持续性肾脏替代治疗CRRT英文精品课件Vascular Access Considerations and Options for Pediatric .ppt

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2018-06-08 发布于贵州
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持续性肾脏替代治疗CRRT英文精品课件Vascular Access Considerations and Options for Pediatric .ppt

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持续性肾脏替代治疗CRRT英文精品课件Vascular Access Considerations and Options for Pediatric

Vascular Access Considerations and Options for Pediatric CRRT Stuart L. Goldstein, MD 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 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 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 Vascular Access for Pediatric CRRT: Pros and Cons of Femoral Site 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 Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site 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 Femoral versus IJ catheter performance 26 femoral 19 20 cm 7 20cm 13 IJ Qb 250 ml/min (ultrasound dilution) Recirculation measurement by ultrasound dilution method Femoral versus IJ catheter performance Femoral versus IJ catheter performance: Pediatrics Venous Access for CRRT:Special 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 pressur