Vascular Access The Alpha and Omega of CRRT

1
Vascular AccessThe Alpha and Omega of CRRT

• Rick Hackbarth MD
• Division of Pediatric Critical Care
• Grand Rapids, Michigan

2
Vascular Access Wisdom

• If you dont have good access you might as well
  go home!

3
Vascular Access

• The portal from patient to circuit
• Affects circuit life
• Lost circuits may expose patients to more
  transfusions and frustrates staff
• Affects clearance
• Lower blood flow rates and hemofiltration rates
• More downtime

4
Vascular Access

• Two questions to be answered-
• What size catheter to use?
• Where to put it?

5
Vascular Access Wisdom

• Size matters!

6
Vascular Access

• Pousielles Law-
• Smaller diameters offer greater resistance to
  flow
• Longer lengths offer greater resistance to flow
• Decreasing the diameter by 1/5th is the same as
  doubling the length (roughly a 2 French size
  difference)

Q ?Ppr4 8?l
7
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 301116-21, 2007
8
Vascular Access

Hackbarth R et al IJAIO 301116-21, 2007
9
Hackbarth R et al IJAIO 301116-21, 2007
10
Vascular Access

1st 72 hrs of circuit life only
Shorter life span for 7 and 9 French catheters
(plt 0.002)
Hackbarth R et al IJAIO 301116-21, 2007
11
Hackbarth R et al IJAIO 301116-21, 2007
12
Vascular Access Wisdom

• Location, location, location!

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
Vascular Access

• Highly variable position of the IJ vein
• Ultrasound can be quite helpful

Maecken T et al CCM 35 S178-85, 2007
18
Hackbarth R et al IJAIO 301116-21, 2007
19
Vascular Access

Survival favors IJ Location (plt 0.05)
Hackbarth R et al IJAIO 301116-21, 2007
20
Vascular Access Wisdom

• Its déjà vu all over again.

21
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

22
Vascular Access
Note the relationship of the line tips.
23
Vascular Access

• Catheter proximity
• Inadvertent removal of infusions
• Circuit clotting with platelet transfusions
• Entraining calcium into the circuit

24
Vascular Access Wisdom

• You cant always get what you want, but you
  might get what you need!

25
Vascular Access
Catheter Specifications
26
Vascular Access
Catheter Specifications
27
Vascular Access
Steinberg et al Catheterization and
Cardiovascular Diagnosis 27 197-201, 1992
28
Vascular Access

• Pousielles Law-

Q ?Ppr4 8?l
29
Vascular Access
30
Vascular Access
31
Vascular Access
Differing Perspectives on the ICU Patient

• It was six men of Indostan
• To learning much inclined,
• Who went to see the Elephant
• (Though all of them were blind),
• That each by observation
• Might satisfy his mind.
• John Godfrey Saxe
• The Blind Men and the Elephant

32
Vascular Access
Differing Perspectives on the ICU Patient

• And so these men of Indostan
• Disputed loud and long,
• Each in his own opinion
• Exceeding stiff and strong,
• Though each was partly in the right,
• And all were in the wrong!
• John Godfrey Saxe
• The Blind Men and the Elephant

33
Vascular Access
34
Vascular Access
35
Vascular Access
36
Vascular Access
37
Vascular Access

• Two questions to be answered-
• What size catheter to use?
• Where to put it?

38
Vascular Access

• What size catheter should we use?
• Dont 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

39
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?

40
Vascular Access

• Where should the catheter go?
• Answer Internal Jugular vein if possible

41
(No Transcript)
42
Disney Wisdom

• I would rather entertain and hope that people
  learned something than educate people and hope
  they were entertained.