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