1. Access for PCRRT Timothy E. Bunchman Professor Pediatrics

2. bunchman The System is Down due to poor Access!

3. bunchman My first choice is….

4. bunchman Factors affecting choice of access Size of access relative to size of child Placement of access –does it matter where it is placed? Configuration –Side by side –Double D –Co-axial

5. bunchman Access Choice The optimal access –Large internal diameter to minimize resistance due to internal diameter –Short length to minimize resistance due to length In the case of vascular access SIZE DOES MATTER

6. bunchman Access Choice Patient SizeAccess SizeLocationCompany NeonateDL 7 FrIJ/SC/FemCook/Med Comp 3-15 KgDL 7 FrIJ/SC/FemCook/Med Comp DL 8 FrIJ/SC/FemMed Cp/Quinton 15-30 KgDL 8 FrIJ/SC/FemQuinton DL 9 FrIJ/SC/FemMed Comp > 30 KgDL 10 FrIJ/SC/FemMultiple Choices

7. bunchman 7 French access Cook mini-puncture soft 10 cm, side by side configuration BFR: 0-100 mls/min venous pressure: 200-250 mm Hg recirculation rate:< 5%

8. bunchman 7 French access Med Comp soft line soft 10 cm, side by side configuration BFR: 0-100 mls/min venous pressure: 200-250 mm Hg recirculation rate:< 5%

9. bunchman 7 French access Cook Bunchman co-axial stiff 10 cm, coaxial BFR: 0-75 mls/min venous pressure: 200-300 mm Hg recirculation rate:< 5%

10. bunchman 8 French access Quinton (Kendall) stiff 9, 12, 15 cm, double D configuration BFR: 0-250 mls/min venous pressure: 50-250 mm Hg recirculation rate:< 5%

11. bunchman 8 French access Arrow soft 11 cm, side by side BFR: 0-200 mls/min venous pressure: 100-300 mm Hg recirculation rate:< 5%

12. bunchman 9 French access Med Comp soft 10 cm, co-axial BFR: 0-200 mls/min venous pressure: 100-300 mm Hg recirculation rate:< 7 %

13. bunchman 12 French access Arrow triple lumen stiff 16 cm, side by side BFR: 0-350 mls/min venous pressure: 50-250 mm Hg recirculation rate:< 5%

14. bunchman Location of Access Is there an optimal location Does the location affect –? BFR –? Flow resistance –? Recirculation

15. bunchman Bunchman Bias All access should be Rt IJ if possible due to effect on patient care, turning in bed, flexing the legs all of which affect BFR Study in Children < 20 kg Quinton (Kendall) 8 Fr catheter Above vs Below the diaphragm

16. bunchman Comparison of upper vs. lower body location line placement (n = 20; 120 Treatments) P value NS NS NS NS

17. bunchman Access-Conclusion Anticoagulation requirements, BFR, flow resistance, happiness at bedside is all correlated to good access Best access is that which correlates to the size of the child Without good access you might as well go home