Internal Jugular Vein Cannulation in Prone Position

Abstract

Since 1970, prone decubitus (PD) has been used as adjuvant therapy to treat severe hypoxia in patients with acute respiratory distress syndrome (ARDS), and now with the COVID-19 pandemic, its use has become widespread in ICUs. ARDS is characterized by diffuse bilateral radiographic infiltrates, decreased respiratory compliance, small lung volumes, and severe hypoxemia. The placement of vascular access in PD seems to be feasible and safe, since, as has been described, the number of complications such as pneumothorax, bleeding, and arterial punctures are almost nil, especially when performed under ultrasound guidance. The patients who could benefit most from this procedure seem to be those with obesity, mainly with a body mass index greater than 30 kg/m², in whom the return to the supine position may represent a risk of respiratory or hemodynamic deterioration.

To the Editor:

We read with exceptional interest the article by Lussier et al (1) published in a recent issue of Critical Care Explorations. In which a commendable case series has been performed, reporting 36 cases of internal jugular vein cannulation in the prone position. Since 1970, prone decubitus (PD) has been used as adjuvant therapy to treat severe hypoxia in patients with acute respiratory distress syndrome (ARDS), and now with the COVID-19 pandemic, its use has become widespread in ICUs (2).

ARDS is characterized by diffuse bilateral radiographic infiltrates, decreased respiratory compliance, small lung volumes, and severe hypoxemia (3). The physiologic effects of PD positioning in patients with severe lung injury manifest as improvements in oxygenation and respiratory mechanics. There may also be a reduction in the mechanical factors associated with ventilator-induced lung injury, such as in homogeneous pleural pressure distribution, alveolar inflation and ventilation, increased lung volume, and reduction of atelectasis lung regions, finally favoring secretion clearance (3).

Significantly, favorable survival effects have been demonstrated when PD was applied for 12 to 16 consecutive hours in the most severe forms of respiratory failure, Pao₂/Fio₂ less than 150 mm Hg (4). The COVID-19 pandemic popularized the use of noninvasive ventilation devices such as high-flow nasal cannula and PD-associated invasive mechanical ventilation.

However, the potential exposure to aerosols, exhaustion of personnel and health systems conducive to PD episodes for a period longer than 16 hours hindered the procedures usually applied to critically ill patients. We know that critical patients require prolonged infusions of drugs such as vasopressors, sedatives, antibiotics, and electrolytes or develop a renal injury that requires replacement therapy, so the placement of vascular access (VA) is a priority.

Currently, the use of ultrasound at the bedside of critically ill patient has become popular; one of its main uses is the placement of VA, which has shown a significant decrease in the number of complications. In 2010, Sofi and Arab (5) described for the first time the placement of a VA in PD, in a patient with severe bleeding after fixation of an acetabulum fracture. In 2021, Lima and Cheung (2) published the largest case series, up to that time, of VA placed on PD. In 2022, our working group published a series of seven cases of VA in PD, three of which were placed in the internal jugular vein (6). We consider that it would be important to analyze some points on which we agree with Lussier et al (1). First, the placement of VA in PD seems to be feasible and safe, since, as has been described, the number of complications such as pneumothorax, bleeding, and arterial punctures are almost nil, especially when performed under ultrasound guidance. Second, the patients who could benefit most from this procedure seem to be those with obesity, mainly with a body mass index greater than 30 kg/m², in whom the return to the supine position may represent a risk of respiratory or hemodynamic deterioration. Finally, we agree that there is still a lack of evidence to clarify and protocoled a technique, so large-scale research is necessary.