# Umbilical Vein Catheterisation

## Overview

This module describes how to utilise the exposed umbilical stump in a neonate up to 14 days old as a site for emergency central venous access. Umbilical vein catheterization (UVC) provides a safe and effective route for intravenous delivery of medication and fluids during resuscitation.

## Indications

1. IV access in a resuscitation or when IV access cannot be obtained otherwise

2. Exchange transfusion

3. Administration of inotropes

4. Parenteral nutrition

5. Administration of high concentrations of glucose

## Contraindications

1. Gastroschisis
   Gastroschisis

   Gastroschisis is a paraumbilical abdominal wall defect associated with protrusion of the bowel through the defect.

2. Omphalitis
   Omphalitis

   Marked by a red, indurated area around the umbilicus, fever, irritability, and a generally ill-appearing neonate.

3. Omphalocele
   Omphalocele

   Omphalocele is an umbilical abdominal wall defect with bowel protruding through the defect but covered by a thin sac.

4. Peritonitis

5. Necrotizing enterocolitis
   Necrotizing enterocolitis

   Suspect NEC in neonates, especially preterm, with poor feeding, bloating, decreased activity, bloody stool, bilious vomiting, and multiorgan failure.

   (NEC)

6. Consider the risks and benefits in patients requiring an abdominal surgical incision above the umbilicus, patients with evidence of lower limb vascular compromise and patients with anterior abdominal wall defects

## Patient information and consent

### How do I explain this procedure?

“I need to put a drip up on your baby. This type of drip goes into a blood vessel that is in the baby’s cord.”

### What can my patient expect?

“You will see a tube protruding from your baby’s cord. When the belly button stump dries up and falls off, there will be no sign of there having been a drip.”

### What is my patient’s role?

“Please wash your hands before and after handling your baby, but you don’t have to be afraid of handling your baby. Take care not to touch or move the tube. Tell a nurse or doctor if you see any redness around the tube.”

## Preparation

1. Perform hand hygiene.

2. Switch on the warmer or Mecca crib. Ensure that the lighting works.

3. Once it is warm, place the neonate in the centre of the crib. Undress the neonate if they are not already exposed, keeping on any hat or socks. Attach the thermometer with a piece of tape to the abdomen.

4. Determine the

   depth
   depth

   This is calculated in centimetres as (baby's weight in kg * 1.5) + 5.5

   of the catheter insertion.

###

### Documentation

1. Patient notes

2. Nursing notes with instructions for monitoring and infusion dosages of fluid or parenteral nutrition

### Equipment

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile umbilical vein catheter pack

4. Sterile gloves

5. Sterile gown

6. Umbilical catheter
   Umbilical catheter

   Size 3.5 for neonates < 1500 g, or size 5 for neonates ≥ 1500 g

7. 3-way tap

8. Infusion set with filter and

   infusion pump
   infusion pump

   If unavailable, use a dial-a-flow or any infusion set where the fluid dosage can be preset and controlled. This is crucial as fluid overadministration rapidly results in fluid overload, cardiac failure and death.

9. Umbilical tape

10. Povidone-iodine solution
    Povidone-iodine solution

    There is no consensus on the superiority of one disinfectant agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

11. 5 ml syringe

12. 10 ml of 0.9% NaCL or normal saline

13. Umbilical tie

14. Scalpel blade

15. Transparent dressing

16. Curved artery forceps

17. Fine forceps

## Site & Positioning

The baby should be normothermic and

stable

stable

If unstable, consult with a senior first, unless in the case of a resuscitation where urgent venous access is required and intravenous access elsewhere cannot be obtained.

. Inspect the baby’s buttocks and legs for abnormalities that may indicate lower limb hypoperfusion. Position the baby supine.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene and don sterile gown and gloves.

2. Open the sterile pack and create a sterile field on a clean, dry surface. Pour skin disinfectant into the well. Open the catheter, three-way tap, infusion set, blade and syringe onto the sterile field.

3. Attach the 3 way tap to the catheter. Prime the catheter with 0.9% NaCL using the 5 ml syringe.

4. Clean
   Clean

   Clean in concentric circles starting in the middle.

   the umbilical cord area with skin disinfectant. Allow to dry.

5. Place the sterile towels around the umbilicus, leaving the

   head and feet exposed
   head and feet exposed

   Observe the baby closely for vasospasm in the leg or physical distress.

   .

6. Tie an

   umbilical tape
   umbilical tape

   If unavailable, use chromic, silk or other nonabsorbable suture material.

   around the base of the cord tight enough to minimise blood loss but loosely enough for the catheter to pass easily through the vessel.

7. Cleanly cut the umbilical cord with the blade about 1 cm from the

   base
   base

   Leaving 1-1.5 cm of stump allows you to apply pressure to the umbilicus if bleeding occurs on removal.

   .

8. Identify the vein, usually at 12 o’clock. The two arteries have relatively thick walls and a small lumen when compared with the vein.

9. Using the curved artery forceps, grasp the end of the umbilicus to hold it upright and steady.

10. Using fine forceps, gently open the vein.

11. Insert the catheter into the vein and advance slowly cephalad to the required depth. Blood should flow back freely.

12. Aspirate blood after the catheter has been placed correctly. Connect the catheter via the three-way tap to the infusion line.

13. Secure the catheter with the transparent dressing to the abdominal wall.

14. Inspect the baby’s legs for new discolouration. If the leg or toes are blue or white, remove the catheter.

15. X-ray the chest and abdomen to confirm the UVC position. The catheter tip should be visible at the level of the right diaphragm i.e in the inferior vena cava.

16. Dispose of medical waste safely.

17. Document the completion of the procedure in patient notes.

To remove a UVC: you need a sterile pack and sterile gloves, but not a sterile gown. Prepare as in steps 1,2, 4 and 5 above.

1. Withdraw the UVC 1 cm every 15-20 seconds.

2. Use the sterile gauze to put pressure on the umbilical cord until the bleeding stops.

3. Ensure the area is clean and dry. Do not apply a dressing.

4. Leave the baby in a supine position with the umbilicus exposed for an hour to monitor any bleeding.

5. After an hour the baby may be placed prone.

## Troubleshooting

There is resistance to advancing the catheter.

Advance gently with a rotating motion. It is important to prevent the formation of false passages. In some cases, loosening the umbilical tape may help. If resistance is met after entering the abdominal wall, the catheter may be coiled in the liver and should be retracted and repositioned.

The X-ray shows that the catheter is not in far enough i.e the catheter is too short.

Never push a catheter in if it is too short. Repeat the procedure with a new sterile catheter.

The X-ray shows that the catheter is inserted too far.

Decide the length to be withdrawn and identify this using the markings on the catheter. Gradually withdraw until the desired length is reached. This does not have to be done under sterile conditions.

On removing the UVC, the stump won’t stop bleeding.

Place your finger and thumb either side of the umbilicus, about 1-1.5 cm apart. Squeeze the abdominal wall together between your finger and thumb. This applies direct pressure to the umbilical vessels.

I don’t have an umbilical vein catheter.

Use a feeding tube of the same size.

## Risks

1. Trauma to the blood vessels

2. Thrombus formation at the catheter tip

3. Portal vein thrombosis

4. Calcification of the umbilical vein and intrahepatic branches of the portal vein

5. Infection

6. Air embolism

7. Sharps injury to healthcare personnel

## References

1. Lewis K, Sprinack P. Umbilical vein catheterisation. [Updated 2021 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549869/

2. Henning P. Venous umbilical catheterisation. In Neonatology: A guide for doctors. Department of Paediatrics and Child Health and Stellenbosch University. Tygerberg Hospital South Africa. 2012. p. 146-147

3. Joolay Y, Horn A, et al. Central line management-insertion of umbilical venous catheter. In: Neonatal Guidelines and Drug Dosages. Division of Neonatal Medicine Groote Schuur Hospital. 2012. p. 128-129

4. Blitz-Lindeque J. How to insert an umbilical vein catheter. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 242-243.