In a sick neonate where peripheral venous access is not possible, placement of an umbilical venous catheter (UVC) may be lifesaving!
The umbilical vein may remain patent for up to 10 days after birth.
- Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine
- Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
- Vascular compromise of the lower limbs
Umbilical Vessel Anatomy:
From Robert and Hedge’s Clinical Procedures in Emergency Medicine
- Umbilical cord has 2 arteries and 1 vein
- Vein is thin-walled, usually at 12 o’clock
- Arteries are smaller and thick-walled
- Neonatal blood flow:
- Umbilical vein –> ductus venosus –> IVC –> RA –> PA –> ductus arteriosus –> aortic arch
- Umbilical arteries –> internal iliac arteries
Finding your Materials:
- In Hasbro ED:
- In Anderson ED:
- Locate UVC lines in bag on Pediatric Cart, which is located in hall near ambulance overflow area
- There is no UVC Tray in Anderson. So, you will need to gather necessary materials (or call over to Hasbro if there is time…)
- Sterile drapes and gauze
- Scalpel (No. 11-blade)
- 3-0 silk suture on a curved needle
- Small clamps, forceps, scissors, and needle holder
- Curved iris forceps without teeth
- Umbilical tie
- Infusion solution (usually NS or D10W)
- Three-way stopcock
- Tegaderm and tape
- Umbilical Vein Catheter sizing:
- 3.5 Fr for preterm babies (< 3500 gm)
- 5.0 Fr for term babies (> 3500 gm)
** Alternatives if you don’t have a UVC: NGT or IV catheter
From Roberts and Hedges’ Clinical Procedures in Emergency Medicine
- Get sterile (gown, hat, mask, gloves) IF TIME (usually there is NOT time)
- Get kit ready:
- Place stopcock on lines and flush line with sterile saline.
- Hold umbilical stump upright by grasping Wharton’s jelly with forceps. Then clean abdomen and cord with a bacteriocidal solution (ex. Chlorhexidine).
- Drape in sterile fashion so the cord is exposed (leave infant head’s visible)
- Tie a piece of umbilical tape (or nylon suture) around the base of the umbilical cord tightly enough to minimize blood loss but loosely enough so that the catheter can be passed easily through the vessel.
- Using scalpel, cut cord about 1-2 cm above abdomen (take care not to cut the skin).
- Stabilize cord with a forceps or hemostat and identify the vessels (vein = large, thin-walled, usually at 12 o’clock; arteries = thick-walled).
- Dilate the vein if necessary by inserting tips of curved iris forceps and allow spring to gently open the vein.
- Grasping the catheter with a forceps or between the thumb and forefinger, the catheter can be inserted into the lumen of the dilated vein. Supporting the stump is usually necessary.
- Tips if you meet resistance:
- Angle stump toward feet so catheter is directed toward the head
- Try loosening the umbilical tie just a tad
- Tips if you meet resistance:
- Only put in as far as you need to get blood return (usually 4 to 5 cm). This is referred to as a “Low-Lying UVC”.
- Place syringe flush on line and aspirate back to confirm blood return and clear the line of air bubbles.
- Don’t worry about placing a “high line” (threading catheter up into the IVC). This can be done in the ICU for more long-term use.
- Place purse-string suture to stabilize catheter and/or Tegaderm to abdomen.
- Comprehensive Video on Umbilical Vascular Catheterization from New England Journal of Medicine. Includes non-emergent UAC and UVC placement. See “Emergent UVC placement” at 11:29.
3 by 3 Method for Emergent UVC Placement by Indiana University
- Cincinnati Children’s Hospital UVC Placement on Sim Newbie
Santillanes G & Claudius I. Pediatric Vascular Access and Blood Sampling Techniques. Chapter 19, 341-367.e2. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. Elsevier; 2014.