Atlas of Procedures in Neonatology, 4th Edition

Vascular Access

29

Umbilical Vein Catheterization

Brett M. Wortham

Khodayar Rais-Bahrami

  1. Indications
  2. Primary
  3. Emergency vascular access for fluid and medication infusion and for blood drawing
  4. Central venous pressure monitoring (if catheter across ductus venosus)
  5. Exchange transfusion
  6. Secondary
  7. Long-term central venous access in low-birthweight infants. If the line is to be used long-term, particularly if parenteral nutrition is to be infused by this route, the same aseptic techniques must be used to prevent line-related sepsis as are used for any central venous line. See Chapter 31.
  8. Diagnosis of total anomalous pulmonary venous drainage below the diaphragm (1)
  9. Contraindications
  10. Omphalitis
  11. Omphalocele
  12. Necrotizing enterocolitis
  13. Peritonitis
  14. Equipment
  15. Catheter—same as for umbilical artery catheterization, except:
  16. 5-French (Fr) catheter for infants weighing <3.5 kg
  17. 8-Fr catheter for infants weighing >3.5 kg
  18. Catheter used for exchange transfusion (removed after procedure) should have side holes. This reduces risk of sucking thin wall of inferior vena cava against catheter tip, with possible vascular perforation (2).
  19. Other equipment as for umbilical artery catheter, but omit 2% lidocaine (see Chapter 28, C)
  20. Precautions
  21. Keep catheter tip away from origin of hepatic vessels, portal vein, and foramen ovale. Catheter tip should lie in ductus venosus or inferior vena cava (3). Sometimes it will not be possible to advance the catheter through the ductus venosus. Vigorous attempts to advance are to be avoided. In an emergency, vital infusions (avoid very hypertonic solutions) may be given slowly after pulling catheter back into umbilical vein (approximately 2 cm) and checking blood return.
  22. Check catheter position prior to exchange transfusion. Avoid performing exchange transfusion with catheter tip in portal system or intrahepatic venous branch (see F.4).
  23. Once secured, do not advance catheter into vein.
  24. Avoid infusion of hypertonic solutions when catheter tip is not in inferior vena cava.
  25. Do not leave catheter open to atmosphere (danger of air embolus).
  26. Avoid use of central venous pressure monitoring catheter for concomitant infusion of parenteral nutrition (risk of sepsis).
  27. Be aware of potential inaccuracies of venous pressure measurements in inferior vena cava (see Chapter 31).
  28. Technique (See Procedures DVD for Video)

Anatomic note: In the full-term infant, the umbilical vein is 2 to 3 cm in length and 4 to 5 mm in diameter. From the umbilicus, it passes cephalad and a little to the right, where it joins the left branch of the portal vein after giving off several large intrahepatic branches that are distributed directly to the liver tissue. The ductus venosus becomes a continuation of the umbilical vein by arising from the left branch of the portal vein, directly opposite where the umbilical vein joins it. At birth, it is 2 to 3 cm long and 4 to 5 mm in diameter, and it is located in a groove between the right and left lobes of the liver in the median sagittal plane of the body, at a level between the ninth and tenth thoracic vertebrae. It terminates in the inferior vena cava along with hepatic veins, as shown in Fig. 29.1.

  1. Make necessary measurements to determine length of catheter to be inserted, adding length of umbilical stump (Figs. 28.1 and 28.2) (4).

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FIG. 29.1. Anatomy of the umbilical and associated veins, with reference to external landmarks.

  1. Prepare for procedure as for umbilical artery catheter (see Chapter 28, E).
  2. Identify thin-walled vein, close to periphery of umbilical stump (Fig. 29.2).
  3. Grasp cord stump with toothed forceps.
  4. Gently insert tips of iris forceps into lumen of vein and remove any clots.
  5. Introduce fluid-filled catheter, attached to the stopcock and syringe, 2 to 3 cm into vein (measuring from anterior abdominal wall).
  6. Apply gentle suction to syringe.
  7. If there is not easy blood return, catheter may have a clot in tip. Withdraw catheter while maintaining gentle suction. Remove clot and reinsert catheter.
  8. If there is smooth blood flow, continue to insert catheter for full estimated distance.
 

FIG. 29.2. The umbilical stump. Vein is indicated with an arrow.

  1. If catheter meets any obstruction prior to measured distance,
  2. It has most commonly
  3. Entered portal system, or
  4. Wedged in an intrahepatic branch of umbilical vein

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  1. Withdraw catheter 2 to 3 cm, gently rotate, and reinsert in an attempt to get tip through ductus venosus.
  2. If the catheter is in the portal circulation, leave the misdirected catheter in its place. Pass a new 5-Fr catheter into the same vessel. Once the catheter is in good position, remove the misdirected catheter. This procedure has a success rate of 50% (5).
  3. Obtain radiographic verification of catheter position. A lateral radiograph is often necessary for exact localization (Fig. 29.3) (6, 7). Desired location is T9 to T10, just above the right diaphragm. Position of catheter tip may be estimated clinically by measurement of venous pressure (1) and observation of waveform (Figs. 29.4 and 29.5). The catheter has crossed the foramen ovale if the blood obtained is bright red (arterial in appearance). In this case, pull catheter back.
  4. As soon as catheter has been advanced 2 to 3 cm into the vein, have an assistant connect to pressure-monitoring system (seeChapter 8).
  5. While continuing to advance the catheter, measure venous pressure and note pressure changes with respiration (Fig. 29.4). Ideal position is with catheter tip in inferior vena cava, near right atrium, although placement in ductus venosus is acceptable for purposes other than measurement of central venous pressure.
  6. Secure catheter as for umbilical artery catheter (see Chapter 28, E).

There may be more bleeding from the umbilical vein than from the umbilical artery because the vein is not a contractile vessel. Local pressure is usually sufficient to stop oozing. For care of indwelling catheter, sampling technique, and removal of catheter, see Chapter 28.

 

FIG. 29.3. Anteroposterior (A) and lateral (B) radiographs demonstrating the normal course of an umbilical venous catheter, with an umbilical artery catheter (arrows) in position for comparison. Note how the venous catheter swings immediately superior from the umbilicus, slightly to the right as it traverses the ductus venosus into the inferior vena cava (IVC). The distal tip of this line is just superior to the right atrial–IVC junction, and it might optimally be pulled back slightly into the IVC. Note how the thinner umbilical artery catheter (arrows) heads inferiorly as it proceeds to the iliac artery and then ascends posteriorly and to the left until it reaches the level of D7.

  1. Complications
  2. Infections (6, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17)
  3. Thromboembolic (8, 13, 18, 19)

Emboli from a venous catheter may be widely distributed. If catheter tip lies in the portal system and ductus venosus has closed, emboli will lodge in liver. If catheter has passed through ductus venosus, emboli will go to lungs; or because of right-to-left shunting of blood through foramen ovale or ductus arteriosus in sick newborn infants, emboli may be distributed

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throughout entire systemic circulation. These emboli may be infected and therefore may cause widespread abscesses.

 

FIG. 29.4. Venous and arterial pressure tracings may be used to facilitate placement and detect misplacement. A: The catheter has been pulled back through the ductus venosus, and the tip lies in the portal system. The portal venous pressure is higher than the central venous pressure, there are no venous pressure waves, and there is a small positive deflection during inspiration. B: Tip of catheter in the superior vena cava near the right atrium shows a deflection of more than 4 mm Hg during spontaneous inspiration (I) and a large negative deflection of more than 15 mm Hg during a sigh (S). Atrial tracing shows an AC and a V wave. AC wave occurs with atrial contraction and closure of atrioventricular valve after P wave of electrocardiogram. V wave occurs with ventricular contraction near T wave of electrocardiogram. (Based on data from Kitterman JA, Phibbs RH, Tooley WH. Catheterization of umbilical vessels in newborn infants. Pediatr Clin North Am. 1970;17:895, with permission.) C: Pressure tracing from right ventricle and pulmonary artery. Right ventricular pressure tracing shows a single large rise and fall, beginning just after onset of QRS complex. Pulmonary artery tracing usually shows a dicrotic notch at end of T wave. Diastolic pressure is higher than that in right ventricle. Pulmonary capillary wedge tracing should resemble atrial tracing, inasmuch as it reflects left atrial pressure transmitted to the catheter tip when anterograde pulmonary arterial flow is occluded. Note: The marked negative deflection in the right atrial tracing would be more typically seen in infants who are receiving mechanical ventilation and thus have a positive airway pressure that exceeds ventricular filling pressures during each inspiration. In a spontaneously breathing neonate, positive airway pressure occurs only during expiration and never exceeds ventricular filling pressures. There are extremely small changes in cardiac pressures (i.e., on inspiration: right atrial [RA] mean pressure ↑, 1 mm Hg; left atrial [LA] mean pressure ↓ 1 mm Hg; on expiration: RA pressure ↓ 1 mm Hg; LA pressure ↑ 1 mm Hg) during the respiratory cycle as a result of changes in venous filling or preload. Right and left atrial pressures remain approximately equal in both inspiration and expiration (39).

  1. Catheter malpositioned in heart and great vessels (Figs. 29.5 and 29.6)
  2. Pericardial effusion/cardiac tamponade (cardiac perforation) (3, 20, 21 and 22)
  3. Cardiac arrhythmias (23)
  4. Thrombotic endocarditis (24)
  5. Hemorrhagic infarction of lung (7)
  6. Hydrothorax (catheter lodged in or perforated pulmonary vein) (25)
  7. Catheter malpositioned in portal system
  8. Necrotizing enterocolitis (26, 27)
  9. Perforation of colon (28, 29)
  10. Hepatic necrosis (thrombosis of hepatic veins or infusion of hypertonic or vasospastic solutions into liver tissues) (Fig. 29.7) (12,13, 19, 30, 31)
  11. Hepatic cyst (32)
 

FIG. 29.5. A: Radiograph showing venous catheter that has crossed the ductus arteriosus into the thoracic aorta. B: In this situation, the arterial pressure markings were not helpful because the presence of pulmonary hypertension in the patient rendered the tracings from the pulmonary artery and descending aorta virtually identical.

  1. Other
  2. Perforation of peritoneum (33)
  3. Obstruction of pulmonary venous return (in infant with anomalous pulmonary venous drainage) (1)
  4. Plasticizer in tissues (34)
  5. Portal hypertension (18, 24, 35, 36)
  6. Electrical hazard (see Chapter 28, I.C.3) (2)
  7. Fungal mass in right atrium (37)
  8. Pseudomass in left atrium (38)
  9. Digital ischemia (39)
  10. Pneumopericardium (40)

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FIG. 29.6. Spectrum of malpositions of umbilical venous catheters (UVCs) (A–C). A: UVC in right portal vein with secondary air embolization into portal venous system. B: UVC in splenic vein. UAC catheter in good position with its tip at D7. C: UVC extending through heart into the superior vena cava. D, E: Spectrum of malpositions of UVCs. The anteroposterior film (D) shows an indeterminate position of the UVC. The right atrium, the right ventricle, and the left atrium are all possibilities.

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The lateral film (E) shows its posterior position, confirming its presence in the left atrium. The lateral film is particularly important in making this distinction. Measurement of the PO2 in blood from the catheter will be diagnostic of misplacement, unless the infant has severe persistent pulmonary hypertension or other cause of severe intracardiac shunting. F–I: Spectrum of malpositions of UVCs. Series of radiographs demonstrating various malpositions of a venous catheter: right pulmonary artery (F), left main pulmonary artery (G), main pulmonary artery (H), and right ventricle (I).

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FIG. 29.7. A: Hepatic infarction (darkened areas on anterior aspect of liver) related to umbilical vein catheter. B: Section through inferior aspect of liver to show internal appearance of infarcted areas (arrow).

References

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  3. Johns AW, Kitchen WH, Leslie DW.Complications of umbilical vessel catheters. Med J Aust. 1972;2:810.
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  19. Sarrut S, Alain J, Allison F.Early complications of umbilical vein perfusion in the premature infant. Arch Fr Pediatr. 1969;26:651.
  20. Purohit DM, Levkoff AH.Pericardial effusion complicating umbilical venous catheterizations. Arch Dis Child. 1977;52:520.
  21. Walker D, Pellet JR.Pericardial tamponade secondary to umbilical vein catheters. J Pediatr Surg. 1972;7:79.
  22. Savani RC, Valentini RP, Mimouni F.Pericardial effusion as a complication of umbilical venous catheterization. J Perinatol. 1990;10:443.
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  24. Symchych PS, Krauss AN, Winchester P.Endocarditis following intracardiac placement of umbilical venous catheters in neonates. J Pediatr. 1977;90:287.
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  26. Livaditis A, Wallgren G, Faxelius G.Necrotizing enterocolitis after catheterization of the umbilical vessels. Acta Paediatr Scand. 1974;63:277.

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