vascular access the alpha and omega of crrt rick hackbarth md division of pediatric critical care...
TRANSCRIPT
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Vascular AccessThe Alpha and Omega of CRRT
Rick Hackbarth MD
Division of Pediatric Critical Care
Grand Rapids, Michigan
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Vascular Access Wisdom
“If you don’t have good access you might as well go home!”
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Vascular Access
The portal from patient to circuit Affects circuit life
Lost circuits may expose patients to more transfusions and frustrates staff
Affects clearance Lower blood flow rates and hemofiltration rates More downtime
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Vascular Access
Two questions to be answered-
What size catheter to use?
Where to put it?
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Vascular Access Wisdom
“Size matters!”
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Vascular Access
Pousielle’s Law-
Smaller diameters offer greater resistance to flow Longer lengths offer greater resistance to flow Decreasing the diameter by 1/5th is the same as doubling the
length (roughly a 2 French size difference)
Q = ∆Pπr4
8l
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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
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Vascular Access
Figure 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
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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
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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
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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
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Vascular Access Wisdom
“Location, location, location!”
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Vascular Access
“Location, location, location!”
Options: Femoral vein Subclavian vein Internal Jugular vein
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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
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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
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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
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Vascular Access
Highly variable position of the IJ vein Ultrasound can be quite helpful
Maecken T et al: CCM 35: S178-85, 2007
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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
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Vascular Access
Hackbarth R et al: IJAIO 30:1116-21, 2007
Survival favors IJLocation (p< 0.05)
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Vascular Access Wisdom
“It’s déjà vu all over again.”
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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
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Vascular Access
Note the relationship of the line tips.
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Vascular Access
Catheter proximity
Inadvertent removal of infusions Circuit clotting with platelet transfusions Entraining calcium into the circuit
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Vascular Access Wisdom
“You can’t always get what you want, but you might get what you need!”
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Vascular Access
French
Size5 7 8 10 12
Flow Rate
(ml/min)? 80-100 150-200 250-300 285-330
Catheter Specifications
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Vascular Access
French
Size5 7 8 10 12
Diameter
(mm)1.67 2.3 2.7 3.3 4.0
Catheter Specifications
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Vascular Access
Vessel diameter vs Age
0
0.5
1
1.5
2
2.5
3
0 2 4 6 8 10 13 16 19
Years
cmFemoral
IVC
IJ
Steinberg et al: Catheterization and Cardiovascular Diagnosis 27: 197-201, 1992
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Vascular Access
Pousielle’s Law-Q = ∆Pπr4
8l
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Vascular Access
Relative Resistance to IVC Blood Flow
0
2
4
6
5 7 8 10 12
Catheter Size (French)
Rela
tive R
esis
tan
ce
Infant
2 year old
6 year old
10 year old
16 year old
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Vascular Access
Relative Resistance to IVC Blood Flow
0
2
4
6
5 7 8 10 12
Catheter Size (French)
Rela
tive R
esis
tan
ce
4kg
12 kg
20 kg
30 kg
60 kg
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Vascular Access
It was six men of Indostan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.
John Godfrey Saxe
The Blind Men and the Elephant
Differing Perspectives on the ICU Patient
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Vascular Access
And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!
John Godfrey Saxe
The Blind Men and the Elephant
Differing Perspectives on the ICU Patient
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Vascular Access
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Vascular Access
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Vascular Access
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Vascular Access
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Vascular Access
Two questions to be answered-
What size catheter to use?
Where to put it?
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Vascular Access
What size catheter should we use?
Don’t use a 5 French catheter. Choose the largest diameter that is safe for the child. Choose the smallest catheter that will achieve the
necessary flow easily. Choose the the minimum length to position the tip for
optimal flow. In the femoral position, longer catheters will minimize
recirculation
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Vascular Access
Where should the catheter go?
What sites are available? Are there anatomic or physiologic constraints? Which vessel is optimal for the catheter size? Is the patient coagulopathic? Consider patient mobility and risk of kinking. Is there elevated intra-abdominal pressure?
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Vascular Access
Where should the catheter go?
Answer: Internal Jugular vein if possible
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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
(KENDALL, ARROW)
Internal/External-Jugular,
Subclavian or Femoral vein
>30 KG Triple-Lumen 12 French
(KENDALL/ ARROW)
Internal/External-Jugular,
Subclavian or Femoral vein
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Disney Wisdom
“I would rather entertain and hope that people learned something than educate people and hope they were entertained.”