Presentation on theme: "Vascular Access The Alpha and Omega of CRRT"— Presentation transcript:
1 Vascular Access The Alpha and Omega of CRRT Rick Hackbarth MDDivision of Pediatric Critical CareGrand Rapids, Michigan
2 Vascular Access Wisdom “If you don’t have good access you might as well go home!”
3 Vascular Access The portal from patient to circuit Affects circuit lifeLost circuits may expose patients to more transfusions and frustrates staffAffects clearanceLower blood flow rates and hemofiltration ratesMore downtime
4 Vascular Access Two questions to be answered- What size catheter to use?Where to put it?
6 Vascular Access 8l Pousielle’s Law- Q = ∆Pπr4 Smaller diameters offer greater resistance to flowLonger lengths offer greater resistance to flowDecreasing the diameter by 1/5th is the same as doubling the length (roughly a 2 French size difference)Q = ∆Pπr48l
7 Vascular Access ppCRRT Registry Access Study 13 Pediatric Institutions 376 patients1574 circuitsCircuit survival by Catheter size, site, and modalityHackbarth R et al: IJAIO 30: , 2007
8 Vascular AccessHackbarth R et al: IJAIO 30: , 2007
14 Vascular Access “Location, location, location!” Femoral Vein Pros: Accessible under almost any conditionsEasier to maintain hemostasisCons:Potential for kinkingMore recirculationThrombosisProblematic flow with increased abdominal pressures
15 Vascular Access “Location, location, location!” Subclavian Vein Pros: Shorter catheter/better flowLess recirculationCons:Potential for kinkingDifficult hemostasisPotential for venous narrowingLess accessible with cervical trauma
16 Vascular Access “Location, location, location!” Internal Jugular Vein Pros:Shorter catheter/better flowLess recirculationCons:Difficult hemostasisLess accessible with cervical traumaCatheter length problematic in small infants
17 Vascular Access Highly variable position of the IJ vein Ultrasound can be quite helpfulMaecken T et al: CCM 35: S178-85, 2007
31 Vascular Access Differing Perspectives on the ICU Patient It was six men of IndostanTo learning much inclined,Who went to see the Elephant(Though all of them were blind),That each by observationMight satisfy his mind.John Godfrey SaxeThe Blind Men and the Elephant
32 Vascular Access Differing Perspectives on the ICU Patient And so these men of IndostanDisputed loud and long,Each in his own opinionExceeding stiff and strong,Though each was partly in the right,And all were in the wrong!John Godfrey SaxeThe Blind Men and the Elephant
37 Vascular Access Two questions to be answered- What size catheter to use?Where to put it?
38 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
39 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?
40 Vascular Access Where should the catheter go? Answer: Internal Jugular vein if possible