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

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

3. My first choice is….
Nephrology nurse on call or PICU nurse at bedside

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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: , 2007

12. Vascular Access
Hackbarth R et al: IJAIO 30: , 2007

13. Vascular Access “Location, location, location!” Options: Femoral vein
Subclavian vein
Internal Jugular vein

14. 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

15. 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

16. 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

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

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

19. 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: , 2007

20. 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

21. Vascular Access
Note the relationship of the line tips.

22. Do we need triple lumen access?

23. 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:
(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 hrs)

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

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

26. 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

27. 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?

28. ..I’ll tell you where to stick this next drug…
(PICU nurse)

29. Suggested size and company

30. So what have we learned?

31. 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