vascular access considerations and options for pediatric crrt
DESCRIPTION
Vascular Access Considerations and Options for Pediatric CRRT. Stuart L. Goldstein, MD. Vascular Access: Overview. Required performance characteristics Size and site options Pros and cons of femoral vs IJ Recirculation issues Special situations LVAD/ECMO Citrate anticoagulation. - PowerPoint PPT PresentationTRANSCRIPT
Vascular Access Considerations and Options for Pediatric CRRT
Stuart L. Goldstein, MD
Vascular Access: Overview
• Required performance characteristics
• Size and site options– Pros and cons of femoral vs IJ– Recirculation issues
• Special situations– LVAD/ECMO– Citrate anticoagulation
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/1.73m2 or– 10-12 ml/kg/min in neonates and infants
– 4-6 ml/kg/min in children
– 2-4 ml/kg/min in adolescents
Venous 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
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
Vascular Access for Pediatric CRRT: Pros and Cons of Femoral Site
• Relatively larger vessel may allow for– larger catheter
– higher flows
• Ease of placement
• No risk of pneumothorax
• Preserve potential future vessels for chronic HD
• Shorter femoral catheters with increased % recirculation
• Poor performance in patients with ascites/increased abdominal pressure
• Trauma to venous anastamosis site for future transplant
PROS CONS
Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site
• Tip placement in right atrium decreases recirculation
• Not affected by ascites• Preserve potential vein
needed for transplant
• SCV stenosis (SCV)
• Superior vena cava syndrome
• Risk of pneumothorax in patients with high PEEP
• Trauma to veins needed potentially for future HD access
PROS CONS
Femoral versus 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 versus IJ catheter performance
Type Number Qb (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
Femoral versus IJ catheter performance: Pediatrics
103 102 118 119
219
174
3 4
0
50
100
150
200
250
BFR(mls/min)
Venous P(mm Hg)
Arterial P(mm Hg)
% Recirc
IJ/SC
Femoral
P value NS NS NS NS
(Gardner et al, CRRT 1997Quinton 8 Fr; n = 20; 120 Treatments)
Venous Access for CRRT:Special Situation/LVAD-ECMO
• Parallel to other extra-corporeal circuit– ECMO– LVAD
• Blood prime• High ECMO/LVAD flows can cause
minimal negative “arterial” pressure– access disconnect alarms– arterial screw clamp to cause negative pressure
CRRT in LVAD circuit
LVAD
CRRT
Vascular Access for Pediatric CRRT:Some Final Thoughts
• Catheters with poor function will function poorly… over and over and over and over
• Balance between surgical/ICU expertise (preference?) and the necessary evils dictated by the patient– high PEEP… femoral catheter?– massive ascites… IJ catheter?– available sites… are there any?
• Which vessel are you willing to traumatize?