Access options

Goal is to provide adequate vascular access to meet current treatment requirements without compromising future potential access sites
For patients already on extracorporeal therapies such as
or ECMO, consider running apheresis in tandem with these procedures (i.e., accessing the existing circuits)
For patients with a
catheter, the HD catheter should be suitable to tolerate the flows required for the apheresis procedure
Otherwise, a dedicated catheter will likely be required if peripheral venous access is not a viable option

PVA could be considered for clinically stable patients who do not already have a central line
- Not commonly used in North America, where central venous catheters are predominantly used, but is more common in Europe
- If multiple procedures are anticipated, central access may be preferable
Two peripheral lines are necessary
- Unless doing a discontinuous centrifugation technique, in which a single catheter can be used
Smaller lines pose higher risk for suboptimal flows, which can limit efficiency, extend treatment times, and potentially result in premature termination of the procedure
Centrifugal method allows for lower blood flows (some as low as 10 mL/min), which peripheral cannulas may accommodate:
- Typically 19- to 22-gauge IVs are used in pediatrics
  - 19- to 20-gauge IV can usually provide 60 mL/min of flow, while a 22-gauge IV typically provides ~36 mL/min of flow
    - Varies by manufacturer and vein characteristics
Plastic intravenous catheters are often suitable, but a dialysis type steel needle may be used for the inlet access

Central venous catheter (CVC) selection for apheresis therapies

Based on patient weight and expected duration of therapy. Will vary by patient anatomy and institutional availability.

*No cuffed, tunneled option is currently available for patients <5 kg.
^†Apheresis ports can be placed in some patients less than 40 kg, however, patient and vein size will ultimately determine feasibility. These ports cannot be used earlier than 7-21 days after placement.
‡Two 8 Fr single lumen apheresis ports have an effective combined lumen size of ~16 Fr; thus, they can only be used in patients >50 kg. These ports cannot be used earlier than 7-21 days after placement.
Weight	Estimated Use ≤14 Days	Estimated Use >14 Days
<5 kg	7 Fr x 10 cm (uncuffed dialysis catheter)	N/A*
5-10 kg	7 Fr x 10 cm (uncuffed dialysis catheter)	8 Fr (cuffed dialysis catheter)
10-15 kg	7 Fr x 10 cm (uncuffed dialysis catheter) 8 Fr (cuffed or uncuffed dialysis catheter)	8 Fr (cuffed dialysis catheter)
15-20 kg	8 Fr (cuffed or uncuffed dialysis catheter)	8 Fr (cuffed dialysis catheter)
20-30 kg	8 Fr (cuffed or uncuffed dialysis catheter) 9.5 Fr (cuffed PowerHickman®, Bard)	8 Fr (cuffed dialysis catheter) 9.5 Fr (cuffed PowerHickman®, Bard)
30-40 kg	9 Fr (cuffed or uncuffed dialysis catheter) 9.5 Fr (cuffed PowerHickman®, Bard)	9.5 Fr (cuffed PowerHickman®, Bard) 12 Fr dual lumen apheresis port (Vortex®, PowerFlow®)^†
40-50 kg	9 Fr (cuffed or uncuffed dialysis catheter) 9.5 Fr (cuffed PowerHickman®, Bard)	9.5 Fr (cuffed PowerHickman®, Bard) 12 Fr dual lumen apheresis port (Vortex®, PowerFlow®)^†
>50 kg	9 Fr (cuffed or uncuffed dialysis catheter) 9.5 Fr (cuffed PowerHickman®, Bard)	9.5 Fr (cuffed PowerHickman®, Bard) 12 Fr dual lumen apheresis port (Vortex®, PowerFlow®)^† Two 8 Fr single lumen apheresis ports (Vortex®, PowerFlow®)‡

Choice of catheters should be based on both patient size and vein size.
7 Fr minimum (standard of care) for use with the apheresis machine due to the high flow rate, which will collapse the lumens of smaller catheters
- Cannot use arterial line + peripheral IV combination
- Cannot use multiple smaller lumen PICCs
9.5 Fr is sufficient to achieve flows needed for pheresis, i.e., no benefit to using larger-diameter catheter
For short term/temporary access, prefer:
- Internal jugular (IJ)
- Non-tunneled (uncuffed)
7.5 Fr HD catheter not yet planned for use in pheresis at Stanford Children’s