Optimizing Vascular Access in CRRT Therapy
Learn about the critical importance of vascular access in Continuous Renal Replacement Therapy (CRRT), including ideal catheter characteristics, matching catheter size to patient anatomy, performance standards in pediatric CRRT, and key considerations for catheter placement. Explore insights from a comprehensive study on circuit survival factors. Discover how to select the right catheter size and placement site for effective CRRT outcomes.
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Vascular Access in CRRT Timothy E Bunchman MD Professor & Director Pediatric Nephrology tbunchman@mcvh-vcu.edu pedscrrt@gmail.com www.pcrrt.com
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
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 Vascular Access for CRRT
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
Two questions to be answered- What size catheter to use? Where to put it? Vascular Access
ppCRRT Registry Access Study 13 Pediatric Institutions 376 patients 1574 circuits Circuit survival by Catheter size, site, and modality Vascular Access Hackbarth R et al: IJAIO 30:1116-21, 2007
Figure 2: Mean Patient Weight vs Catheter Size 100 80 60 Kg 40 20 0 5 French 7 French 8 French 9 French 10 French 11.5 French 12.5 French Catheter Size Vascular Access Hackbarth R et al: IJAIO 30:1116-21, 2007
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 Vascular Access
% Survival at 60 hours Number of Patients Catheter Size* 5 7 8 9 10 11.5 12.5 6 0 (p <0.0000) 43 (p < 0.002) 55 (NS) 51 (p < 0.002) 53 (NS) 57 (NS) 60 (NS) 57 65 35 46 71 64 Insertion Site Internal Jugular Subclavian Femoral 58 31 260 60 (p < 0.05) 51 (NS) 52 (NS) Hackbarth R et al: IJAIO 30:1116-21, 2007
Survival favors IJ Location (p< 0.05) Vascular Access Hackbarth R et al: IJAIO 30:1116-21, 2007
Catheter proximity Inadvertent removal of infusions Circuit clotting with platelet transfusions Entraining calcium into the circuit Vascular Access
Vascular Access Note the relationship of the line tips.
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 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 Vascular Access for Pediatric CRRT (Hackbarth et al, CRRT 2005)
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
PATIENT SIZE CATHETER SIZE & SITE OF INSERTION SOURCE NEONATE Single-lumen 5 Fr (COOK) Femoral artery or vein Dual-Lumen 7.0 French Femoral vein (COOK/MEDCOMP) 3-6 KG Dual-Lumen 7.0 French Internal/External-Jugular, (COOK/MEDCOMP) Subclavian or Femoral vein www.pcrrt.com Triple-Lumen 7.0 Fr Internal/External-Jugular, (MEDCOMP) Subclavian or Femoral vein 6-30 KG Dual-Lumen 8.0 French Internal/External-Jugular, (KENDALL/ARROW) Subclavian or Femoral vein >15-KG Dual-Lumen 9.0 French Internal/External-Jugular, (MEDCOMP) Subclavian or Femoral vein >30 KG Dual-Lumen 10.0 French Internal/External-Jugular, (KENDALL, ARROW) Subclavian or Femoral vein >30 KG Triple-Lumen 12 French Internal/External-Jugular, (KENDALL/ ARROW) Subclavian or Femoral vein
Vascular access is one of the most important features of CRRT, ECMO, PP and HD Knowing where and what size of access is paramount to a successful therapy Conclusion
