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Review

Clinical review: Alternative vascular access techniques for continuous hemofiltration

Joseph V DiCarlo1*, Scott R Auerbach2 and Steven R Alexander3

Author Affiliations

1 Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Welch Road, Palo Alto, California 94304, USA

2 Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Welch Road, Palo Alto, California 94305, USA

3 Division of Pediatric Nephrology, Stanford University School of Medicine, SUMC G306A, Stanford, California 94305, USA

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Critical Care 2006, 10:230  doi:10.1186/cc5035

Published: 19 September 2006

Abstract

Obtaining or maintaining vascular access for continuous hemofiltration can sometimes be problematic, especially in the child or adult in multiple organ failure with edema and/or coagulopathy. Problems commonly encountered include obstruction of the femoral vein by the catheter, insertion difficulties, safety concerns when cannulating the subclavian vein in coagulopathy, and catheter and circuit occlusion due to disseminated intravascular coagulation. For access in infants we describe a technique utilizing two single-lumen thin-walled vascular sheaths. For infants and small children initial access to the vein may be difficult due to edema or poor perfusion. For this situation we describe the 'mini-introducer' technique of securing the vein and facilitating subsequent insertion of a relatively large guide wire. At any age an alternative route to the subclavian vein, from above the clavicle, is potentially 'compressible' in the event of hemorrhage during the procedure. We remind the reader of the utility of ultrasound guidance for cannulation of the internal jugular and subclavian veins. And lastly we review the options for venous return via the umbilical vein in infants, and via the antecubital vein in larger children and adults.