44: Venous Access: Umbilical Vein Catheterization

I. INDICATIONS

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

2. Central venous pressure monitoring (if UVC passed through the ductus venosus).

3. Exchange or partial exchange transfusion (catheter tip should not be in the intrahepatic venous system or the portal system).

4. Long-term central venous access in extremely low birthweight infants or sick infants for administration of IV fluids, total parenteral nutrition, medications.

5. Delivery of blood and blood products.

6. Other reported indications include general venous access in difficult peripheral IV access, administration of fluids and total parenteral nutrition, infusion of hypertonic solutions (>12.5% only if catheter tip in inferior vena cava), infusion of vasoactive drugs, antibiotics, and medications.

7. Secondary aid in the diagnosis of cardiovascular or other anomalies by an unusual course of the umbilical venous catheter or the blood gas samples are suspicious.

   1. Congenital diaphragmatic hernia. Umbilical venous catheter (UVC) is left of the midline because of the anomalous positioning of the liver in the chest.

   2. Persistent left superior vena cava. Diagnosed by the path of a UVC. UVC catheter extended beyond the lung (it had entered the persistent left superior vena cava and entered the left jugular vein).

   3. Congenital absence of the ductus venosus. This can cause an abnormal path of UVC. (Caudal loop is seen on radiograph in a UVC.)

   4. Infracardiac total anomalous pulmonary venous return. Diagnosed by high partial pressure of oxygen in a UVC below the diaphragm.

II. EQUIPMENT

1. Basic. Identical to umbilical artery catheterization (see Chapter 24).

2. UV catheters

   1. Types. Single lumen: 2.5F, 3.5F, 5.0F; dual lumen: 3.5F, 5.0F; triple lumen: 5.0F, 8.0F.

   2. Size guideline. Preterm: 3.5F; term and late preterm: 5F. Other guidelines: 3.5F or 5F catheter <3.5 kg, 5F or 8F >3.5 kg. An 8F catheter is recommended for exchange transfusion or a large volume replacement. Dual-lumen catheters are sometimes recommended in infants <28 weeks and <1000 g, in infants that need inotropes or insulin, and any critically ill neonates such as persistent pulmonary hypertension or meconium aspiration syndrome.

III. PROCEDURE

1. Important UVC tips

   1. There is only 1 umbilical vein, and it remains open and viable for cannulation for up to 1 week after birth. The umbilical vein carries oxygenated blood from the placenta to the fetus. The UVC passes into the umbilical vein through the umbilicus and follows this path: junction of the right and left portal vein in the liver, the ductus venosus, crosses at the level of the right and left hepatic vein, and enters the inferior vena cava up to the junction of the inferior vena cava and right atrium.

   2. In an emergency postnatal situation (delivery room). The UVC can be rapidly inserted only until adequate blood return is obtained (usually 2–4 cm in a term infant, less in preterm) as an emergency venous access. Resuscitation medications, volume, and blood can be given.

   3. Cochrane review does not make any recommendations on using single- versus multiple-lumen catheters. Double-lumen catheters decreased the number of additional venous lines during the first week of life, but double-lumen catheters broke, leaked, and clogged more (smaller diameter). No difference in catheter placement ...