Dialysis catheter insertion in the prone position in a patient with severe hypoxemia and hemodynamic instability: a case report.

PURPOSE: Central venous access in the prone position has historically been challenging, but recent advancements, particularly following the COVID-19 pandemic, have made this approach increasingly feasible. The internal jugular vein (IJV) is one of the most accessible sites for central venous cannulation in patients in the prone position, especially under ultrasound guidance. In this case report, we sought to describe the feasibility and step-by-step approach of central venous dialysis catheter insertion under ultrasound guidance in a patient with critical illness who was transferred in prone position and required urgent plasmapheresis. TECHNICAL FEATURES: A 69-yr-old female patient was transferred with severe hypoxemic respiratory failure (partial pressure of oxygen [PaO2]/ fraction of inspired oxygen [FIO2] ratio, 70), new-onset pancytopenia, hemoptysis, and acute renal failure requiring dialysis catheter insertion. Due to inability to tolerate supine positioning and hemodynamic instability, the procedure was performed prone. For right IJV access, the head was slightly rotated contralaterally, the shoulders elevated with an extra pillow, and the bed placed in 20° Trendelenburg position. Placing a linear ultrasound probe transversely, we visualized the sternocleidomastoid muscle, IJV, and carotid artery. We used a modified anterior approach for needle insertion, targeting the lateral wall of the IJV instead of the anterior wall as done in the traditional anterior approach. Once the vein was punctured, the 15-cm, 12-Fr double-lumen dialysis catheter was inserted using the Seldinger technique. CONCLUSIONS: Prone central venous dialysis catheter insertion, using a modified anterior approach, can be a potential option for patients with severe hypoxemia in prone position. This unusual and infrequently described approach to dialysis catheter insertion requires further study to better characterize potential associated complications.