Emergent Umbilical Venous Catheter (UVC) Placement

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.

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http://www.uichildrens.org/insertion-of-umbilical-vessel-catheters/

Indication:

  • Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine

Contraindications:

  • Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
  • Vascular compromise of the lower limbs

 

Umbilical Vessel Anatomy:

Neonatal 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:
    • Locate UVC Tray and UVC lines in Hasbro Trauma Bay
    • Other materials not in kit:
      • 3-0 silk suture on a curved needle
      • Infusion solution (usually NS or D10W)
      • Three-way stopcock
      • Tegaderm and tape

  • 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…)
    •  Materials:
      • 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

 

Technique:

UVC Procedure 

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.
  • Procedure:
    1. Hold umbilical stump upright by grasping Wharton’s jelly with forceps. Then clean abdomen and cord with a bacteriocidal solution (ex. Chlorhexidine).
    2. Drape in sterile fashion so the cord is exposed (leave infant head’s visible)
    3. 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.
    4. Using scalpel, cut cord about 1-2 cm above abdomen (take care not to cut the skin).
    5. Stabilize cord with a forceps or hemostat and identify the vessels (vein = large, thin-walled, usually at 12 o’clock; arteries = thick-walled).
    6. Dilate the vein if necessary by inserting tips of curved iris forceps and allow spring to gently open the vein.
    7. 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
    8. 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.
    9. Place purse-string suture to stabilize catheter and/or Tegaderm to abdomen.

 

Video Resources:

  1. 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.
  2. 3 by 3 Method for Emergent UVC Placement by Indiana University

  3. Cincinnati Children’s Hospital UVC Placement on Sim Newbie

 

Textbook References:

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.

4 thoughts on “Emergent Umbilical Venous Catheter (UVC) Placement

  1. Beautiful work. Good to identify the pedi cart’s location as a reminder. Can you present a brief case example that shows algorithmically how we would arrive at a point where we would need to place a UVC (ie: what steps would occur just prior to – and during – the neonatal resuscitation)?

    • The most common scenario in which UVCs are placed is just after birth during neonatal resuscitations. This is a large enough topic for another blog post… but, see this link for the algorithm for neonatal resuscitation by the AHA: http://circ.ahajournals.org/content/122/18_suppl_3/S909/F1.expansion.html

      Essentially, if you have an apneic newborn with a pulse < 60 that has not responded to 60 seconds of effective PPV by BVM and 30 seconds of chest compressions, you should give Epinephrine. The most effective way to give Epinephrine in a newborn is via UVC. Interestingly, IO epinephrine for this indication hasn’t been studied so is not suggested or used by NICU teams. Additionally, use of IOs may be quite difficult or impossible in a small, premature infant.

      Hope that helps!

  2. Interestingly, just went to a neonatal resuscitation lecture at ACEP. Speaker did say that UVC placement was standard, but that we should consider IO because there’s evidence that in the hands of regular (non PEM) EP’s that it was much faster. However, if it’s not recommended to give epi this way then that would, of course, give me pause (and it flies in the new mantra that ANYTHING that can be given IV can be given IO…maybe they should amend that to say ‘in adults’?)

    And it does seem that in those little teeny bones that a correctly placed IO would be quite difficult.

    Thanks for a nice review–handy in my phone for the next time it comes up!!

  3. Pingback: Vascular access in first week of life | PEM Source

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