access for pediatric crrt
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
Timothy E. Bunchman, Professor & Director
VCU School of MedicineFounder PCRRTwww.pcrrt.com
Access for Pediatric CRRT
The System is Down due to poor Access!
Nephrologist orIntensivist
My first choice is….
Nephrology nurse on call or PICU nurse at bedside
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.
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
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
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
Comparison of upper vs. lower body location line
placement(Kendall 8 Fr 9 and 12 cmn = 20; 120 Treatments)
BFR(mls/min)
Venous P(mm Hg)
Arterial P(mm Hg)
% Recirc
103 102 118 119
219
174
3 40
50
100
150
200
250
BFR(mls/min)
Venous P(mm Hg)
Arterial P(mm Hg)
% Recirc
IJ /SCFemoral
P value NS NS NS NSGardner et al, CRRT San Diego 1998
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
Femoral vs IJ catheter performance
Type NumberQb
(ml/min)
Recirculation(%)
95% CI
Femoral 26 237.1 13.1*7.6 to 18.6
> 20cm
19 233.3 8.5**2.9 to 13.7
< 20cm
7 247.5 26.3**17.1 to
35.5
Jugular 13 226.4 0.4*-0.1 to
1.0
Little et al: AJKD 36:1135-9, 2000
* p<0.001** p<0.007
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
Vascular AccessFigure 2: Mean Patient Weight vs Catheter Size
0
20
40
60
80
100
5 French 7 French 8 French 9 French 10 French 11.5French
12.5French
Catheter Size
Kg
Hackbarth R et al: IJAIO 30:1116-21, 2007
Vascular Access
“Location, location, location!”
Options: Femoral vein Subclavian vein Internal Jugular vein
Vascular Access
“Location, location, location!”Femoral VeinPros: Accessible under almost any conditions Easier to maintain hemostasisCons: Potential for kinking More recirculation Thrombosis Problematic flow with increased abdominal pressures
Vascular Access
“Location, location, location!”Subclavian VeinPros: Shorter catheter/better flow Less recirculationCons: Potential for kinking Difficult hemostasis Potential for venous narrowing Less accessible with cervical trauma
Vascular Access
“Location, location, location!”Internal Jugular VeinPros: Shorter catheter/better flow Less recirculationCons: Difficult hemostasis Less accessible with cervical trauma Catheter length problematic in small infants
Figure 1: Catheter Location by Size
0
10
20
30
40
50
60
70
80
90
100
5 French 7 French 8 French 9 French 10 French 11.5 French 12.5 French
Catheter Size
%
Femoral
IJ
Subclavian
Unknown
Hackbarth R et al: IJAIO 30:1116-21, 2007
Number of Patients% Survival at 60
hours
Catheter Size*5 6 0 (p <0.0000)7 57 43 (p < 0.002)8 65 55 (NS)9 35 51 (p < 0.002)
10 46 53 (NS)11.5 71 57 (NS)12.5 64 60 (NS)
Insertion Site
Internal Jugular 58 60 (p < 0.05)Subclavian 31 51 (NS)
Femoral 260 52 (NS)
Hackbarth R et al: IJAIO 30:1116-21, 2007
Vascular Access
Hackbarth R et al: IJAIO 30:1116-21, 2007
Shorter life span for 7 and 9 Frenchcatheters (p< 0.002)
1st 72 hrs of circuitlife only
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
Vascular Access
Note the relationship of the line tips.
Do we need triple lumen access?
(Citrate = 1.5 x BFR150 mls/hr)
(Ca = 0.4 x citrate rate60 mls/hr)
Normocarb Dialysate
Normal Saline Replacement Fluid
Calcium can be infused in 3rd lumen of triple lumen access if available.
(BFR = 100 mls/min)
ACD-A/Normocarb Wt range 2.8 kg – 115 kgAverage life of circuit on citrate 72 hrs (range 24-143 hrs)
Pediatr Neph 2002, 17:150-154
Citrate ~ running it
Arterial access
Venous access
Citrate infusion via “y” adaptor
“arterial” line
Venous line
CaCl infusion line/or TPN/or Med line
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
Vascular Access for Pediatric CRRT
(Hackbarth et al, CRRT 2005)
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?
..I’ll tell you where to stick this next drug…
(PICU nurse)
PATIENT SIZE CATHETER SIZE &
SOURCE
SITE OF INSERTION
Neonates to 8 kg Dual-Lumen 7.0 French
(COOK/MEDCOMP)
Internal/External-Jugular/Fem
8 kg-15 kg Dual-Lumen 8.0 French
(KENDALL, ARROW)
Internal/External-Jugular,/fem
15-30 KG Dual-Lumen 9.0
(MEDCOMP) French or
10 Fr
(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
Suggested size and company
So what have we learned?
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