Mariam M. Said

Khodayar Rais-Bahrami

30 Umbilical Vein Catheterization

A. Indications

1. Primary

a. Emergency vascular access for fluid and medication

infusion and for blood drawing

b. Long-term central venous access in low-birthweight

infants. If the line is to be used long-term, particularly if parenteral nutrition is to be infused by this

route, the same aseptic techniques must be used to

prevent line-related sepsis as are used for any central

venous line (see Chapter 32).

c. Exchange transfusion

2. Secondary

a. Central venous pressure monitoring (if catheter

across ductus venosus)

b. Diagnosis of total anomalous pulmonary venous

drainage below the diaphragm (1)

B. Contraindications

1. Omphalitis

2. Omphalocele

3. Necrotizing enterocolitis

4. Peritonitis

C. Equipment

1. Catheter—same as for umbilical artery catheterization,

except:

a. 3.5-French (Fr) catheter for infants weighing <3.5 kg

b. 5-Fr catheter for infants weighing >3.5 kg

c. Double lumen umbilical venous catheters may be

used in critically ill neonates to allow administration

of inotropes or medications.

d. Catheters used for exchange transfusion (removed

after procedure) should have side holes. This

reduces risk of sucking thin wall of inferior vena

cava against catheter tip, with possible vascular perforation (2). Avoid double lumen catheters for

exchange transfusions.

2. Other equipment as for umbilical artery catheter, but

omit 2% lidocaine (see Chapter 29, C)

D. Precautions

1. Keep catheter tip away from origin of hepatic vessels,

portal vein, and foramen ovale. Catheter tip should

lie ideally at the junction of the inferior vena cava and

the right atrium. The tip should at least be well into the

ductus venosus to protect the liver from receiving inappropriate infusions (3). Sometimes it will not be possible to advance the catheter through the ductus venosus.

Vigorous attempts to advance are to be avoided. In an

emergency, vital infusions (avoid very hypertonic solutions) may be given slowly after pulling catheter back

into umbilical vein (approximately 2 cm) and checking

blood return.

2. Check catheter position prior to exchange transfusion.

Avoid performing exchange transfusion with catheter

tip in portal system or intrahepatic venous branch (see

Fig. 30.1)

3. Once secured, do not advance catheter into vein.

4. Avoid infusion of hypertonic solutions when catheter

tip is not in inferior vena cava.

5. Do not leave catheter open to atmosphere (danger of

air embolus).

6. Avoid using a central venous pressure monitoring catheter for concomitant infusion of parenteral nutrition

(risk of sepsis).

7. Be aware of potential inaccuracies of venous pressure

measurements in inferior vena cava (see Chapter 32).

E. Technique (See Procedures Website

for Video)

Anatomic note: In the full-term infant, the umbilical vein is

2 to 3 cm in length and 4 to 5 mm in diameter. From the

umbilicus, it passes cephalad and slightly to the right, where

it joins the portal sinus, a confluence of the umbilical vein

with the right and left intrahepatic portal veins. The portal

veins have intrahepatic branches that are distributed directly

to the liver tissue. The ductus venosus becomes a continuation of the umbilical vein by arising from the left branch of

the portal vein, directly opposite where the umbilical vein

joins it. The ductus is located in a groove between the right