Umbilical Vein Catheterization 

Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation. The umbilical vein remains patent and viable for cannulation until approximately 1 week after birth. After proper placement of the umbilical line, intravenous fluids and medication may be administered to critically ill neonates.^[1]

When critically ill newborns present to the emergency department, peripheral access is preferred. If this is impossible, umbilical vein catheterization may be attempted.

• The principal indication for umbilical vein catheterization is to gain vascular access during emergency resuscitation.
• Alternative uses of the umbilical vein may include exchange transfusions and central venous access.^[2]

Absolute contraindications to umbilical vein catheterization include the following:

• Omphalitis
• Peritonitis
• Necrotizing enterocolitis

Umbilical vein catheterization typically requires no anesthesia.

Before initiating the procedure, a radiant warmer should be obtained, and the patient should be connected to a cardiac monitor. Necessary equipment includes the following:

• Personal protective equipment (ie, sterile gown, gloves, mask)
• Sterile drapes
• Umbilical catheter, 3.5F or 5F (See the images below.)5F umbilical catheter. Note proximal attachment for stopcock. Close-up of umbilical catheter.
• Iris forceps without teeth
• Small clamps
• Scalpel
• Scissors
• Needle holder
• Silk suture (3-0) or umbilical tape
• Intravenous tubing and 3-way stopcock
• Infusion solution (dextrose 5% in water or 0.9% sodium chloride [NaCl] with heparin 1 U/mL solution)

The newborn should be restrained in a supine position and placed beneath a radiant warmer.

• The umbilical cord stump and surrounding abdomen should be sterilized with a bactericidal solution. Sterile drapes should be placed.
• A purse-string suture or umbilical tape is tied around the base of the stump to provide hemostasis and to anchor the line after the procedure.
• Using the scalpel, the cord is cut horizontally, approximately 1.5-2 cm from the abdominal wall. Two thick-walled small arteries and one thin-walled larger vein should be identified. The umbilical vein may continue to ooze blood. See the images below. Umbilical stump illustrating arteries and vein. Illustration of umbilical vein and arteries.
• Hemostasis is achieved through tightening the umbilical tape or suture. The arteries do not usually bleed secondary to vasospasm.
• Forceps are then used to clear any thrombi and dilate the vein. See the image below.Dilating the umbilical vein and clearing thrombus.
• A 3.5F catheter is used for preterm newborns, and a 5F catheter is used for full-term newborns.
• The catheter should be flushed with pre-heparinized solution and attached to a closed stopcock.
• The catheter is then grasped 1 cm from its distal tip with the iris forceps and gently inserted, aiming the tip toward the right shoulder. Advance the catheter only 1-2 cm beyond the point at which good blood return is obtained. This is approximately 4-5 cm in a full-term neonate. If resistance is initially met, loosen the umbilical tape or suture and manipulate the angle of approach. See the images below. Insertion of umbilical vein catheter.

  Technique for umbilical vein dilation and insertion of catheter.
• Do not force the advancement.
• Secure the catheter with a suture through the cord, marker tape, and a tape bridge.
• The position of the catheter must be confirmed radiographically. A properly placed umbilical vein catheter appears to travel cephalad until it passes through the ductus venosus.^[3]
• Standardized graphs estimate the length of catheter insertion based on shoulder-to-umbilicus length. Alternatively, the shoulder-to-umbilicus length may be multiplied by 0.6 to determine a length that leaves the tip of the catheter above the diaphragm but below the right atrium.
• In an emergency resuscitation, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained.

• When identifying vessels, remember that the vein is usually located in the 12-o’clock position.
• To ensure an air-free catheter, fill the lumen with infusion solution and close the stopcock until the catheter is in the vein.
• Umbilical vein catheters may be placed in the inferior vena cava above the level of the ductus venosus and below the level of the right atrium (10-12 cm). This acts as central venous access, allowing central venous pressure (CVP) monitoring, medication infusions, and the administration of hyperalimentation solutions.
• In an emergency, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained to avoid injecting hyperosmolar fluids into the portal vessels and causing liver necrosis.
• The catheter may be pulled back, but not advanced, once the sterile field is down.
• To avoid air embolism as the catheter is removed, tighten the purse-string suture or tape and apply pressure to the umbilicus.
• Intraosseous access is another option that can be used in neonates. Evidence suggests that intraosseous access may be obtained more rapidly than umbilical vein access.

Complications of umbilical vein catheterization include the following:^{[4, 5]}

• Infection
• Hemorrhage
• Vessel perforation
• Creation of a false luminal tract^[6]
• Hepatic abscess or necrosis^[7]
• Air embolism
• Catheter tip embolism
• Portal venous thrombosis^[8]
• Dysrhythmia and pericardial tamponade or perforation (if the catheter is advanced to the heart)^{[9, 10, 11]}