Umbilical Artery Catheterization

The umbilical artery can be used for arterial access during the first 5-7 days of life, but it is rarely
used beyond 7-10 days.

Indications

Indications for umbilical artery catheterization include the following:

 Continuous arterial blood pressure monitoring

 Arterial blood gas sampling

 Blood sampling for other laboratory tests and studies

 Exchange transfusion

 Angiography

 Infusion of maintenance fluids when other routes are not available

Contraindications

Contraindications for umbilical artery catheterization include the following:

 Omphalocele

 Omphalitis

 Cord anomalies

 Peritonitis

 Necrotizing enterocolitis

 Vascular compromise to the kidneys, buttocks, or lower limbs

Equipment

An umbilical catheter insertion tray should be available that includes the following:

 Syringe, 1 mL

 Syringe, 3 mL (2)
  Syringe, 5 mL (2)

 Hypodermic needle, 20 gauge

 Mosquito hemostat, straight, 5 in.

 Mosquito hemostat, curved, 5 in. (2)

 Vessel dilator probe, 5.5 in.

 Iris forceps, full curve, 4 in.

 Iris forceps, half curve, 4 in.

 Iris forceps, straight, 4 in., 1 × 2 teeth

 Straight forceps, smooth

 Hemostat needle holder, 5 in.

 Straight Iris scissors

 Safety scalpel with No. 11 blade

 Silk suture, 4-0, with curved cutting needle

 Umbilical tape, 15 in.

 Measuring tape

 Drape with 6-cm orifice

 Gauze pads, 4 × 4 in. (6)

 Gauze pads, 2 × 2 in. (6)

Additional equipment used in the procedure includes the following:

 Single-lumen umbilical artery catheter, 3.5 French (neonate weight < 1500 g) or 5 French
(neonate weight >1500 g)

 Stopcock, three-way

 Additional 5-mL syringes (2)

 Heparinized flush (0.45% sodium chloride plus 1:1 heparin)

  Skin preparation solution (4% chlorhexidine gluconate or povidone iodine)

 Sterile surgical towels (4)

 Surgical mask

 Surgical gown

 Sterile gloves

 Arterial pressure transducer

Positioning

The neonate should be placed in a supine position under a radiant warmer. The head of the
neonate should be positioned toward the top of the warmer.

Care must be taken to ensure adequate thermal support during the procedure, especially in
neonates with extremely low birth weight.

Technique

Determining catheter depth

.In the high position, the catheter tip lies above the diaphragm, between thoracic vertebrae T6 and
T9. This position is above the celiac artery (T12), the superior mesenteric artery (T12-L1), and
the renal arteries (L1).

For the high position, the insertion depth can be calculated :

 Umbilical artery catheter depth (cm) = (birth weight [kg] × 3) + 9

 Umbilical artery catheter depth (cm) = (birth weight [kg] × 4) + 7

In the low position, the catheter tip lies above the aortic bifurcation (L4-L5). The tip of the
catheter lies near the origin of the inferior mesenteric artery (L3-L4).

Umbilical artery cannulation

 Restrain the neonate under the radiant warmer using soft arm and leg restraints.

 Prepare the catheter under sterile conditions by connecting the three-way stopcock to the
end of the catheter. Connect one prefilled 5-mL syringe to each port of the stopcock.
 Flush the system with heparinized solution (0.45% sodium chloride plus 1:1 heparin).
Ensure that no air bubbles are present in the system. Turn the stopcock off to the catheter.

 An assistant should hold the umbilicus upright with the cord clamp while the physician
cleans the cord and an area of surrounding skin (~3-5 cm around the cord base) in sterile
fashion with 4% chlorhexidine gluconate or povidone-iodine solution.

 Drape the neonate’s abdomen with sterile towels, allowing adequate exposure to the
umbilical cord and base.

 Place the umbilical tape at the base of the umbilicus. Tie a square knot around the base of
the cord as close to the abdominal wall as possible. Tighten the knot securely to avoid
bleeding after the umbilical stump is cut.

 Cut the umbilical stump to within 1-2 cm of the abdominal wall using a No. 11 scalpel
blade. Use a straight cut across with a gentle sawing motion.

 Identify the vessels in the freshly cut cord (a large, single, thin-walled umbilical vein and
two small muscular arteries. Vessel identification and isolation are made easier by
holding the edges of the cord with the curved 5-in. mosquito hemostats.

 Isolate one umbilical artery, and carefully dilate the lumen using curved Iris. Insert the tip
of the forceps into the lumen as deeply as possible, then allow the forceps tips to spread
open over 15-30 seconds while holding the tips in the vessel lumen.

 Perform the dilation technique two or three times until the lumen of the vessel appears
dilated enough to accept the catheter.
 Umbilical artery catheterization.
Dilation of umbilical artery.

 Grasp the end of the catheter, approximately 1 cm from the tip, with the half-curve Iris
forceps. Hold the vessel lumen open with the full-curve forceps, and gently insert the
catheter into the dilated umbilical artery lumen.

Umbilical artery catheterization.

Introduction of umbilical artery catheter into vessel.

 Once the catheter is advanced into the lumen to a depth of 2 cm, remove the half-curve
Iris forceps. If it is not possible to advance the catheter to 2 cm, withdraw it and dilate the
vessel again.

 Continue to advance the catheter to a depth of 4-5 cm, and aspirate to verify position in
the lumen. If blood is easily aspirated, the catheter is within the lumen. Clear the catheter
of blood by injecting 0.5 mL of heparinized flush.

 If resistance is met prior to this depth, try to loosen the umbilical tie. If a “popping”
sensation is encountered while advancing the catheter, the catheter has likely exited the
lumen and created a false tract.
  Continue to advance the catheter to the predetermined depth. Once there, again aspirate
to verify position in the aorta and flush the catheter. The catheter should draw and flush
easily.

 If resistance is encountered in the first 5 cm during advancement, apply gentle steady

pressure for 30-60 seconds to allow the vessel to relax.

 Once the catheter has been advanced to the predetermined depth, confirm placement with
chest and abdominal radiography. The catheter tip should lie above the level of the
diaphragm between T6 and T9.

 On radiograph, the catheter should be seen entering the umbilical cord and then
proceeding inferiorly to connect with the internal iliac artery (see the image below). The
catheter should be seen curving cephalad to enter the aorta and proceeding in a straight
line to the left of the vertebral column.

Umbilical artery catheterization.

Correctly positioned umbilical artery catheter with tip at T8-9.

 If the catheter is noted to be in the femoral artery or gluteal artery, pull it back to a depth
of 4-5 cm and attempt reinsertion. The femoral and gluteal arteries are not suitable sites
for sampling, infusion, or blood pressure monitoring.

 Once correct position is verified on radiography, secure the catheter in place using a
purse-string suture through the umbilical cord stump (not through the skin or vessels).
This is done by taking two or three bites through the cord in an in-to-out manner. Secure
the catheter to the stump by wrapping the tails of the suture snugly around the catheter
and then tying securely with a surgical instrument tie (see the images below).
 Umbilical artery catheterization.
Securing suture in umbilical stump.

Umbilical artery catheterization.

Securing suture in umbilical stump looped around umbilical catheter and tied securely in place.

Further secure the catheter by means of a self-made or commercially available umbilical catheter
bridge adhered to the abdominal wall (see the image below).
 Umbilical artery catheterization. Tape
bridge placed to secure umbilical catheters in place.

Once the catheter is secured, loosen and remove the umbilical tape. Connect the arterial pressure
transducer, and verify a good arterial waveform.

To remove the umbilical artery catheter, stop fluid infusion, cut the retention suture, and pull the
catheter back to a depth of 1-2 cm. Wait at least 5-10 minutes to allow the umbilical artery to
constrict before removing the catheter. If bleeding occurs, use umbilical tape secured around the
base of the cord. Alternatively, pressure can be applied to the iliac artery to control bleeding.
Keep the neonate supine for 30-60 minutes after umbilical artery catheter removal to allow easy
monitoring of bleeding.

The umbilical vein, not the umbilical artery, is the preferred route for medication and fluid
administration during neonatal resuscitation

Complications

Related to catheter malpositioning:

 Vessel perforation

 Refractory hypoglycemia (if glucose-containing fluids are being infused and the catheter
tip is near the celiac axis)

 Peritoneal perforation

 Sciatic nerve damage

Related to vascular accidents:

 Thrombosis

 Embolism/infarction

 Vasospasm

 Loss of extremity

 Hypertension

 Paraplegia

 Heart failure (from aortic thrombosis)

 Air embolism

Equipment-related complications:

 Broken catheter

 Transection of catheter

Other complications include the following:

 Hemorrhage

 Infection [12]

 Necrotizing enterocolitis

 Intestinal necrosis or perforation (related to a vascular accident or infusion of hypertonic

solution)

 Cotton fiber embolus

 Wharton-jelly embolus

 Hypernatremia (true or factitious)