Vascular Access for CRRT Timothy E Bunchman Professor & Director Helen DeVos Children’s Hospital Grand Rapids, MI (Thanks to Rick Hackbarth MD for his.

Vascular Access for CRRTTimothy E Bunchman Professor & Director

Helen DeVos Children’s HospitalGrand Rapids, MI

(Thanks to Rick Hackbarth MD for his help and slides)

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/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

Vascular Access

Two questions to be answered-

What size catheter to use?

Where to put it?

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 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

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

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

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

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

Survival favors IJLocation (p< 0.05)

Vascular Access

Catheter proximity

Inadvertent removal of infusions Circuit clotting with platelet transfusions Entraining calcium into the circuit

Vascular Access

Note the relationship of the line tips.

Vascular Access for Pediatric CRRT

(Hackbarth et al, CRRT 2005) Children on CRRT/24 months Age range 2 days – 18 yrs Wt range 2.5-78 Kg Citrate anticoagulation Avg circuit life 3.1 days (0.3-11 days) Access was size dependent

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?

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

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?

Vascular Access

Where should the catheter go?

Answer: Internal Jugular 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

(KENDALL, ARROW)

Internal/External-Jugular,

Subclavian or Femoral vein

>30 KG Triple-Lumen 12 French

(KENDALL/ ARROW)

Internal/External-Jugular,

Subclavian or Femoral vein