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Skill 2 into the lumen of the umbilical Skill Umbilical Catheterization vein and advance it gently toward the liver for 4 to 5 cm or until blood return Umbilical vein catheterization should be con- is noted. sidered as a potential intravenous access site 9. If resistance to advancement of the 2 in infants up to 2 weeks old. The procedure is catheter is encountered, the tip might be indicated for neonates with or car- in the portal vein or the ductus venosus. diopulmonary failure. The catheter should be pulled back until blood can be withdrawn smoothly. Equipment 10. Remove the catheter when •5 or 8 French catheter, or a 5 French is complete and peripheral vascular access has been obtained. • 10-mL syringe • Umbilical cord tape or suture to tie the base of the cord • Flush solution

Technique 1. Place the infant beneath a radiant warmer and restrain the extremities. 2. Prepare the abdomen and umbilicus with antiseptic solution (surgical prep). 3. Drape the umbilical area in a sterile manner. Expose the infant’s head for observation. 4. To anchor the line after placement, place a constricting loop of umbilical tape at the base of the cord. Using a scalpel blade, trim the umbilical cord to 1 to 2 cm above the skin surface. 5. Identify the umbilical vessels. The umbilical vein is a single, thin-walled, large-diameter lumen, usually located at 12 o’clock. The are paired and have thicker walls with a small-diameter lumen (Figure 2.1). 6. Obtain an umbilical vascular catheter (5 Fr). Flush the catheter with heparinized (1 unit per mL) and attach it to a 3-way stopcock. 7. Measure and mark 5 cm from the tip of the catheter. 8. Close the ends of a pair of smooth forceps, then insert the end into the lumen of the umbilical vein. Dilate the opening by allowing the ends of the forceps to separate, then insert the Figure 2.1 Umbilical vein catheterization.

Umbilical Vein Catheterization 1 Pediatric Length-Based Resuscitation Tape

Skill Complications and Pitfalls than 3 mL/hr. Flushing the catheter with Central venous catheterization is an invasive when it is not in use and using form of , and many potential heparinized fluid when the rate of infusion complications are associated with this tech- is less than 3 mL/hr might prevent 2 nique. Some of these potential complications thrombus formation. made of are common to all sites of insertion, while oth- Teflon have surface characteristics that are ers are site specific. The complications com- not conducive to thrombus formation. mon to all insertion sites are as follows: Unfortunately, these catheters are also •Arterial injury: The most common quite stiff and can injure vascular of this technique is structures. Likewise, catheters that are accidental puncture and/or cannulation of impregnated with heparin are less often the adjacent . In most cases, this associated with thrombus formation. results in a minor injury to the artery that • Guidewire misplacement: In rare can be easily managed with direct instances, the guidewire enters the central pressure at the insertion site or by venous circulation and must be retrieved application of a pressure . by an angiographer or a surgeon. This Obviously, it is much harder to control complication can be avoided by ensuring significant bleeding of one of the carotid that one hand remains in firm contact arteries, but fingertip pressure applied with the wire at all times. directly to the site might be sufficient. • Air embolus: Allowing a bolus of air to Use of the vein dilator or a mishap with enter the catheter can result in an air the scalpel can result in more serious embolus when the end of the needle or injury to the artery, necessitating the catheter is open to the air and the venous involvement of a vascular surgeon. If pressure is low. This complication is most possible, it is best to avoid injuring the likely to occur when the catheter is placed artery. into the internal or the • Infection: Central venous catheters are . An air embolus can be foreign bodies and can, like any such avoided by covering the open end of the object, become colonized by bacteria. catheter with the thumb after the guidewire infections can has been removed, before connecting the have devastating consequences, intravenous fluids, and by positioning the particularly in critically ill children. patient with the insertion site slightly Furthermore, the emergence of multiple- dependent. Such positioning has the added resistant bacteria in many hospitals benefit of aiding catheter placement increases the risks substantially. Attention because it dilates the . Aspirating the to sterile technique is critical. When time catheter before flushing will remove air permits, those involved in the placement within the catheter. Older patients can be should don sterile gowns and wear masks asked to perform a Valsalva maneuver and hats. Large sterile drapes can prevent during internal jugular and subclavian inadvertent contamination of the cannulation to avoid negative pressure guidewire and catheter prior to insertion. within the vein. • : Just as any foreign object can 1,2 become infected, almost any foreign object Site-Specific Complications can become a nidus for thrombus • Umbilical vein catheterization should be formation. The risk is highest with used for temporary vascular access only, polyvinylchloride catheters and when the and the catheter should be removed once rate of infusion through the catheter is less the patient is stable and vascular access

Skill 2 2 has been secured via other sites. Skill Umbilical vein catheterization can cause hepatic thrombosis, infection, and hemorrhage due to vessel perforation. 2 References 1. Lavelle J, Costarino AT. Central and . In Henretig FM, King CC, eds. Textbook of Pediatric Emergency Procedures. Baltimore, Md: Williams & Wilkins; 1997:251-278. 2. Goutail-Flaud MF, Sfez M, Berg A et al. Central venous catheter-related complications in new- borns and infants: a 587-case survey. J Pediatr Surg. 1991;26:645.

Umbilical Vein Catheterization 3