

Poor Access-- May as well stopPoor Access-- May as well stop Choice- patient size and optimal flowsChoice- patient size and optimal flows Site- IJ/Femoral -recommendedSite- IJ/Femoral -recommended Care- Local standard + Lock issues- Care- Local standard + Lock issues-

heparinheparin Troubleshooting- anticipate, what is Troubleshooting- anticipate, what is

the machine saying?the machine saying? Happy Hemofiltering!Happy Hemofiltering!

Thanks!Thanks!

Stu GoldsteinStu Goldstein Tim BunchmanTim Bunchman Theresa MottesTheresa Mottes Tim KudelkaTim Kudelka Betsy AdamsBetsy Adams Tammy KellyTammy Kelly Robin NievaardRobin Nievaard