Hemodialysis vascular access in prone position for critically ill patients with ARDS

Introduction: Acute respiratory distress syndrome (ARDS) is defined in critically ill patients with acute hypoxemia and positive-pressure ventilation in association with several clinical disorders including trauma, pneumonia, sepsis, and aspiration. The prone position has been used for many years and is now recommended for patients with severe or moderate-to-severe ARDS on invasive mechanical ventilation. Acute kidney injury (AKI) is a common complication in patients with ARDS, with up to a 35% incidence rate. Initiation of Kidney Replacement Therapy (KRT) requires wise clinical judgment and collaboration between nephrologists and intensivists. A properly functioning vascular access is critical for an optimized KRT. Our institute is a national referral center for respiratory diseases.

Results: We describe 11 cases of dialysis catheter placement for KRT in critically ill patients with ARDS on mechanical ventilation in prone position. The catheter was placed in the first puncture attempt in nine cases, Blood flows (Qb) achieved were 283.4 ± 20.4 ml/min during the session, in six cases the radiologic tip location was achieved in the peri cavoatrial junction; in four cases was achieved in mid to- deep right atrium. The dialysis quality standards were based on KTV and in URR; in nine cases (81.81%) KTV was in 1.3 and in all cases (100%) URR was >65%, lumen dysfunction was reported only in two cases (18.1%), but these cases did respond to mobilization maneuvers. The procedure time of placement was 29.8 min, no arterial punctures or complications were reported.

Conclusions: We demonstrate that in our study hemodialysis non-tunneled catheter placement in the prone position is safe and effective. We believe this practice could be frequently used in the near future and represent an opportunity window for the training of interventional nephrologists and related areas.