Achieving superficial femoral venous access in a critically ill COVID-19 patient in the prone position

Central venous accesses in prone position during the pandemic period: A narrative review

The unprecedented challenges posed by the global COVID-19 pandemic have magnified the significance of managing intensive care patients in prone positions, particularly those requiring mechanical ventilation. Central venous access is crucial for delivering essential therapies to patients, particularly in intensive care settings. However, the shift in patient management during the pandemic, necessitating prone positioning for improved oxygenation, presented unique hurdles in maintaining and establishing central venous access. Before the pandemic, scant literature detailed the insertion of vascular access devices in prone or unconventional positions. Limited case reports and letters highlighted the feasibility of procedures like ultrasound-guided central catheter placement in patients undergoing surgery or with specific clinical needs. During the pandemic, a surge in case reports and series illuminated the complexities faced by clinicians in maintaining vascular access during pronation procedures. These reports delineated critical scenarios, ranging from rapid clinical deterioration necessitating immediate interventions to challenges with vascular access device (VAD) malfunctions or misplacements during prone maneuvers. Patient selection and device types emerged as critical considerations. Various scenarios, including patients transitioning to prone position from non-invasive ventilation and those requiring additional access for therapies like dialysis, posed challenges in device selection and placement. Successful VAD insertion techniques in prone patients encompassed multiple anatomical sites, including the internal jugular, brachial, femoral, and popliteal veins. However, challenges persisted, particularly with respect to anatomical variations and technical complexities in cannulation. Further research, standardized protocols, and randomized studies are needed to refine and validate the proposed strategies in both pandemic and non-pandemic settings.

Comparison of outcomes from tunnelled femorally inserted central catheters and peripherally inserted central catheters: a propensity score-matched cohort study

OBJECTIVES

To compare catheter-related outcomes of individuals who received a tunnelled femorally inserted central catheter (tFICC) with those who received a peripherally inserted central catheter (PICC) in the upper extremities.

DESIGN

A propensity-score matched cohort study.

SETTING

A 980-bed tertiary referral hospital in South West Sydney, Australia.

PARTICIPANTS

In-patients referred to the hospital central venous access service for the insertion of a central venous access device.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of interest was the incidence of all-cause catheter failure. Secondary outcomes included the rates of catheters removed because of suspected or confirmed catheter-associated infection, catheter dwell and confirmed upper or lower extremity deep vein thrombosis (DVT).

RESULTS

The overall rate of all-cause catheter failure in the matched tFICC and PICC cohort was 2.4/1000 catheter days (95% CI 1.1 to 4.4) and 3.0/1000 catheter days (95% CI 2.3 to 3.9), respectively, and when compared, no difference was observed (difference -0.63/1000 catheter days, 95% CI -2.32 to 1.06). We found no differences in catheter dwell (mean difference of 14.2 days, 95% CI -6.6 to 35.0, p=0.910); or in the cumulative probability of failure between the two groups within the first month of dwell (p=0.358). No significant differences were observed in the rate of catheters requiring removal for confirmed central line-associated bloodstream infection (difference 0.13/1000 catheter day, 95% CI -0.36 to 0.63, p=0.896). Similarly, no significant differences were found between the groups for confirmed catheter-related DVT (difference -0.11 per 1000 catheter days, 95% CI -0.26 to 0.04, p=1.00).

CONCLUSION

There were no differences in catheter-related outcomes between the matched cohort of tFICC and PICC patients, suggesting that tFICCs are a possible alternative for vascular access when the veins of the upper extremities or thoracic region are not viable for catheterisation.

Femoral venous access: State of the art and future perspectives

In the past 5 years, non-dialysis femoral venous access has changed in terms of indications, techniques of insertion, and expected incidence of complications. To the traditional non-emergency indication for femoral catheters-obstruction of the superior vena cava-many other indications have been added, both in intensive and non-intensive care. The insertion technique has evolved, thanks to ultrasound guided venipuncture, tunneling, and ultrasound based intraprocedural tip location. Insertion of femorally inserted central catheters may be today regarded as a procedure with an extremely low intraprocedural and post-procedural risk. The risk of infection is reduced by the possibility of the exit site at mid-thigh, by the use of cyanoacrylate glue for sealing the exit site, and by appropriate intraprocedural strategies of infection prevention. The risk of catheter-related thrombosis is low, due to several concomitant strategies: a proper match between vein diameter and catheter caliber; an accurate intraprocedural assessment of tip location by ultrasound and/or intracavitary ECG; the consistent use of ultrasound guided venipuncture and micro-introducer kits; an adequate stabilization of the catheter at the exit site. The risk of mechanical complications and the risk of lumen occlusion are minimized when using polyurethane, power injectable catheters. All these novelties have brought a revolution in the field of femoral venous access, so that this route may be considered as safe and effective as other approaches to central venous catheterization.

Renal replacement therapy via popliteal vein for exhausted vascular access in emergency: A case report

A 59 year-old man was admitted as his left antecubital arterio-venous fistula was thrombosed, and hemodialysis could not be succeeded for the last two sessions. It was a brachio-basilic fistula without transposition, which also required thrombectomy 8 months ago, and had been created 18 months before. He had multiple catheter insertions during the period of 6 years. Following the failed catheter insertions from both jugular and femoral veins, an ultrasound-guided venography via the left popliteal vein demonstrated the intact left popliteal and femoral vein with well-developed collaterals at the level of occluded left iliac vein. A temporary hemodialysis catheter was placed through the popliteal vein with an antegrade manner under ultrasound guidance in prone position, which effectively worked during hemodialysis sessions afterwards. Transposition of basilic vein was performed. Following the wound recovery, arterialized basilic vein has started to be used effectively for hemodialysis, and the popliteal catheter was displaced.

Cannulation of the popliteal vein as an intraoperative emergency access in prone position: A case report

Many surgeries have to be performed in the prone position. Access to central vessels is very limited in this position. This requires forward planning with regard to the placement of a central venous catheter. Emergency situations or unexpected intraoperative events in prone position are challenging, as a conventional central venous access is not possible. We describe the cannulation of the popliteal vein in such a case. We report the case of a patient with severe intracerebral hemorrhage who was transferred to our emergency department where his clinical condition rapidly deteriorated. Due to the surgical approach, a prone position was necessary and preoperative central venous cannulation was not possible. We therefore performed an alternative vascular access in prone position using a ultrasound-guided cannulation of the popliteal vein. The cannulation of the popliteal vein described here can be carried out as a quick and easy feasible alternative in emergency situations in prone position. The ultrasound-guided catheter insertion succeeded without any problems and there was no evidence of a deep vein thrombosis after the intervention.