Vascular Access Considerations and Options for Pediatric CRRT

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Vascular Access Considerations and Options for
Pediatric CRRT

• Stuart L. Goldstein, MD

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Vascular Access Overview

• Required performance characteristics
• Size and site options
• Pros and cons of femoral vs IJ
• Recirculation issues
• Special situations
• LVAD/ECMO
• Citrate anticoagulation

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Pediatric CRRT Vascular AccessPerformance
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

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Venous 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

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Vascular Access for Pediatric CRRT Pros and Cons
of Femoral Site
PROS
CONS

• Relatively larger vessel may allow for
• larger catheter
• higher flows
• Ease of placement
• No risk of pneumothorax
• Preserve potential future vessels for chronic HD

• Shorter femoral catheters with increased
  recirculation
• Poor performance in patients with
  ascites/increased abdominal pressure
• Trauma to venous anastamosis site for future
  transplant

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Vascular Access for Pediatric CRRT Pros and Cons
of IJ/SCV Site
PROS
CONS

• Tip placement in right atrium decreases
  recirculation
• Not affected by ascites
• Preserve potential vein needed for transplant

• SCV stenosis (SCV)
• Superior vena cava syndrome
• Risk of pneumothorax in patients with high PEEP
• Trauma to veins needed potentially for future HD
  access

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Femoral versus IJ catheter performance

• 26 femoral
• 19 gt 20 cm
• 7 lt 20cm
• 13 IJ
• Qb 250 ml/min (ultrasound dilution)
• Recirculation measurement by ultrasound dilution
  method

Little et al AJKD 361135-9, 2000
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Femoral versus IJ catheter performance
plt0.001 plt0.007
Little et al AJKD 361135-9, 2000
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Femoral versus IJ catheter performance
Pediatrics
P value NS NS NS NS
(Gardner et al, CRRT 1997Quinton 8 Fr n 20
120 Treatments)
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Venous Access for CRRTSpecial
Situation/LVAD-ECMO

• Parallel to other extra-corporeal circuit
• ECMO
• LVAD
• Blood prime
• High ECMO/LVAD flows can cause minimal negative
  arterial pressure
• access disconnect alarms
• arterial screw clamp to cause negative pressure

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CRRT in LVAD circuit
CRRT
LVAD
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Vascular Access for Pediatric CRRTSome Final
Thoughts

• Catheters with poor function will function
  poorly over and over and over and over
• Balance between surgical/ICU expertise
  (preference?) and the necessary evils dictated by
  the patient
• high PEEP femoral catheter?
• massive ascites IJ catheter?
• available sites are there any?
• Which vessel are you willing to traumatize?