Umbilical vein catheterisation for neonates

During an emergency, short-term umbilical venous access is acceptable as a route for resuscitation drugs and fluids, with the catheter tip inserted only 3-5 cm beyond the muco-cutaneous junction (in this situation the catheter will not have reached as far as the portal circulation).

Other than in an extreme emergency, insertion of a UVC is a sterile procedure, requiring the following equipment:

• sterile gloves and gown
• instrument pack (as for umbilical artery catheterisation) and sterile drape (transparent plastic is preferred for better patient visualisation)
• umbilical catheter:
  • multiple lumen catheters are preferable if the infant is < 1,000 g or extremely sick
  • a single lumen catheter (FG 3.5 < 1,500 g, FG 5.0 = 1,500 g) is inserted for short-term use.
  • if unavailable, or in an emergency, a feeding tube (size 5) can be used
• 3-way taps and syringes with NaCl 0.9 per cent flush for each lumen
• 2 per cent aqueous chlorhexidine solution as skin prep. (dilute 1:1 with sterile water if infant < 750 g)
• routine IV line tubing set-up and tape.

1. Set out equipment, observing strict sterile technique.
2. Select appropriate catheter (5 Fr. = 1,500 g or 3.5 Fr. if < 1,500 g).
3. Calculate the estimated length of the UVC:
   1. Umbilicus to xiphisternum (cm) + umbilical stump length (cm)
4. The catheter must be attached to a syringe via a three-way tap and filled with infusion solution before insertion.
5. Open a size 22 scalpel blade and an atraumatic suture (3/0 silk on a cutting edge needle) onto the sterile field.
6. Use 2 per cent aqueous chlorhexidine solution as skin prep. (dilute 1:1 with sterile water if infant < 750 g).
7. If using an infusion, check solution is correct and prepared to the stage where it can immediately run into the catheter.

Preparing the infant

1. Place infant on open heated cot.
2. Consider the use of appropriate measures to relieve distress including:
   1. oral sucrose
   2. containing the infant by holding
   3. securing the catheter as soon as possible
   4. avoid placing clamps or sutures on the skin.

1. Monitor the infant (oximetry and cardiorespiratory) and ensure all four limbs are adequately restrained throughout the procedure.
2. Flush the selected catheter via the three-way tap with heparinised saline. Leave the syringe to the three-way tap throughout the procedure.
3. Prepare umbilicus, cord and cord clamp with antiseptic solution as above.
4. Loosely tie a sterile cotton tape tie around the base of the umbilicus (secure enough to maintain haemostasis, but not too tight to prevent passage of the catheter).
5. Trim the umbilical cord to about 1.5 cm from the abdomen in a single cut with a straight blade and establish a sterile field.
6. Insert a purse-string suture at the base of the umbilical cord through the Wharton's jelly for haemostasis. Tie a single knot.
7. Immobilise the cord by grasping the cord edges with two artery forceps at 3 and 9 o'clock, taking care not to include the vessels. Identify the umbilical vein: thin walled, patulous, compared to the thick-walled, smaller calibre arteries. Insert the tip of an iris forcep into the lumen of the vein. Gently and repeatedly dilate the vein by allowing the forceps to spring open.
8. Gently introduce the primed catheter into the vein, advancing cautiously in a cephalad direction. Take care not to force a false passage. There is often a degree of resistance just at the level of entry into the body.
9. Advance the catheter to the desired length.
10. Make sure that blood can be freely aspirated, collect specimens at this stage, then flush the catheter gently.
11. Tie purse string and tie onto catheter or secure to catheter with tape.
12. Label catheter to distinguish from umbilical artery catheter, if present.
13. Obtain an abdominal x-ray to check the position of the catheter prior to use, unless using as a ‘short’ UVC in an emergency situation.
14. If the catheter tip position of a ‘long’ UVC is too high (inside R atrium), it can be pulled back by an appropriate amount and x-rayed again. If the tip position is below the diaphragm, a fresh catheter should be reinserted to avoid contamination, or the catheter should be partly withdrawn to the safe ‘short’ position (below the liver).
15. Start infusion once the correct placement has been confirmed. Check the fluid type and rate.
16. Routine heparinisation of umbilical venous catheters is not recommended.

Possible complications when inserting an umbilical vein catheter include:

• sepsis
• bleeding due to disconnection of tubing (always use a Luer locked connection when attaching the catheter to infusion lines)
• perforation never cut off the rounded end of any indwelling catheter
• clot formation, embolism and spasm
• effects of catheter malpositioning include cardiac arrhythmias, hepatic necrosis or portal hypertension - avoided by checking catheter positioning by x-ray prior to use.

1. Removal is performed by medical staff or experienced nursing staff.
2. Turn the infusion off.
3. Withdraw the catheter gradually in a single action.
4. Send the tip for culture if infection is suspected.
5. If bleeding occurs, press firmly just above the umbilicus.
6. Do not nurse the infant in the prone position during removal of the catheter and for the immediate 4 hours after removal. Leave the abdomen visible for inspection, not covering the umbilicus with a nappy or dressing, so that inadvertent bleeding from the umbilicus does not go unnoticed.

References

• Umbilical Vein Catheterisation Protocol, Southern health Care Network - Monash Medical Centre, Newborn Services
• Stabilisation and Transport of Newborn Infants and At-risk Pregnancies, 4th Edition, 1998, Editors E.D. Bowman, S.M. Levi, A.J. Mclean, F.E. Presbury. NETS publication