ABSTRACT
INTRODUCTION: A significant number of patients with ARDS secondary to Covid-19 pneumonia require prone positioning. Common practice is to return patients to a supine position prior to performing invasive bedside procedures such as central venous access. This may present prohibitive risk in patients with refractory hypoxemia. DESCRIPTION: We present the case of a 46 year old male, admitted to the ICU with Covid-19 pneumonia complicated by ARDS. Intermittent prone positioning was initiated. The patient remained with refractory hypoxemia despite prone positioning, optimal ventilator settings and inhaled epoprostenol. The length of time the patient could be supine progressively decreased. The patient developed AKI necessitating hemodialysis (HD) catheter placement. Attempts to supine patient to perform HD catheter placement resulted in near cardiorespiratory arrest. It was decided to attempt HD catheter placement in the RIJ vein via a posterior lateral approach with the patient prone. Patient was brought to the head of the bed allowing the chin to rest on the edge of the bed with head turned laterally and endotracheal tube supported by the respiratory therapist. The patient was placed in an oblique "swimming position" by aid of a pillow under the center torso and right shoulder girdle. An optimal insertion site was selected via real time ultrasound guidance. Utilizing a micropuncture needle, guidewire, and dilator, a 15cm 12 Fr BARD hemodialysis catheter was placed using a standard Seldinger technique. DISCUSSION: Our experience indicates that a posterior lateral approach for CVC placement is a viable option. Given the complexity of this procedure and the paucity of case reports describing it, we felt it prudent to share our approach. Structures of interest to avoid in posterior approach to the RIJ include the phrenic nerve traveling along the scalenus anterior muscle tissue posterior to the internal jugular vein. Accessing the vein below the omohyoid muscle offers the best opportunity to avoid the phrenic nerve and the scalenus. A steep 90 degree angle to access the RIJ was intentionally attempted to minimize the amount of soft tissue to dilate. Utilizing this approach allowed us to safely and effectively place the line without immediate complications.
ABSTRACT
During the COVID-19 pandemic, the lives of healthcare professionals are at significant threat because of the enormous workload and cross-infection risk. Ultrasound (US) imaging plays a vital role in the diagnosis and follow-up of COVID-19 patients;however, it requires a close-physical contact by the sonographer. In this context, this paper presents a Telerobotic Ultrasound (TR-US) system for complete remote control of the US probe, thereby preventing direct physical contact between patients and sonographers. The system consists of a 6-DOF robot arm at the remote site and a haptic device at the doctor's site. The control architecture precisely transmits the intended position and orientation of the US probe to the remote location for transversal and sagittal plane scanning. This architecture, when integrated with an admittance controller-based force modulation and feedback transmission, enables the radiologists to obtain high-quality images for diagnosis. The advantages and effectiveness of the system are demonstrated by conducting in-vivo feasibility study at AIIMS, Delhi, for imaging abdomen organs (liver, spleen, kidneys, bladders). The system provides image quality equivalent to a manually-guided probe, can identify various pathology and reports high acceptability among volunteers and doctors from a questionnaire survey.