Overview of Umbilical Vein Catheterization
Umbilical vein catheterization is a procedure used to gain quick and safe access to a baby’s bloodstream through their remaining umbilical cord. This can be done up to 14 days after the baby is born. It’s often used in emergencies to provide medications and fluids. Even though it’s most commonly used for newborns right after birth, it is also a useful option for healthcare providers who are trained in this procedure.
Typically, when a baby needs medication, it is preferably given through a peripheral intravenous line, which is a small tube inserted into a vein. However, those who work with newborns should know how to establish multiple types of IV access. This includes using bones (intraosseous lines), regular veins (peripheral IVs), large central veins (central venous catheters), and the umbilical cord (umbilical vein access).
Even though using an intraosseous line can sometimes be faster than setting up an umbilical vein catheter, it can be challenging to establish in a newborn. This method also has a higher risk of being accidentally dislodged during a critical situation. Because of these factors, umbilical vein catheterization is a beneficial method for trained staff to gain IV access in newborns.is a beneficial method for trained staff to gain IV access in newborns.
Anatomy and Physiology of Umbilical Vein Catheterization
The umbilical cord starts to grow from the yolk sac and a part of the baby called the allantois around the fifth week of pregnancy. For the entire duration of pregnancy, it’s about the same length as the baby from head to bottom. When a baby is born, the umbilical cord usually measures about 2 centimeters thick and 50 centimeters long. It then needs to be clamped and cut.
The umbilical cord has two arteries and one vein. The arteries are smaller and have thicker walls, making them easily distinguishable. On the other hand, the vein is usually positioned at 12 o’clock, has thinner walls, and a larger opening than the arteries. If a doctor needs to insert a catheter (a thin, flexible tube) into the umbilical vein, it should ideally reach the inferior vena cava, a large vein in the body that carries deoxygenated blood from the lower body back to the heart, just below the right atrium (one of the four chambers of the heart).
Why do People Need Umbilical Vein Catheterization
A doctor might need to insert a catheter into the umbilical vein of a newborn baby for various reasons. These may include the baby needing to be resuscitated, needing blood transfusions, or needing an intravenous line (IV) for a short time, especially when other methods of accessing a vein are not possible.
A consensus guideline from McMaster University suggests when this procedure should be used; 1. It is recommended for all premature babies born at 28 weeks gestation or less. 2. The technique is suggested for newborns born at or after 29 weeks if they need help breathing and are on a machine, or if they need more than 40% oxygen while they are under continuous positive airway pressure, often called a CPAP machine. 3. The catheterization procedure is also recommended for newborns born at or after 29 weeks if they are not stable, including symptoms like irregular heartbeat or low blood pressure.
When a Person Should Avoid Umbilical Vein Catheterization
If a person has conditions like gastroschisis (a birth defect where the baby’s intestines are outside the body), omphalitis (infection of the belly button), omphalocele (another birth defect where organs are outside the body), peritonitis (inflammation of the lining of the belly), vascular compromise (poor blood flow), or necrotizing enterocolitis (serious infection of the intestines), doctors can’t place a type of tube called an umbilical vein catheter. This tube is usually inserted into a blood vessel in the belly button area to provide medicine or nutrients.
Equipment used for Umbilical Vein Catheterization
To perform a medical procedure on a newborn, your healthcare providers will wear a clean hospital gown, sterile gloves, a cap, and a mask to maintain cleanliness and reduce the risk of infection. They would also set up a radiant warmer to provide comfortable heat for your baby. The procedure is carried out under sterile drapes to reduce infection risk.
They will use sterilizing solution to clean the area. A tool termed an ‘umbilical tape’ is used. To make a cut, the healthcare provider will use a small, sharp knife known as a scalpel. There are several types of forceps used, including Iris and non-toothed forceps. Forceps are like tweezers, used for picking up or holding small items.
A catheter specifically designed for umbilical veins is used. Catheters are thin tubes used to deliver or remove fluids. Catheters are controlled using a ‘three-way stopcock’. This device can open, close, and direct the fluid flowing through the system. Regular medical tubing is also used to manage fluids.
A tool called a ‘needle driver’ is used to hold the needle while sewing. The healthcare provider also uses 3-O silk sutures. Sutures are the medical term for stitches. They help close wounds or surgical incisions. Finally, a sterile saline solution is used to clean and maintain the humidity of your child’s skin.
The size of the umbilical vein catheter is determined by the weight of your newborn. Infants weighing less than 3.5 kg will get a smaller (3.5 French) catheter. Babies who weigh 3.5 kg or more will get a larger (5 French) catheter. The catheters are flushed with a saltwater solution (normal saline) and connected to a 10-cc syringe for use with the three-way stopcock.
Who is needed to perform Umbilical Vein Catheterization?
The procedure of placing an umbilical vein catheter (a thin tube that goes into a vein in the belly button to deliver medicine or fluids) should be carried out by a doctor, a doctor-in-training, or an advanced healthcare provider who has been specifically trained for this task. Apart from this, there should be another person such as a nurse or a paramedic present during this process. They will help observe the patient from start to finish and assist with placing the patient in the right position and handling the medical equipment.
Preparing for Umbilical Vein Catheterization
Before a procedure can be performed on a newborn, there are several important steps that the medical team must complete. First, all of the necessary equipment needs to be gathered and checked to make sure it’s functioning correctly. Then, any available lab results should be reviewed.
Next, it’s important to get written permission from the baby’s parent or guardian. This happens after there’s a conversation about the pros and cons of the procedure and also a discussion about other possible treatment options. This consent step might be skipped if it’s a life-threatening emergency and the procedure must be done right away.
Then, a “time-out” is done. This is a final check to make sure that the correct baby has been identified for the procedure and that there are no reasons that would make the procedure unsafe.
The procedure will be done inside a heated machine known as a “radiant warmer”. This is to protect the newborn from any exposure to cold temperatures that could be harmful.
A slender tube known as a catheter is prepared. It’s flushed out with a mixture of heparin and a fluid similar to the body’s own blood. This does two things: it removes any air bubbles that might be in the catheter and it also helps to prevent blood clotting inside the catheter. After that, a small device called a three-way stop-cock is attached to the catheter. This allows the medical team to control the flow of fluids through the catheter.
How is Umbilical Vein Catheterization performed
In order to prepare for the procedure, the belly button (umbilical stump) is cleaned with a special solution that kills bacteria. A special sterile medical band (umbilical tape) is wrapped around at the point where the skin connects with the belly button. The area around the procedure is covered with clean, sterile drapes. The belly button is secured with a non-sharp medical tool (non-toothed forceps) and is pulled upwards to make it straight. A cut is made across the belly button about half an inch away from the skin to expose the core of the belly button, this helps the physician see the inside and properly place the catheter in the umbilical vein.
The umbilical vein is bigger than the two umbilical arteries, it is located at the 12 o’clock position, and is identified by its thin wall. If there is any bleeding, the umbilical tape can be tightened. A special tool called ‘iris forceps’ is used to create an opening and make space inside the umbilical vein, and also to remove any blood clot present in the vein. Then the catheter is held with iris forceps and gently inserted into the umbilical vein.
The base of the belly button is held steady with the non-dominant hand. The catheter, which has been rinsed inside (flushed), is then inserted into the vein. The depth of the catheter is based on the baby’s maturity, usually 1 to 2 inches in a full-term baby and about 1 inch in a premature baby. Once the catheter is in place, ensure that there’s blood returning into the catheter. Ideally, the catheter end should be located where the main vein carrying deoxygenated blood to the heart (inferior vena cava) joins the heart’s right upper chamber (right atrium).
The catheter is gently pushed if resistance is met. If there still found significant resistance after loosening the umbilical tape, the procedure is stopped, and a different method of creating a vein access is looked for. If the catheter is needed for emergency access, it is placed a bit more farther (usually by about 1 inch) from where the initial blood return was seen. If the catheter is needed for longer periods, it is usually positioned inside the inferior vena cava and below the right atrium, which generally requires an insertion of about 4 to 5 inches in a full-term baby.
The catheter within the inferior vena cava is considered central and is useful for monitoring the pressure in the veins or for administering certain medications or feeding solutions. If the intent is to place the catheter at this location, it must be confirmed via X-ray to ensure it is correctly positioned to avoid any complications. There are many standard charts and formulas to help estimate the exact placement depth. Once the catheter is in place, it is secured using a suture, tape is used for extra support to prevent the catheter from shifting, and a transparent dressing is applied on top.
The correct catheter tip position should be affirmed either by an X-ray of the chest and abdomen, or by an abdominal ultrasound. Currently, the preferred method is an abdominal ultrasound.
Possible Complications of Umbilical Vein Catheterization
The placement of a central venous access, a tube inserted into a large vein to deliver medication or fluids, may sometimes lead to certain complications. These may include uncontrolled bleeding, infection, harm to nearby structures, blood clotting, and incorrect placement into an artery. When we talk about umbilical vein catheters, specifically, there is a risk of putting the catheter in the portal venous system, which carries blood to the liver. If this happens and strong solutions leak out, it can cause liver damage.
Some reports have also noted complications like liver abscess (a pocket of pus in the liver), blood clots in the portal vein, and formation of new blood vessels in a tangled mass known as a cavernoma. Because newborn babies have a small venous system, it is extremely important that central lines are cleaned with saline solution to make sure there’s no air in the line, avoiding air embolism, a potentially life-threatening condition where an air bubble enters a vein or artery.
Incorrect placement of an umbilical vein catheter into the umbilical artery can lead to obstruction of the limb arterial supply or clotting. This can starve the limb of blood and nutrients, causing tissue damage or death (known as ischemia). If the catheter is placed in the right atrium of the heart, it can lead to a situation where the heart is unable to pump blood (perforation), followed by a build-up of fluid around the heart (pericardial effusion).
If a newborn becomes unstable after the placement of an umbilical vein catheter, cardiac tamponade, pressure on the heart caused by fluid in the sac around the heart, should be considered. However, despite these potential issues, the rate of complications from umbilical venous catheters is similar to that of central venous catheters placed through the skin. Some reports have suggested lower rates of blood clotting and obstruction of the large vein in the pelvis or thigh (iliofemoral vein occlusion) with umbilical vein catheters when compared to femoral central venous catheters, which are placed in the groin.
What Else Should I Know About Umbilical Vein Catheterization?
Inserting a catheter into the umbilical vein is a trusted method for quickly establishing access to the bloodstream for babies up to 14 days old. This can be used to deliver medications quickly in emergency situations.