Umbilical Vessel Catheterization

CHAPTER 184 Umbilical Vessel Catheterization



Carman H. Whiting


Being able to quickly assess and rapidly intervene in a severely ill infant is essential. Because the umbilical vessels are easily visualized, they are an excellent route for catheterization to provide central vascular access. Whereas umbilical artery catheterization allows for accurate monitoring of central arterial pressure directly through the aorta, umbilical vein catheterization allows for central venous pressure (CVP) monitoring through the inferior vena cava. Umbilical vein catheterization also provides access for rapid infusion of life-sustaining therapies (Fig. 184-1).


image

Figure 184-1 Fetal circulation at term.


(Modified from Carlson B: Human Embryology and Developmental Biology, 2nd ed. St. Louis, Mosby, 1999.)


Primary care clinicians may need to perform umbilical vessel catheterization in the delivery room for a newborn resuscitation or in the emergency department for a newborn or infant in distress. They may also need to perform it in the nursery or neonatal intensive care unit (NICU) for an infant requiring continuous monitoring or frequent infusions of medications or fluids. In fact, both vessels are frequently catheterized in the NICU for premature infants requiring prolonged vascular access or monitoring.


Compared with the vein, the umbilical artery is a more durable vessel with higher-velocity blood flow; therefore it is easier to visualize and there is a slightly lower risk of complications when it is catheterized. Inserting an umbilical artery catheter (UAC) or an umbilical vein catheter (UVC) is easier if performed in the first 30 to 60 minutes of the infant’s life. However, a UAC may be inserted up to the 7th day of life and a UVC at up to 2 weeks of age. Despite the fact that the vessels are easily accessible, placing a UAC can be a time-consuming procedure and requires skill and experience. Contraindications or difficulty obtaining a UAC insertion may necessitate the need for a UVC for infusions because a UVC insertion is easier to perform. A UVC is also an option if peripheral intravenous access is difficult to obtain, which is likely the case in very premature infants. After the first day of life, there are few data supporting any benefit of a UAC over a UVC for infusion, although an attempt should always be made to obtain peripheral venous access before either of these is inserted, except in infants of very low birth weight.



Indications



Umbilical Artery Catheterization



• Newborn resuscitation requiring monitoring for cardiorespiratory distress (e.g., arterial pressure monitoring, frequent arterial sampling)

• Newborn or infant in a NICU requiring
• Mechanical ventilation for respiratory distress (i.e., frequent arterial sampling)

• Oxygen hood and greater than 40% oxygen (FIO2 >0.4) requirement with an abnormal chest radiograph (i.e., frequent arterial sampling)

• Exchange transfusion that can be performed through a UAC (e.g., newborn weighing <1800 g)


Umbilical Vein Catheterization



• Newborn resuscitation requiring
• Administration of drugs, blood, blood expanders, or fluids

• Monitoring for possible cardiorespiratory distress (e.g., CVP monitoring)

• Newborn or infant in the NICU requiring
• Greater than 12.5% dextrose to maintain blood glucose while taking nothing by mouth (NPO)

• Pressor drips, total parenteral nutrition (TPN) solution, or hypertonic medications (e.g., newborn weighing <1000 g or who is critically ill)

• Exchange transfusion or partial exchange transfusions that can be performed through a UVC (e.g., newborn weighing <1800 g)

NOTE: By convention, a newborn is defined as an infant younger than 1 month of age.



Contraindications



• There are no contraindications during the first hours of life if the newborn has normal anatomy and no local skin infections.

• Vascular insufficiency of a lower extremity is a contraindication to UAC.

• Local infection (e.g., omphalitis, impetigo) and abdominal distention (possibly caused by intestinal hypoperfusion or necrotizing enterocolitis) are contraindications that can develop after the first few hours of life.


Equipment



• Sterile measuring tape

• 3.5- to 5.0-Fr umbilical catheter for UAC; up to 8-Fr umbilical catheter for UVC

• Surgical cap and mask; sterile gown and gloves

• Eye protection for clinician

• Povidone–iodine or antiseptic scrub solution

• Three-way stopcock (sterile); locking connectors

• Heparin for flush (1 to 2 U heparin/mL of 0.25 normal saline [NS])

• Sterile instrument tray with small hemostats, forceps (iris curved), scissors, needle holder, straight forceps, mounted no. 11 scalpel blade, and drapes

• Antibiotic ointment

• 4-0 or 5-0 silk suture with a small needle or a catheter stabilizer

• Sterile umbilical tape

• Infant radiant warmer, means of restraint, cardiac and oxygen saturation monitors, supplemental oxygen

• 5% or 10% dextrose in water or NS infusion setup (use heparin 1 U/mL, unless medications are to be administered that are incompatible with heparin) with fluid chamber, 0.22-µg filter, and infusion pump

• Adhesive tape

A rule of thumb for selecting UAC size is to use a 5-Fr catheter for infants weighing more than 2000 g and a 3.5- to 4-Fr catheter for infants weighing less. Because the lumen of the vein is larger, a 5- to 8-Fr catheter can be used for UVC in term infants (>1800 g), especially infants requiring exchange transfusion. The catheter may be composed of any U.S. Food and Drug Administration–approved material; double-lumen catheters are also available.



Preprocedure Patient Preparation


The newborn needing umbilical catheterization typically demonstrates signs and symptoms of cardiorespiratory distress shortly, if not immediately, after birth. If performed as an emergency procedure, implied consent and the indications should be documented in the chart. Explain the need for the procedure to the parent(s) when there is time. For less urgent insertions, obtain informed consent from the parent(s) after discussing the alternatives, risks, and potential benefits of the procedure.



Technique


When the infant arrives at the nursery, if umbilical catheterization is probable, the umbilical stump should be left at least 4 cm long. The two thick-walled arteries and the single vein should be easily identifiable. Place the infant under an infant warmer and restrain, if possible. The cardiac rate should be monitored and adequate oxygenation should be provided throughout the procedure.


1 Set up the tubing, fluids, fluid chamber, 0.22-µg filter, and infusion pump. Flush and fill the tubing with heparin flush to remove air from the system.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Umbilical Vessel Catheterization

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