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Continuous kidney replacement therapy (CKRT): access
Choosing the right vascular access for CKRT in pediatric patients
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Access options
- Goal is to provide adequate vascular access to meet current kidney replacement therapy requirements without compromising future potential access sites
- For patients already on extracorporeal therapies such as ECMO, consider running
in tandem with these procedures (i.e., accessing the existing circuit) - Otherwise,
is performed using a catheter
Tables: catheter selection based on patient size
General catheter sizes for hemodialysis (HD) and continuous kidney replacement therapy (CKRT)
Based on patient weight. Will vary by patient anatomy, institutional availability, and expected duration of therapy.
| Weight | Catheter size |
|---|---|
| ≤3 kg | ≤7 Fr, double lumen 4 Fr single lumen power rated PICC in IJ* & 3 Fr single lumen power rated PICC in femoral* |
| 3-10 kg | 7 Fr, double lumen |
| 10-20 kg | 8-9 Fr, double lumen |
| 20-30 kg | 9-10 Fr, double lumen |
| 30-40 kg | 10-11 Fr, double lumen |
| >40 kg | 11.5-12.5 Fr, double lumen |
Catheters for hemodialysis (HD) and continuous kidney replacement therapy (CKRT)
Based on patient weight and expected duration of therapy. Will vary by patient anatomy and institutional availability. The following catheters are used at Lucile Packard Children's Hospital.
| Weight | Estimated Use ≤14 Days | Estimated Use >14 Days |
|---|---|---|
| 1-3 kg | 4 Fr single lumen power rated PICC in IJ* & 3 Fr single lumen power rated PICC in femoral* | |
| 3-5 kg | 7 Fr (uncuffed dialysis catheter) | 7.5 Fr GlidePath® |
| 5-10 kg | 7 Fr (uncuffed dialysis catheter) 8 Fr (cuffed dialysis catheter) | 7.5 Fr GlidePath® |
| 10-20 kg | 8 Fr (cuffed or uncuffed dialysis catheter) 9 Fr (uncuffed dialysis catheter) | 7.5 Fr GlidePath® 10 Fr GlidePath® |
| 20-30 kg | 9 Fr (uncuffed dialysis catheter) 10 Fr (cuffed dialysis catheter) 11.5 Fr (uncuffed dialysis catheter) | 10 Fr GlidePath® |
| 30-40 kg | 10 Fr (cuffed dialysis catheter) 11.5 Fr (uncuffed dialysis catheter) | 10 Fr GlidePath® |
| 40-50 kg | 11.5 Fr (uncuffed dialysis catheter) 12.5 Fr (uncuffed dialysis catheter) | 12.5 Fr (cuffed dialysis catheter) 14 Fr GlidePath® |
| >50 kg | 12.5 Fr (uncuffed dialysis catheter) | 14 Fr GlidePath® |
Vessel preference for catheter placement
- Right IJ > Right EJ > Left IJ > Left EJ > Femoral [Cho et a., 2006, Wang et al., 2016]
- Neck > femoral
- Lower infection risk
- Enables greater patient mobility
- Generally cannot mobilize patients with a femoral line due to risk of catheter kinking/displacement which can lead to circuit failure
- Neck veins can accommodate larger caliber catheters and optimal blood flow rates
- Flow through femoral catheters may be negatively impacted by increased abdominal pressures or patient movement
- Right-sided
- Allows for a more direct trajectory to the cavoatrial junction
- Internal jugular
- Highly accessible to the practitioner for catheter placement
- Can accommodate a large caliber catheter and optimal blood flow rates
- Superior circuit survival compared to femoral or subclavian lines
- Risk for pneumothorax/hemothorax
- Avoid subclavian lines
- High risk of stenosis (may be as high as 80%)
- Stenosis can result in the loss of functional vascular access of the affected extremity for the life of the patient
- High risk of stenosis (may be as high as 80%)
Who places acute dialysis catheters?
- Pediatric IR
- Critical care
Who places chronic dialysis catheters?
- Pediatric IR
- CT surgery after ECMO decannulation
- Transplant surgery