Achieving a popliteal venous access for renal replacement therapy in critically ill COVID-19 patient in prone position

Abstract

This patient is a 67-year-old man who initially presented to our facility with acute respiratory failure secondary to COVID-19. Soon after arrival at our facility, the patient decompensated, developing severe acute respiratory distress syndrome requiring intubation and prone positioning to maintain adequate oxygenation. During the next few days, acute kidney injury with oliguria and severe volume overload developed. The vascular surgery service was consulted to obtain central venous access for emergent continuous renal replacement therapy. On examination, the patient was sedated and paralyzed in a rotating prone-positioning bed. He could not be positioned supine without immediately becoming hypoxic and decompensating. A 50-cm Permcath (Medtronic, Santa Rosa, Calif) was inserted through the left popliteal vein. This case report outlines a possible challenging scenario that the vascular interventionist may encounter in dealing with COVID-19 patients with respiratory compromise in the prone position.

Prone positioning as an emerging tool in the care provided to patients infected with COVID-19: a scoping review

“…This finding is corroborated by a case report that used popliteal venous access to enable renal replacement therapy in a critical patient with COVID-19 who was in PP. This procedure was justified by the difficulty in finding another site to puncture the intravenous route (43) .…”

Renal replacement therapy by the popliteal vein in a critical patient with COVID-19 in the prone position

“…The popliteal vein is easily accessible in patients with SARS-CoV-2 in the prone position and in need of RRT 1 . In addition, it avoids access to the internal jugular veins and subclavian veins, thus reducing the risk of contamination and central venous stenosis, as these patients, for the most part, require prolonged hospitalization 1 . Regarding disadvantages, this access method is highly operator-dependent, requiring familiarization with the anatomy of the popliteal fossa and the use of an ultrasound device 1 .…”

“…In addition, it avoids access to the internal jugular veins and subclavian veins, thus reducing the risk of contamination and central venous stenosis, as these patients, for the most part, require prolonged hospitalization 1 . Regarding disadvantages, this access method is highly operator-dependent, requiring familiarization with the anatomy of the popliteal fossa and the use of an ultrasound device 1 . Another disadvantage is the risk of deep vein thrombosis, although this risk appears to be the same compared with catheters inserted in the jugular or subclavian veins 1 .…”

“…Regarding disadvantages, this access method is highly operator-dependent, requiring familiarization with the anatomy of the popliteal fossa and the use of an ultrasound device 1 . Another disadvantage is the risk of deep vein thrombosis, although this risk appears to be the same compared with catheters inserted in the jugular or subclavian veins 1 . In our limited experience, this complication did not occur.…”

Proposed Algorithm for Treatment of Pulmonary Embolism in COVID-19 Patients

“… Prone position and the possible need to access popliteal or jugular veins for interventions. 23 In popliteal vein access, the length of the catheter needs to be determined, and 135 cm may be considered. The patient may have other contraindications to systemic thrombolysis, warranting catheter-directed therapy even in high-risk patients …”