Atlas of Procedures in Neonatology, 4th Edition

Vascular Access

28

Umbilical Artery Catheterization

Brett M. Wortham

Chrysanthe G. Gaitatzes

Khodayar Rais-Bahrami

  1. Indications

Catheters should remain in place only as long as primary indications exist, with the exception of secondary indication A.3. Because of the risk of complications, catheters should usually not remain in place for more than 2 weeks.

Primary

  1. Frequent or continuous (see Chapter 9) measurement of lower aortic blood gases for oxygen tension (PO2) or oxygen content (percent saturation)
  2. Continuous monitoring of arterial blood pressure
  3. Angiography
  4. Resuscitation (use of umbilical venous line may be first choice)

Secondary

  1. Infusion of maintenance glucose/electrolyte solutions or medications. If this line is to be used to provide intravenous nutrition, the same aseptic techniques must be used to prevent line-related sepsis as are used for any central line. See Chapter 31.
  2. Exchange transfusion
  3. To provide vital infusions (1) and a port for frequent blood sampling in the extremely low-birthweight infant.
  4. Contraindications
  5. Evidence of local vascular compromise in lower limbs or buttock areas
  6. Peritonitis
  7. Necrotizing enterocolitis (2)
  8. Omphalitis
  9. Omphalocele
  10. Acute abdomen etiology
  11. Equipment

Several standardized graphs for premeasurement of catheter length to be inserted are available (Figs. 28.1 28.2 and 28.3).

Sterile

  1. Sterile gown and gloves
  2. Cup with antiseptic solution
  3. Surgical drape with central aperture (transparent drape recommended)
  4. Catheter
  5. Single hole
  6. Reduces surfaces for potential thrombus formation
  7. Recorded pressure tracing will change when hole is occluded.
  8. Made of flexible material that does not kink as it follows the curves of vessels
  9. Relatively rigid walls with frequency characteristics suitable for accurate measurement of intravascular pressure
  10. Small capacity (minimum volume of blood to be withdrawn to clear catheter prior to blood sampling)
  11. Radio-opaque (the need to visualize the catheter position on x-ray film outweighs the theoretical risk of increased thrombogenicity related to a radio-opaque strip) (3)
  12. Smooth, rounded tip (4), nonthrombogenic material (5)
  13. 5-French (Fr) gauge for infants weighing >1,200 g
  14. 3.5-Fr gauge for infants weighing <1,200 g
  15. Scissors for cutting catheter
  16. Blunt needle adapter (if using catheter without hub)
  17. No. 18 for 5-Fr catheter
  18. No. 20 for 3.5-Fr catheter
  19. Three-way stopcock with Luer-Lok
  20. 10-mL syringe
  21. 0.25 to 0.5 N saline flush solution (saline with heparin, 1 to 2 U/mL)
  22. In very small premature infants, particularly in the first week of life, hypernatremia may result from receiving excess sodium in flush solutions. We recommend using 0.25 N rather than more concentrated saline solutions (6). Use of heparinized flush solution is common

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practice. Rajani and others (7,8) have shown that using a heparinized solution containing 1 U heparin/mL for flushing the umbilical arterial line prolonged catheter life by reducing the incidence of fibrin thrombus formation in the catheter lumen. Horgan et al. (9) found that the use of 1 U/mL heparin did not reduce the incidence of umbilical artery catheter (UAC)-related thrombi but did lower the incidence of their sequelae. Butt et al. (10) could demonstrate no significant benefit associated with increasing the rate of infusion from 1 to 2 mL/h (heparin 1 U/mL), and Bosque and Weaver (11) showed that continuous infusion of 1 U/mL heparin is more effective than intermittent infusion in maintaining patency of the UAC. More recent data have indicated that heparin decreases the incidence of thrombotic complications (12), and a Cochrane Database Review found that the use of as little as 0.25 U/mL heparin in the infusate decreases the likelihood of line occlusion (13).

  1. Tape measure
  2. 20-cm narrow umbilical tie
  3. No. 11 scalpel blade and holder
  4. 4- x 4-in gauze sponges
  5. Two curved mosquito hemostats
  6. Toothed iris forceps
  7. Two curved, nontoothed iris forceps
  8. 2% lidocaine HCl without epinephrine
  9. 3-mL syringe and needle to draw up lidocaine
  10. Small needle holder
  11. 4-0 silk suture on small, curved needle
  12. Suture scissors
 

FIG. 28.1. Graph for determination of length of catheter to be inserted for appropriate low aortic or venous placement. Length of catheter is measured from umbilical ring. Length of umbilical stump must be added. The shoulder–umbilicus distance is the perpendicular distance between parallel horizontal lines at the level of the umbilicus and through the distal ends of the clavicles. (Adapted from 

Dunn P. Localization of the umbilical catheter by postmortem measurement. Arch Dis Child. 1966; 41:69

, with permission.)

 

FIG. 28.2. A: Graph for distance of catheter insertion from the umbilical ring for L3, L5, and aortic bifurcation. Large dots represent catheters positioned at L4. B: Graph for catheter insertion to level T8 using total body length. (From 

Rosenfeld W, Biagtan J, Schaeffer H, et al. Evaluation of graphs for insertion of umbilical artery catheters below the diaphragm. J Pediatr. 1981;98:628

, with permission.)

Nonsterile

  1. Cap and mask
  2. Wooden tongue depressor
  3. Precautions
  4. Avoid use of feeding tubes as catheter (associated with higher incidence of thrombosis) (14).
  5. Fold drapes so as not to obscure infant's face and upper chest.

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  1. Take time and care to dilate lumen artery before attempting to insert catheter.
  2. Catheter should not be forced past an obstruction.
  3. Never advance catheter once placed and secured.
  4. Loosen umbilical tie slightly upon completion of procedure and obtain radiographic confirmation of position.
  5. Avoid covering the umbilicus with dressing. Dressing may delay recognition of bleeding or catheter displacement.
  6. Always obtain radiographic or ultrasound (15,16) confirmation of catheter position. If doubt remains, obtain a lateral radiographic study (17,18).
  7. Be certain that catheter is secure, and examine frequently when infant is placed in prone position, because hemorrhage may go unrecognized.
  8. Take care not to allow air to enter the catheter. Always have catheter fluid filled and attached to closed stopcock prior to insertion. Check for air bubbles in catheter before flushing or starting infusion.
  9. When removing catheter, cut suture at skin, not on catheter, to avoid catheter transection.
 

FIG. 28.3. Estimates of insertion length of umbilical catheters (umbilical artery catheter tip inserted between T6 and T10; umbilical vein catheter tip inserted above diaphragm in inferior vena cava near right atrium) based on birthweight (BW) (with 95% confidence intervals). Modified estimating equations utilizing BW are as follows: umbilical artery length = 2.5 BW + 9.7 (top) and umbilical vein length = 1.5 BW 5.6 (bottom), where BW is measured in kilograms and lengths are measured in centimeters. (From 

Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child. 1986;140:787

, with permission.)

  1. Technique (See also Umbilical Catheterization on the Procedures DVD)

Anatomic note: The umbilical arteries are the direct continuation of the internal iliac arteries. Their diameters at their origins are 2 to 3 mm. As they approach the umbilicus, their lumina become small and the walls thicken significantly. In a full-term infant, each artery is approximately 7.0 cm long (Fig. 28.4). A catheter introduced into the umbilical artery will usually pass into the aorta from the internal iliac artery. Occasionally, it will pass into the femoral artery via the external iliac artery or into one of the gluteal arteries. The latter two sites are unsuitable for sampling, pressure measurement, or infusion.

  1. Choose either of two positions (Fig. 28.5).

High position is associated with fewer episodes of blanching and cyanosis of the lower extremities (19). High catheters were found to have decreased incidence of clinical vascular complications with a relative risk of 0.53 (95% confidence interval, 0.44 to 0.63) with no statistically significant increase in any adverse sequelae, including the incidence of hypertension, intraventricular hemorrhage, hematuria, necrotizing enterocolitis, or death (20).

  1. Low position(21,22 and 23): Level of lumbar vertebrae 3 to 4 (Fig. 28.6)
  2. Catheter tip is below major aortic branches such as renal mesenteric arteries.
  3. In most newborns, this position coincides with the aortic bifurcation at the upper end of the fourth vertebra.
  4. High position(14,19,24): Level of thoracic vertebrae 6 to 9 (Fig. 28.7); catheter tip above origin of celiac axis
  5. Make external measurements as necessary to estimate length of catheter to be inserted (see Figs. 28.1,28.2 and 28.3) (25,26,27,28,29,30 and 31).
  6. Prepare as for major procedure (see Chapter 4).

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FIG. 28.4. Anatomic relations of the umbilical arteries, showing relationships with major arteries supplying buttocks and lower limb.

 

FIG. 28.5. The aorta and branches.

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  1. Attach stopcock to hub of catheter and fill system with flush solution. Turn stopcock “off” to catheter. If catheter does not have a hub, cut flared end of catheter with scissors and insert blunt needle adapter of appropriate size. This will reduce catheter dead space.
  2. Place sterile gauze around umbilical stump and elevate out of sterile field, or have ungloved assistant grasp cord by cord clamp or forceps and pull cord vertically out of sterile field.
  3. Prepare cord and surrounding skin with antiseptic solution to radius of approximately 5 cm. The use of chlorhexidine in infants <2 months of age is not suggested (32).
  4. Drape area surrounding cord.
  5. Place umbilical tie around umbilicus and tie loosely with a single knot.
  6. Tighten only enough to prevent bleeding and place, if possible, around Wharton jelly rather than skin.
  7. It may be necessary to loosen the tie when inserting the catheter.
 

FIG. 28.6. Anteroposterior (A) and lateral (B) radiographs showing optimal low position of an umbilical artery catheter. Catheter tip is at the level of the superior margin of the fourth lumbar vertebral body, which in newborns usually corresponds to the aortic bifurcation.

  1. Cut cord horizontally with scalpel (Fig. 28.8).

 .   Approximately 1 to 1.5 cm from skin

  1. Avoid tangential slice.

Bloom et al. (33) have described an alternative approach to the artery with lateral arteriotomy. To perform this method, 3 to 4 cm of cord must be preserved because the cord must be rolled over a Kelly clamp 180 degrees (33,34).

  1. Clamp across end of cord with a mosquito hemostat in the nondominant hand and pull firmly toward the infant's head.
  2. Roll cord 180 degrees over hemostat toward abdominal wall.
  3. Identify arteries in superior right and left lateral aspects of cord.
  4. Approximately 1 cm from abdominal wall, incise Wharton jelly down to arterial wall, using no. 11 scalpel blade.
  5. Incise artery through half of circumference. If necessary, dilate lumen with iris forceps.
  6. Insert catheter into lumen of artery, directed in a caudad direction, for predetermined distance.
  7. Control bleeding by gentle tension on umbilical tape.
  8. Blot surface of cord stump with gauze swab. Avoid rubbing, because this damages tissue and obscures anatomy.

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FIG. 28.7. Umbilical arterial catheter in satisfactory high position at the level of the ninth thoracic vertebral body on anteroposterior (A) and lateral (B) projections.

  1. Identify cord vessels (Fig. 28.9).

 .   Vein is easiest to identify as large, thin-walled, sometimes gaping vessel. It is most frequently situated at the 12 o'clock position at the base of the umbilical stump.

  1. Arteries are smaller, thick-walled, and white and may protrude slightly from cut surface.
  2. Omphalomesenteric duct is rarely present.
 

FIG. 28.8. Traction is being placed on cord in direction of the arrow. Operator is about to make a horizontal cut across cord.

 

FIG. 28.9. The vessels of the umbilical cord. Thin-walled umbilical vein at 12 o'clock position is indicated by a white arrow. One of the two umbilical arteries is to the right and directly below the vein.

  1. Grasp cord stump, using toothed forceps, at point close to (but not on) artery to be catheterized. If available,

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it may be helpful to have an assistant scrub and assist.

  1. Apply two curved mosquito hemostats to Wharton jelly on opposite sides of cord, away from vessel to be cannulated.
  2. Apply traction to stabilize cord stump.
 

FIG. 28.10. An iris forceps is pointed into the umbilical artery in order to dilate the lumen of the artery.

 

FIG. 28.11. A: Inserting the catheter into the artery between the prongs of dilating forceps. Note that the umbilical tape has been tied around the skin of the umbilicus; this should be loosened once the catheter is secured in place. B: Close-up photo of the umbilical stump with the arterial catheter in place.

  1. Introduce one of the points of the curved iris forceps into the lumen of the artery and probe gently to a depth of 0.5 cm.
  2. Remove forceps and bring points together before introducing them once more into the lumen.
  3. Probe gently to a depth of 1 cm (up to the curved “shoulder” of the forceps), keeping the points together.
  4. Allow the points to spring apart, and maintain forceps in this position for 15 to 30 seconds to dilate vessel (Fig. 28.10). Time spent in ensuring dilatation prior to catheter insertion increases the likelihood of success.
  5. Release cord and set aside toothed forceps, while keeping curved forceps within artery.
  6. Grasp catheter 1 cm from tip, between free thumb and forefinger or with curved iris forceps.
  7. Insert catheter into lumen of artery, between prongs of dilating forceps (Fig. 28.11).
  8. Remove curved forceps, having passed catheter approximately 2 cm into vessel with a firm, steady motion. Grasp cord again with toothed tissue forceps and pull gently toward head of infant. This mild traction will facilitate passage of catheter at an angle between the cord and the abdominal wall.
  9. After passing the catheter approximately 5 cm, aspirate to verify intraluminal position. Clear blood by injecting 0.5 mL of flush solution. The catheter may now be used to measure blood gases.
  10. Take appropriate action if insertion is complicated (Fig. 28.12).

 .   Resistance before tip reaches abdominal wall (<3 cm from surface of abdominal stump)

  1. Loosen umbilical tape.
  2. Redilate artery.
  3. “Popping” sensation rather than “relaxation”

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FIG. 28.12. Some reasons for failure of umbilical artery catheterization. A: Sagittal midline section to show normal anatomy of umbilical artery. B: Catheter has perforated the umbilical artery within the anulus umbilicalis and is dissecting perivascularly and external to peritoneum. C: Catheter has ruptured through the tunica intima (t.i.) and dissected into subintimal space. D:Catheter invaginating the tunica intima after stripping it from a more distal point. (Adapted from 

Clark JM, Jung AL. Umbilical artery catheterization by a cut down procedure. Pediatrics (Neonatol Suppl). 1977;59:1036

, with permission of American Academy of Pediatrics.)

  1. Catheter may have exited lumen and created a false channel.
  2. Remove and use a second artery.
  3. If unsuccessful, draw 0.5 mL of lidocaine from vial. Reinsert tip of catheter approximately 2 cm into UAC and drip lidocaine into vessel. Apply constant gentle pressure until vessel dilates.
  4. Backflow of blood, particularly around vessel
  5. Tighten umbilical tape.
  6. Catheter may be in false channel, with extravascular bleeding.
  7. Resistance is encountered at anterior abdominal wall or sharp turn in vessel as it angles around bladder toward internal iliac artery (approximately 6 to 8 cm from surface of umbilical stump in 2- to 4-kg neonate).
  8. Apply gentle but steady pressure for 30 to 60 seconds.
  9. Position infant on side with same side elevated as artery being catheterized. Flex hip.
  10. Instill lidocaine as for 23.b (3). Do not force catheter.

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  1. Easy insertion, but no blood return
  2. Catheter is outside vessel in false channel.
  3. Remove and observe infant carefully for evidence of complication.
  4. Place marker tape on catheter with base of tape flush with surface of cord, so that displacement of the catheter may be readily recognized.
  5. Remove umbilical tape and place purse-string suture around base of the cord (not through skin or vessels). Three bites into cord (with needle facing away from catheter) are sufficient to include all three vessels within the suture.

If desired, form marker tape into bilateral wings, and sew the tails of the purse-string suture through the wings to anchor the catheter in a symmetrical fashion. This is a useful method in very small premature infants because it avoids sticking tape to the abdominal wall (35). Or remove needle and wrap ends of suture in opposite direction around catheter for about 3 cm and tie, taking care not to kink catheter.

  1. Secure catheter temporarily by looping over upper abdomen and taping.
  2. Obtain radiograph or ultrasound (see D.8) to check catheter position.

 .   Catheter tip above T6 or between T11 and L2

  1. Measure distance between actual and appropriate position on radiograph.
  2. Withdraw equal length of catheter.
  3. Repeat radiographic study.
  4. Note procedure in chart.
  5. Catheter tip below L5
  6. Remove catheter.
  7. Never advance catheter once in situ, because this will introduce a length of contaminated catheter into the vessel.
  8. If desired, secure catheter with tape bridge (Fig. 36.14).
  9. Continue routine cord care with triple dye or other agent of choice.
  10. Stabilize catheter, stopcock, and syringe, using tongue depressor (optional).

 .   Reduces risk of air embolus if syringe is maintained in vertical position

  1. Prevents accidental disconnection of catheter system
  2. Alternative Technique: Umbilical Artery Cutdown

This method is usually successful even after failed insertion through the umbilical stump, as there is less tendency for false tracts. The most frequent reason for failed umbilical artery cutdown is mistaking the urachus for a vessel. Because of the time and risks associated with the cutdown procedure, standard insertion should be attempted first.

Indications

  1. Failed umbilical artery catheterization through conventional technique described earlier in this chapter

Contraindications

  1. Same as for umbilical artery catheterization by conventional technique
  2. Bleeding diathesis

Equipment

  1. Same as for umbilical artery catheterization by conventional technique.
  2. 1% lidocaine HCl without epinephrine in 3-mL syringe with 25- to 27-gauge needle
  3. No. 15 surgical blade and holder
  4. Curved delicate dressing forceps, two pairs (1/4 or 1/2 curved)
  5. Tissue forceps
  6. Self-retaining retractor (such as eyelid retractor)
  7. Absorbable suture, plain
  8. Absorbable suture on small cutting needle
  9. Nonabsorbable suture on a small, curved needle
  10. Needle holder
  11. Suture scissors
  12. Skin-closure tapes

Precautions

  1. Same as described earlier for conventional technique.
  2. If possible, leave catheter from previously attempted standard procedure in place to aid in vessel identification.
  3. Ensure that abdominal incision is on abdominal wall and not too close to umbilical stump.
  4. Identify landmarks carefully to avoid cutting or catheterizing urachus.
  5. When incising mesenchymal sheath, take care to avoid transecting vessel.
  6. Secure the catheter with an internal ligature that is just tight enough to prevent accidental removal but loose enough for elective removal or reinsertion in case the catheter becomes occluded by thrombus or precipitate.

Technique (36,37)

  1. See Fig. 28.13.
  2. Insert an oral gastric tube to keep the bowel as decompressed as possible.
  3. Prepare infant and drape as for umbilical artery catheterization (see earlier in chapter).

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  1. If catheter has been left in place after previous attempt, include vessel and catheter in the preparation, leaving the catheter accessible for removal.
  2. Anesthetize area of skin immediately below umbilicus, at umbilical stump–abdominal wall junction, with 0.5 mL of lidocaine.
  3. Prepare umbilical artery catheter as for standard procedure, leaving catheter filled with flush solution. Estimate length for insertion based on patient size. Subtract 1 to 2 cm from that recommended for standard insertion, as cutdown catheter will enter vessel farther along course.
  4. Make a smile-shaped incision from 4 to 8 o'clock through the skin of the abdominal wall at the junction with the umbilical stump.
  5. Place self-retaining retractor to maintain exposure.
  6. Using blunt dissection through the subcutaneous tissue with mosquito forceps, identify the fascia overlying the urachus and umbilical vessels.

The mesenchymal sheath is composed of three layers of fascia and is from 1 to 3 mm thick. Although it is barely perceptible in extremely premature infants, in term infants it may be thick enough to require making an incision through the sheath prior to blunt dissection.

  1. While elevating the fascia with two forceps, make a small incision between their tips. Enlarge incision with scissors to the same size as skin incision. In very immature infants, simple dissection should suffice.
  2. With curved mosquito forceps, dissect in the midline and identify the urachus (Fig. 28.13).
 

FIG. 28.13. Subumbilical cutdown. Anatomic view through incision. (Redrawn from 

Sherman NJ. Umbilical artery cutdown. J PediatrSurg. 1977;12:723

, with permission.)

  1. The urachus is a white, glistening, cordlike structure in the midline. Its position may be confirmed by traction cephalad, pulling the dome of the bladder into view. The umbilical arteries lie posterolaterally on either side but not touching the urachus.
  2. Identify the umbilical arteries lying to either side of the urachus.

The vessels with their surrounding tissues appear larger than expected. When elevated, there will be no caudal bulge, distinguishing them from the urachus. If a previously attempted catheter was left “in place,” palpation of the area allows more ready identification of the vessel. Previously unsuccessful attempts, with failure to pass more than a few centimeters, are usually associated with perivascular hematoma formation from unrecognized perforation and dissection through a false tract. Visualization of a hematoma helps distinguish the vessel from the urachus.

  1. Try to avoid entering the peritoneum. In infants with very little subcutaneous tissue, it may be impossible to avoid penetrating the peritoneum. Should this occur, replace any bowel that may protrude and carefully close the peritoneum with absorbable suture, taking extreme care not to include any bowel within the suture. Start antibiotics for peritonitis prophylaxis.
  2. Insert the tip of the mosquito forceps under the vessel and pull a doubled strand of plain absorbable suture under the vessel. Position sutures 1 cm apart.
  3. While elevating the sutures and with suture scissors directed cephalad, make a V-shaped incision through three fourths of the diameter of the vessel. Take care not to transect the vessel, but cut cleanly into the lumen.

If the artery is accidentally transected and if the catheter insertion is unsuccessful, tie off the caudal end of the artery to prevent hemorrhage.

  1. Use curved tissue forceps or a catheter introducer to dilate the artery.
  2. Pass the catheter through the opening for the predetermined distance, checking for blood return after a few centimeters. The catheter should advance without resistance.
  3. When the catheter is properly positioned, have an assistant check the perfusion in the lower extremities. If that is satisfactory, secure the catheter by tying the lower ligature firmly around the catheter.
  4. Using absorbable suture, close the fascia and approximate the subcutaneous tissues.

Hashimoto et al. (38) proposed an alternative technique that allows for catheter reinsertion in case of catheter thrombosis or occlusion. They use loose ligation around the artery once the catheter is in proper

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position. They then fix the artery by using the same sutures that close the fascia, thus creating an arteriocutaneous fistula, making it easy to find the insertion site and use it for reinsertion.

  1. Close the skin with nonabsorbable suture or with skin-closure tape after cleaning the area.
  2. The catheter may be further secured with a tape bridge (Fig. 36.14).

Removal of catheter

  1. Remove any tape and withdraw catheter slowly as described earlier in this chapter.
  2. If the internal ligature around a catheter is too tight to allow removal with reasonable traction, it may be necessary to dissect and cut the ligature after sterile skin preparation.
  3. Apply pressure for hemostasis.
  4. Approximate wound edges with skin-closure tape.

Complications

  1. Catheterization of urachus (39)
  2. Vesicoumbilical fistula (39)
  3. Transection of urachus with urinary ascites (40)
  4. Perforation (41,42 and 43) or rupture (44) of urinary bladder— although Nagarajan (45) has suggested that the risk of bladder injury is minimal if bladder is emptied prior to procedure.
  5. Transection of umbilical artery with hemorrhage
  6. Incision of peritoneum (with possible evisceration)
  7. Bleeding from incision
  8. Care of Dwelling Catheter

For setup and maintenance of arterial pressure transducer, see Chapter 8.

  1. Keep catheter free of blood to prevent clot formation.
  2. Flush catheter with 0.5 mL of flush solution, slowly over at least 5 seconds, each time a blood sample is drawn.
  3. Between samples, infuse intravenous solution continuously through catheter to prevent retrograde flow.
  4. Note amounts of blood removed and intravenous fluid/flush solution infused, and add to fluid balance record.
  5. Watch for indications of clot formation.
  6. Decrease in amplitude of pulse pressure on blood pressure tracing
  7. Difficulty withdrawing blood samples
  8. Take appropriate action if clot forms.
  9. Do not attempt to flush clot forcibly.

Remove catheter. Replace only if critical line.

If further assistance is needed, the International Children's Thrombophilia Network is available to answer questions at 1-800-NO-CLOTS.

  1. Avoid enteral feedings with catheter in situ if possible. Increased risk of mesenteric thromboembolism has been suggested (46).
  2. Obtaining Blood Samples from Catheter

(With emphasis on aseptic technique and minimizing stress to the vessel)

Equipment

  1. Gloves
  2. Alcohol swabs
  3. Rubber-tipped clamps or disposable intravenous tubing clamps
  4. Syringe of 0.6 mL of flushing solution
  5. Syringe for cleaning line
  6. Syringe for blood sample
  7. Ice, if necessary for sample preservation
  8. Appropriate requisition slips and labels

Technique

  1. Wash hands and put on sterile gloves.
  2. Form sterile field.
  3. Clean the connection site of the stopcock/catheter using an alcohol swab.
  4. Clamp the umbilical catheter.
  5. Connect the 3-mL syringe, release the clamp, and slowly draw back 2 to 3 mL of fluid over 1 minute to clear the line. Reclamp the catheter. Remove syringe and place on sterile field. Data published by Davies et al. (47) indicate that accurate measurements of electrolytes can be obtained after withdrawal of a minimum of 1.6 mL of blood. However, if blood glucose values are desired, a minimum of 3 mL from a 3.5-Fr and 4 mL from a 5-Fr catheter must be withdrawn.
  6. Attach sampling syringe. Release clamp and draw back specimen desired. Reclamp the catheter.
  7. Reattach the syringe containing the fluid and blood cleared from the line.
  8. Clear the connection of air.
  9. Slowly replace the fluid and blood cleared from the line and remove the syringe.

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FIG. 28.14. Various umbilical artery catheter (UAC) malpositions. A: Unacceptable position at L2 because of the proximity of the renal arteries. B: UAC in left brachycephalic artery. C: UAC in right brachycephalic artery. D: UAC in pelvic artery.

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  1. Attach the syringe of flushing solution to the stopcock, clear air from the connection, and slowly flush the line.
  2. Clean the stopcock connection with alcohol.
  3. Record on infant's daily record sheet all blood removed and volume of flush used.

A study was carried out that looked at cerebral oxygenation and blood sampling from UAC in high position preterm infants (median gestational age 30 weeks). Although the clinical significance is unclear, the study showed that blood sampling of 2.3 mL (including flush volumes) through the UAC within 20 seconds resulted in a significantly decreased cerebral oxygenated hemoglobin and tissue oxygenation index. It also caused an increase in deoxygenated hemoglobin. This was not seen when the sampling time was extended to 40 seconds (48).

  1. Removal of Umbilical Artery Catheter
 

FIG. 28.15. Anteroposterior (A) and lateral (B) radiographs demonstrating passage of an umbilical artery catheter into the pulmonary artery via a patent ductus arteriosus.

Indications

  1. No further clinical indication
  2. Need for less frequent direct PO2measurements
  3. Sufficient stabilization of blood pressure to allow intermittent monitoring
  4. Hypertension
  5. Hematuria not due to other recognizable cause
  6. Catheter-related sepsis and/or infections with Staphylococcus aureus, gram-negative bacilli, or Candida mandate removal of the catheter (49)
  7. Catheter-related vascular compromise
  8. Onset of platelet consumption coagulopathy
  9. Peritonitis
  10. Necrotizing enterocolitis
  11. Omphalitis

Technique

  1. Leave umbilical tie loose around cord stump as precaution against excessive bleeding.

Reinsertion of purse-string suture through dried Wharton jelly is preferable:

  1. Umbilical tape must be tied on skin rather than Wharton jelly.
  2. Catheter has been in situ for longer than 48 hours, because artery may have lost ability to spasm.
  3. Withdraw catheter slowly and evenly, until approximately 5 cm remains in vessel, tightening purse-string suture or umbilical tie.

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  1. Discontinue infusion.
  2. Pull remainder of catheter out of the vessel at rate of 1 cm/min (to allow vasospasm). If there is bleeding, apply lateral pressure to the cord by compressing between thumb and first finger.
  3. Complications (50,51,52,53,54 and 55)

Catheterization of the umbilical artery is probably always associated with some degree of reversible damage to the arterial intima (56,57).

  1. Malpositioned catheter (Figs. 28.14, 28.15 and 28.16) (46,58,59)
  2. Vessel perforation (58,60,61)
  3. Refractory hypoglycemia with catheter tip opposite celiac axis (62,63 and 64)
  4. Peritoneal perforation (65)
  5. False aneurysm (66,67,68,69,70 and 71)
  6. Movement of catheter tip position because of changes in abdominal circumference
  7. Sciatic nerve palsy (72,73)
  8. Misdirection of catheter into internal or external iliac artery (see Figs. 28.14D and 28.17) (50).

Schreiber et al. (56) have described a double-arterial catheter technique to correct this problem.

  1. Vascular accident
  2. Thrombosis (Fig. 28.18) (21,74,75,76,77 and 78)
  3. Embolism/infarction (Fig. 28.17) (18,35,79,80,81 and 82) seen days or weeks after line insertion (83)
  4. Vasospasm (18,83,84,85,86,87 and 88) is seen within minutes to a few hours after insertion.
  5. Loss of extremity (Fig. 28.19) (86)
  6. Hypertension (Fig. 28.20) (19,89,90,91,92,93,94 and 95)
  7. Paraplegia (96,97,98,99,100 and 101)
  8. Congestive heart failure (aortic thrombosis) (100)
  9. Air embolism (Fig. 28.21)

P.171

 

 

FIG. 28.16. Effect of abdominal mass stimulating catheter misplacement. Anteroposterior (A) and lateral (B) films show remarkable displacement of an umbilical artery catheter by a giant hematocolpos in a 1-day-old infant.

 

FIG. 28.17. Vascular compromise in the left buttock and loin owing to a complication of umbilical artery catheter displaced into the internal iliac artery. For vascular anatomy, see Fig. 28.4.

 

FIG. 28.18. Arrows indicate mural thrombus in the abdominal aorta, which was associated with an umbilical arterial line. Upon further dissection of this autopsy specimen, the left renal artery was found to be occluded by thrombus. The left kidney is showing a degree of atrophy. Both kidneys showed scattered infarction.

P.172

 

  1. Equipment-related
  2. Breaks in catheter and transection of catheter (58,85,97,102,103,104 and 105)
  3. Plasticizer in tissues (60,104)
  4. Electrical hazard (77)
  5. Improper grounding of electronic equipment
  6. Conduction of current through fluid-filled catheter
  7. Intravascular knot in catheter (105)
  8. Other
  9. Hemorrhage (including that related to catheter loss or disconnection and overheparinization) (50,79,85, 106,107 and 108)
  10. Infection (25,80,85,109,110,111,112,113,114,115,116,117 and 118)
  11. Necrotizing enterocolitis (46,86)
  12. Intestinal necrosis or perforation (119)
  13. Vascular accident
  14. Infusion of hypertonic solution (120)
  15. Transection of omphalocele (Fig. 28.22) (121)
  16. Herniation of appendix through umbilical ring (122)
  17. Cotton fiber embolus (123)
  18. Wharton jelly embolus (124)
  19. Hypernatremia
  20. True (6)
  21. Factitious (104)
  22. Factitious hyperkalemia (104)
  23. Bladder injury (ascites) (125,126 and 127)
  24. Curving back of the catheter on itself as a result of it catching in the intima (128)
  25. m Pseudo-coarctation of the aorta (129,130)
  26. Pseudo-mass in left atrium (131)
  27. Displacement by thoracoabdominal abnormality (132)
 

FIG. 28.19. Autoamputation of forefoot, owing to vascular complication of umbilical artery catheter.

 

FIG. 28.20. Generalized mottling of skin in infant with severe hypertension secondary to umbilical artery catheter-associated thrombus in renal artery.

 

FIG. 28.21. Anteroposterior roentgenogram demonstrating air embolism from an umbilical artery catheter in the left subclavian artery (upper arrow) and the femoral arteries (lower arrows).

P.173

 

 

FIG. 28.22. Small omphalocele. This gut-containing hernia was transected during placement of umbilical artery catheter.

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