【持续性肾脏替代治疗CRRT英文精品课件】Access Brophy.pptVIP

Access in Pediatric CRRT Patrick D Brophy MD Pediatric Nephrology, Dialysis Transplantation CS Mott Children’s Hospital University of Michigan From Gina The System is Down due to poor Access! My first choice is…. Access If you don’t have it you might as well go home. This is the most important aspect of CVVH 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 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 Catheter Position No Right or Wrong Choice of Placement FACTORS Clinical expertise Body Habitus Other catheters (Citrate anticoag-triple preferred) Coagulopathy Intra-abdominal distension Catheter Position Internal Jugular-Right- aim for RA to secure adequate BFR Subclavian-Patient mobility? Most frequent site of inadequate performance -catheter curves and abutts against SVC-Vein collapses against catheter due to positional/volume change Femoral- optimal position in tip of IVC 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 Vasc