Access for Pediatric CRRT Timothy E. Bunchman, Professor & Director VCU School of Medicine Founder PCRRT www.pcrrt.com

The System is Down due to poor Access! Nephrologist or Intensivist

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 cm n = 20; 120 Treatments) P value NS NS NS NS Gardner et al, CRRT San Diego 1998

Femoral vs IJ catheter performance 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 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 * p<0.001 ** p<0.007 Little et al: AJKD 36:1135-9, 2000

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 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 Vein Pros: Accessible under almost any conditions Easier to maintain hemostasis Cons: Potential for kinking More recirculation Thrombosis Problematic flow with increased abdominal pressures

Vascular Access “Location, location, location!” Subclavian Vein Pros: Shorter catheter/better flow Less recirculation Cons: Potential for kinking Difficult hemostasis Potential for venous narrowing Less accessible with cervical trauma

Vascular Access “Location, location, location!” Internal Jugular Vein Pros: Shorter catheter/better flow Less recirculation Cons: Difficult hemostasis Less accessible with cervical trauma Catheter length problematic in small infants

Hackbarth R et al: IJAIO 30:1116-21, 2007

Hackbarth R et al: IJAIO 30:1116-21, 2007

Vascular Access 1st 72 hrs of circuit life only Shorter life span for 7 and 9 French catheters (p< 0.002) Hackbarth R et al: IJAIO 30:1116-21, 2007

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?

ACD-A/Normocarb Wt range 2.8 kg – 115 kg (Ca = 0.4 x citrate rate 60 mls/hr) (Citrate = 1.5 x BFR 150 mls/hr) Pediatr Neph 2002, 17:150-154 (BFR = 100 mls/min) Normal Saline Replacement Fluid Calcium can be infused in 3rd lumen of triple lumen access if available. Normocarb Dialysate ACD-A/Normocarb Wt range 2.8 kg – 115 kg Average life of circuit on citrate 72 hrs (range 24-143 hrs)

Citrate ~ running it Arterial access Venous access Citrate infusion via “y” adaptor

CaCl infusion line/or TPN/or Med line Venous line “arterial” line

Vascular Access for Pediatric CRRT (Hackbarth et al, CRRT 2005) 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

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)

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