Central Venous Access in the Prone Patient: Using a Traditional Approach to Solve a Contemporary Problem
Introduction: Proning is the standard of care for patients with severe acute respiratory distress syndrome (ARDS), however, this position presents challenges to patient care, especially when patients are unable to tolerate supine positioning. Central venous catheters (CVCs) are typically placed into the internal jugular, subclavian, or femoral veins in supine patients, and with the introduction of ultrasound, internal jugular vein (IJV) central line placement is typically via the anterior or lateral approach in a supine patient. In a prone patient, only the IJV can be accessed, however, it is not easily approached anteriorly or laterally. We describe utilizing a posterior approach to place a CVC into the IJV in a patient with severe ARDS who was unable to tolerate supine positioning and needed emergent leukapheresis. Case: A morbidly obese thirty-three year old female presented with epistaxis, and found to have a leukocytosis of 45,000, findings consistent with disseminated intravascular coagulopathy, and a smear concerning for hematologic malignancy. She was empirically started on chemotherapy, including alltransretinoic acid (ATRA), and received multiple blood product transfusions early in her hospitalization. Several days into her treatment, she required intubation after developing ARDS thought to be secondary to ATRA differentiation syndrome. She rapidly declined, and on the date of intubation, required paralysis and proning secondary to refractory hypoxemia. Daily attempts to revert to supine positioning resulted in desaturations. Oncology recommended emergent leukapheresis given concern for differentiation syndrome, however patient was unable to tolerate supine positioning for traditional ultrasound-guided placement of a hemodialysis catheter. Ultimately, the posterior approach was used to identify and then subsequently successfully cannulate the right IJV with a 14-French hemodialysis catheter utilizing Seldinger technique under ultrasound guidance. Discussion: There is limited literature regarding the insertion of CVC into the proned patient. Patients with severe ARDS typically have limited physiologic reserve and present a challenge to clinicians who are faced with performing bedside procedures while the patient is in the prone position. This abstract offers a safe solution to a challenging dilemma faced by intensivists who manage patients with severe ARDS. In this case, the patient’s positioning and morbid obesity made the procedure technically challenging, but a larger bore (14-French) central venous catheter was successfully inserted utilizing the posterior approach under active ultrasound guidance. This approach could be extrapolated for emergent conventional CVC placement, introducer sheath placement, or preparing a venous access site for extracorporeal life support cannulation in a decompensating patient.