Chapter 38

1. Indications

1. Immediate, primarily postnatal access for intravenous (IV) fluids or emergency medications.

1. Central venous pressure monitoring.

1. Exchange transfusion or partial exchange transfusion.

1. Long-term central venous access in extremely low birthweight infants.

1. Other frequently reported indications are general venous access, intravenous fluids, total parenteral nutrition, and medications.

2. Equipment. Identical to umbilical artery catheterization (see Chapter 23), except use a 5F catheter for infants <3.5 kg and 8F catheter for >3.5 kg.

3. Procedure

1. Place the infant supine with a diaper wrapped around both legs to help stabilize the infant.

1. Prepare the area around the umbilicus with povidone-iodine solution. Use a gown, gloves, and mask.

1. Prepare the tray as you would for the umbilical artery catheterization (Chapter 23).

1. Place sterile drapes, leaving the umbilical area exposed.

1. Tie a piece of umbilical tape around the base of the umbilicus.

1. Cut the excess umbilical cord with a scalpel or scissors, leaving a stump of ~0.5–1.0 cm. Identify the umbilical vein. The umbilical vein is thin walled, larger than the two arteries, and close to the periphery of the stump (see Figure 23–1B).

1. Grasp the end of the umbilicus with the curved hemostat to hold it upright and steady (Figure 38–1A).

1. Open and dilate the umbilical vein with the forceps. Once the vein is sufficiently dilated, insert the catheter (Figure 38–1B).

1. To determine the specific length of catheter needed, see Figure 38–2. Another method is to measure the length from the xiphoid to the umbilicus and add 0.5–1.0 cm. This number indicates how far the venous catheter should be inserted.

1. Connect the catheter to the fluid and tubing. Place a piece of silk tape on the catheter, and secure it to the base of the umbilicus with silk sutures (see Figure 23–3). You can also place a pursestring suture at the base of the cord, not the skin or vessels, and sew it through the tape on two sides. Another way is to place a pursestring suture at the base of the cord and lightly tighten it, and then wrap it three times around the cord and tie.

1. Obtain a radiograph (includes abdomen and chest, the imaging study of choice for catheter placement) to confirm the position (see Figure 10–8). The correct position for an umbilical venous catheter (UVC) is with the catheter tip 0.5–1.0 cm (some units use 0–1cm, 1–2 cm) above the diaphragm. (UVC tip at thoracic vertebrae 8 or 9 corresponding to the junction of the right atrium and inferior vena cava.) Recently, some centers have used ultrasound combined with radiography for catheter placement and to verify position. Real time ultrasound has been shown to reduce complications during catheter insertion.

1. Never advance a catheter once it is secured in place.

1. Occasionally, a catheter enters the portal vein (Figure 38–3). You should suspect that you have entered the portal vein if you meet resistance and cannot advance the catheter the desired distance or if you detect a "bobbing" motion of the catheter. Several ...

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