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
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If you don’t have it you might as well
go home.
This is the most important aspect of
CRRT therapy.
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Adequacy.
Filter life.
Increased blood loss.
Staff satisfaction.
Vascular Access
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Ideal Catheter Characteristics
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Easy Insertion
Permits Adequate Blood Flow without Vessel Damage
Minimal Technical Flaws
 High Recirculation Rate
 Kinking
Shorter and Larger Catheters
SIZE DOES MATTER
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Lower Resistance
Improved Bloodflow
Vascular Access for CRRT
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Match catheter size to patient size and
anatomical site
One dual- or triple-lumen or two single
lumen uncuffed catheters
Sites
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femoral
internal jugular
avoid sub-clavian vein if possible
Pediatric CRRT Vascular Access:
Performance = Blood Flow
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Minimum 30 to 50 ml/min to minimize access
and filter clotting
Maximum rate of 400 ml/min or
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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
250
(Kendall 8 Fr 9 and 12 cm
n = 20; 120 Treatments)
219
174
200
150
103 102
118 119
IJ/SC
Femoral
100
50
0
3
4
BFR
Venous P Arterial P % Recirc
(mls/min) (mm Hg) (mm Hg)
P value NS
NS
NS
NS
Gardner et al, CRRT San Diego 1998
Femoral vs IJ catheter performance
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26 femoral
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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
Femoral
Number
Qb
Recirculation(%)
(ml/min)
95% CI
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
13
226.4
0.4*
-0.1 to 1.0
Jugular
* p<0.001
** p<0.007
Little et al: AJKD 36:1135-9, 2000
Vascular Access
ppCRRT Registry Access Study
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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 C atheter Size
100
80
60
Kg
40
20
0
5 French
7 French
8 French
9 French
10 French
Catheter Size
Hackbarth R et al: IJAIO 30:1116-21, 2007
11.5
French
12.5
French
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
Figure 1: Catheter Location by Size
100
90
80
70
60
Femoral
%
IJ
50
Subc lavian
U nknown
40
30
20
10
0
5 F renc h
7 F renc h
8 F renc h
9 F renc h
Cathet er Size
Hackbarth R et al: IJAIO 30:1116-21, 2007
1 0 F renc h
1 1 .5 Frenc h 1 2 .5 Frenc h
Number of Pati ents
% Survival a t 60
hours 
Catheter Size*
5
7
8
9
10
11.5
12.5
6
57
65
35
46
71
64
0 (p <0.0000)
43 (p < 0.002)
55 (NS)
51 (p < 0.002)
53 (NS)
57 (NS)
60 (NS)
Insertion Site
Internal Jugu lar
Subclavian
Femoral
58
31
260
60 (p < 0.05)
51 (NS)
52 (NS)
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
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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?
(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)
Normocarb
Dialysate
Normal
Saline
Replaceme
nt Fluid
Calcium can be infused in 3rd
lumen of triple lumen access if
available.
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)
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7 Fr dual lumen with clot in 50%
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8 Fr dual lumen with clot in 20%
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Avg BFR 27 mls/min
Avg BFR 73 mls/min
12 Fr triple lumen with no clot in any
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Avg BFR 127 mls/min
This was used in in all children > 35 kg
Triple vs Dual in Peds RRT
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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
PATIENT SIZE
CATHETER SIZE &
SITE OF INSERTION
SOURCE
Neonates to 8 kg
Dual-Lumen 7.0 French
Internal/External-Jugular/Fem
(COOK/MEDCOMP)
8 kg-15 kg
Dual-Lumen 8.0 French
Internal/External-Jugular,/fem
(KENDALL, ARROW)
15-30 KG
Dual-Lumen 9.0
Internal/External-Jugular,
(MEDCOMP) French or
Subclavian or Femoral vein
10 Fr
(ARROW, KENDALL)
>30 KG
Triple-Lumen 12.5 French
Internal/External-Jugular,
(ARROW, KENDALL)
Subclavian or Femoral vein
So what have we learned?
Access Summary
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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