The placement of umbilical catheters is an essential technique for the treatment of many newborns in unstable condition this video

will
demonstrate the placement of catheters in the umbilical vein and the umbilical artery careful preparation sterile technique and attention
to detail are instrumental in successful catheter placement we will demonstrate the regional anatomy of the umbilicus indications and
contraindications for the insertion of an umbilical catheter the recommended technique for catheter placement in both the umbilical
artery and vein selected.

Umbilical vein catheterization may be indicated for emergency vascular access monitoring of central venous pressure exchange
transfusion and central venous access in infants requiring long-term parenteral nutrition umbilical artery catheterization is indicated for
frequent measurement of arterial blood gases continuous monitoring of arterial blood pressure and geography and occasional
resuscitation the umbilical vein is considered the optimal vessel in this situation.

The contraindications are similar for both vessels and include omphalocele, gastroschisis um philetus and peritonitis in umbilical artery.
Catheterization evidence of vascular compromise in the lower limbs or buttocks and necrotizing enterocolitis are considered additional
relative contraindications

Within the Wharton's jelly of the umbilical cord the arteries are located lateral of midline in the inferior portion of the chord positions 5
and 7 on the face of a clock in a full-term infant the artery is approximately 7 centimeters from the umbilicus to where it joins the internal
iliac artery the umbilical vein is a larger midline vessel with thinner walls located at position 12 on the face of a clock in a full-term infant
it is 2 to 3 centimeters in length and 4 to 5 millimeters in diameter after the procedure has been explained and consent obtained from
the parent or parents review the records and examine the patient to confirm that there are no contraindications to catheterization in your
examination concentrate on the anatomic landmarks you must then decide how deeply to place each line the umbilical artery catheter or
UAC can be placed in a high lying position between thoracic vertebra number six and nine or in a low lying position below the third
lumbar vertebral body here we will describe the procedure for the placement of each type of catheter there are many acceptable
methods for determining the appropriate depth of placement to calculate the depth for inserting a high lying UAC multiply the weight in
kilograms by three and add nine centimeters then measure and add the length of the stump to this value to calculate the appropriate
depth for the
umbilical vein catheter or UVC insertion
multiply the weight in kilograms by
three and add nine centimeters divide
that total by two then add one
centimeter standardized grafts for
determining the depth of catheter
insertion are available and they are
included in the supplement
to ensure the highest level of sterility
the operator should wear a sterile gown
and gloves as well as a surgical cap
mask and face shield in addition to
these items most of the equipment can be
found in commercially prepared kits and
should include skin preparation solution
a surgical drape with central opening
and/or sterile towels sterile 4x4 gauze
a three-way stopcock with the luer lock
one for each catheter port a five or ten
milliliter luer lock syringe one for
each port a number 11 blade scalpel
saline or heparinized flushing solution
straight iris scissors three mosquito
hemostats two smooth curved iris forceps
one tooth two mosquito hemostat an
umbilical tie suture and a needle driver
there are numerous types of umbilical
catheters from which to choose a five
French arterial catheter should be used
in infants weighing more than 1.2
kilograms a 3.5 French arterial catheter
should be used in infants weighing less
than 1.2 kilograms arterial catheters
should have a single hole and be as non
thrombogenic as possible the umbilical
vein catheter should be 5 French for
infants weighing less than 3.5 kilograms
and 8 French for infants weighing more
than 3.5 kilograms consider using a
venous catheter with side holes when the
catheter will be used for exchange
transfusion otherwise venous catheters
can be single or double lumen and should
have one hole
the infant should be placed in the
supine position on a radiant warmer the
infant's arms and legs should be secured
to avoid movement that might contaminate
the sterile field sedation is generally
not needed because the skin is typically
not cut or punctured with a needle make
the necessary measurements to estimate
the depth of catheter insertion after
you are fully scrubbed and garbed to
perform the procedure attach a stopcock
to the hub of each catheter and fill the
system with flushing solution be sure
each stopcock is in the off position ask
an assistant who need not be wearing a
sterile gown to grasp the cord by the
cord clamp and apply traction vertically
apply antiseptic solution to the cord
and surrounding skin apply sterile
towels or surgical drape in such a way
that the patient's face is visible then
wrap the cord tie around the base of the
umbilicus and tie with a single knot the
knot should be tight enough to prevent
bleeding from the cord but loose enough
to allow the catheters to pass through
the vessels of the cord cut the cord
horizontally with the scalpel
approximately 1.5 centimeters from the
skin take care not to cut the skin that
is at the base of the cord ask the
assistant to remove the cut cord and
clamp from the field identify vessels
within the cord control any bleeding by
adjusting tension on the umbilical tie
and by blotting not rubbing the freshly
cut surface it is feasible for a single
operator to place an umbilical catheter
successfully however we will describe
and demonstrate the procedure for the
operator working with an assistant
donning sterile attire
the assistant should use the tooth
cheeto hemostat to grab the side of the
court near the artery to be cannulated
and should avoid grabbing the artery
clamp a curved hemostat to the opposite
side of the court
the assistant should apply traction to
these hemostats in opposite directions
to stabilize the chord using your
non-dominant hand placed the closed or
pinched tip of the curved iris forceps
into the lumen of the artery to a depth
of approximately 0.5 centimeters keep
the tip closed on initial insertion and
then removed the forceps to dilate the
artery further place the closed tip of
the forceps back into the artery insert
to a depth of 1 centimeter and allow the
forceps to open slowly leave the forceps
in an open position for 20 seconds to
dilate the vessel completely use your
dominant hand to grasp the catheter one
centimeter above the lumen using the
other mosquito forceps or using the
thumb and forefinger slide the catheter
between the tips of the forceps within
the umbilical artery using a firm steady
motion past the catheter 1.5 to 2
centimeters into the artery and remove
the indwelling forceps grasp the
cephalad portion of the cord with the
tooth mosquito forceps and apply
traction in the cephalic direction to
assist in passing the catheter deeper
once a depth of 5 centimeters has been
reached draw back on the syringe to
ensure the blood is able to flow as the
catheter is passed to the predetermined
depth you may encounter resistance at
the curvature of the vessel
approximately 6 to 8 centimeters in
depth the vessel should slowly relax not
pop as you apply constant pressure
confirm placement with radiography or an
ultrasound image a low-lying catheter
should be at lumbar vertebra three to
four high line catheters should be at
thoracic vertebra 6 to 9 secure the
catheter with a purse string suture
avoid puncturing the catheter the
vessels or the skin
there are several stages at which you
may encounter difficulty with insertion
if the catheter threads to only three
centimeters
the umbilical tie may be too tight
loosen the tie redial 8 the vessel and
reinsert if insertion is easy but there
is no blood return or if you sense a pop
after entering the lumen the catheter
may be in a false track outside the
vessel remove the catheter and prepare
the other umbilical artery for insertion
if you encounter resistance at six to
eight centimeters in a full-term infant
the catheter may be at the curvature in
the umbilical artery curving around the
bladder before it enters the internal
iliac artery apply gentle pressure for
30 seconds
some experts recommend positioning the
infant on the side with the artery being
cannulated in the superior position
flexing the hip to facilitate insertion
in our experience it is often best to
move on to the second artery if
resistance is encountered at this
curvature
to insert an umbilical vein catheter
with your non-dominant hand grasp the
cord with the toothed forceps with your
dominant hand using the mosquito forceps
remove any blood clots from the entrance
of the vein using the mosquito forceps
introduce the pre flushed venous
catheter attached to the stopcock and
syringe into the lumen of the vein and
insert three centimetres gently pull
back on the syringe to ensure blood
return and proper placement if blood
returns continue inserting the catheter
to the predetermined depth obtain
radiographic or ultrasonographic
confirmation of the catheter position
the ideal position is in the inferior
vena cava near the right atrium secure
the catheter as you did for the arterial
catheter
if the catheter meets resistance before
it reaches the predetermined distance it
has most likely entered the portal
system become wedged in an intra hepatic
branch of the umbilical vein or doubled
back on itself in these circumstances
pull the catheter out of the vein
approximately four centimeters and
rotate the catheter as you reinsert it
into the vein occasionally this will
allow the tip to slip through the ductus
venosus often it is necessary to repeat
this maneuver several times
during an extensive resuscitation it may
be necessary to obtain emergent
intravenous access immediately following
birth the umbilical vein is the vessel
of choice the procedure is altered
slightly from what has been previously
described prepare the umbilical cord
with an antiseptic solution it is often
impossible to create a sterile field in
an emergency situation the operator
should Don sterile gloves and keep the
catheter as sterile as possible the
catheter must be pre flushed and
attached to a stopcock and syringe if an
assistant isn't available you can tie
the cord at the base with a cord tie and
cut the umbilical cord 2 centimeters
above the skin quickly insert the
umbilical venous catheter into the
umbilical vein to a depth of 3 to 5
centimeters below the skin in a
full-term infant check for blood return
and secure the catheter between your
fingers or with tape it is imperative
that the catheter not be inserted too
deeply as it may enter the hepatic
vessels in which medications
administered during the urgent situation
could potentially cost hip had a
cellular damage
to prevent clot formation keep the
catheter free of blood by flushing it
with 0.5 milliliters of solution each
time blood is drawn from the catheter
solution should flow continuously
through the catheter to prevent
retrograde flow watch closely for
evidence of clot formation including
difficulty with drawing blood samples or
decreased amplitude of pulse pressure on
a blood pressure tracing if a clot forms
do not attempt to flush the clot
forcibly unless the line is critical it
should be removed
you ACS can cause or be associated with
multiple complications including but not
limited to thrombosis embolism
vasospasm loss of extremity hypertension
air embolism necrotizing enterocolitis
infection and bladder injury if mal
positioned these catheters can result in
vessel perforation refractory
hypoglycemia peritoneal perforation and
sciatic nerve palsy complications
associated with uvcs
include infection thromboembolism
perforation of the peritoneum portal
hypertension digital ischemia and
pneumopericardium when placed in the
wrong position you VCS can cause
pericardial effusion and tamponade and
cardiac arrhythmias
umbilical catheters should be removed
when complications occur the length of
time an uncomplicated catheter may
remain in place is the subject of some
controversy at present we recommend
strict adherence to individual
institutional policies until consensus
on this important issue can be obtained
the placement of umbilical catheters is
an indispensable technique used to
stabilize the condition of critically
ill newborns proper insertion technique
and knowledge of potential complications
will improve the utility of these
catheters in the newborn population
English (auto-generated)