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Umbilical Vein Catheterization in the Critical Newborn
As the number of critical-care transport (CCT) programs has grown, they’ve begun to specialize into pediatric, neonatal and even high-risk obstetric/gynecological teams.1,2 Specialized pediatric education programs now exist for critical-care paramedics (CCPs), who require unique advanced skills. One of those is umbilical vein catheterization line placement, which involves placement of an intravenous line into the vein of the umbilical cord of a newborn following delivery. It’s not a difficult procedure, but it requires a review of the anatomy of the umbilical cord and the technique itself.
Umbilical Vein Catheterization
The umbilical cord is a baby’s lifeline in utero. It serves as a conduit for nutrients between the fetus and mother’s placenta. It consists of two (paired) thicker-walled arteries and one thinner-walled vein located at 12 o’clock (Figure 1) covered by a proteoglycan-rich matrix of connective tissue referred to as Wharton’s jelly. This covering not only protects the vessels but keeps the umbilical cord from twisting and cutting off fetal circulation.3 Once the baby is born, the umbilical arteries typically spasm shut, whereas the umbilical vein does not. (What we often refer to as a baby is more accurately described as a newborn for the first few hours following birth and then a neonate for the next 28 days.)
Umbilical vein catheterization (UVC) has been used by neonatal specialists for many years for central pressure monitoring, infusion of fluids, and administration of medications during and following neonatal resuscitation.4 Since the umbilical vein remains patent for up to one week after birth,4,5 it offers an effective route for vascular access in the neonate, and even more so in the premature neonate. The procedure does require specialized equipment, training and confirmation of correct placement by x-ray.3 Many organizations have begun looking at this option for vascular access in the depressed newborn.
Fast-Cath
One option for placing a UVC line is the Fast-Cath system developed by the OB department and pediatricians at Minnesota’s Lakeview Hospital. The Fast-Cath was designed for use by physicians, nurses and paramedics during the initial resuscitation of a depressed newborn. It places a traditional UVC line under sterile conditions for use in central venous pressure monitoring and infusion of fluids and medications.
The Fast-Cath technique utilizes equipment most physicians, nurses and paramedics use regularly and are familiar with. This provides an advantage over specialized kits in time-stressed environments6 and leads to higher success rates.7–9 The Fast-Cath utilizes a standard 14-gauge protective IV catheter inserted until it flushes easily. Other UVC line kits utilize a specialized umbilical vein catheter and require formulas for correct placement and radiographic confirmation.3 The Fast-Cath kit can be made by purchasing the various components and packaging them into a medium-size sealable plastic bag (Figure 2). For hospital-based services, the central supply department can sterilize and package all the components.
Insertion of the Fast-Cath is best accomplished by two clinicians: The primary clinician (PC) inserts the catheter, and the secondary clinician (SC) assists by stabilizing the umbilical cord. The PC opens the kit and lays out the components, verifying that all are present. The SC takes the Betadine swabs and paints the umbilical cord base and the cord itself. The SC then takes the umbilical tape and ties it at the base of the cord. It should be tied tightly enough to stop blood flow, but not so tight that you can’t pass the catheter through the vein. While the SC does this, the PC puts on sterile gloves, takes the 14-gauge angiocatheter and removes the needle. Next the PC connects the preloaded 10-ml syringe to the extension tubing and flushes it. Once the SC has an IV solution bag and administration set flushed and ready to go, placement of the UVC line can begin.
Wearing sterile gloves, the SC grasps the umbilical cord with a sterile 2x2 and cuts horizontally across it. The cord should be left long in case it is cut at an angle and needs to be recut later by neonatal specialists. Typically, the minimum an umbilical cord can be cut down to is around 1–2 cm from the abdominal wall.10 The SC continues to stabilize the umbilical cord while the PC inserts the angiocatheter into the umbilical vein to the hub of the catheter and then aspirates for blood return into the extension tubing. If blood is not aspirated, attempt to flush the IV line with saline. If it flushes easily, the line is patent.
Due to the short length of the angiocatheter, this is essentially a peripheral IV line—unlike a traditional UVC, which is placed near the right atrium. Ideally this procedure is done by two clinicians, though it can be accomplished by one by setting up the equipment and placing it on a sterile field. In that case the PC takes a sterile 2x2, grasps the umbilical cord and inserts the Fast-Cath, then stabilizes the cord and catheter and attempts to aspirate and/or flush the line.
Once it’s established that the UVC is patent, clamp the extension tubing (with clamp-on tubing) to prevent possible air embolisms. Since this is a venous line, not arterial, the risk of air embolism is greatly reduced. Next disconnect the syringe and attach a three-way stopcock to the extension tubing and IV administration set. Unclamp the extension tubing and adjust the IV flow rate accordingly. Secure the catheter in place by making a small tape bridge so the weight and movement of the stopcock and IV line do not dislodge it.
The Fast-Cath system also allows receiving neonatal specialists to place their UVC by using a modified Seldinger technique.11,12 A 3.5 French UVC can be inserted through the angiocatheter, then the angiocatheter is removed and slid up the UVC. This allows the UVC line to be used as a central line.
Summary
Why attempt a UVC line when intraosseous access is often available EMS clinicians and the literature has demonstrated its ease of placement and effectiveness even in neonates?13,14 This article is not intended to suggest giving up IO vascular access if you currently have it in your toolbox. The intent was to discuss an alternative to IO vascular access when it fails—for example, when a tibia fractured during an IO attempt15 or is not an option for other reasons. The Fast-Cath UVC is another tool in the advanced EMS clinician’s arsenal that can be easily learned and utilized. It is an effective option for vascular access in the distressed newborn when other options have failed or are not available.
References
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2. AirLife Denver. High Risk OB, https://airlifedenver.com/specialty-teams/high-risk-ob.dot.
3. Butler-O’Hara M, Buzzard CJ, et al. A randomized trial comparing long-term and short-term use of umbilical venous catheters in premature infants with birth weights of less than 1251 grams. Pediatrics, 2006 Jul; 118(1): e25–35.
4. British Columbia Ambulance Service. Critical Care Transport Program, www.bcas.ca/EN/main/services/critical-transport-program.html.
5. Stathers CL, et al. Chapter 1: Introduction to Critical Care Transport. In: Murphy M, Stathers CL, et al, eds, Critical Care Transport. Burlington, MA: Jones and Bartlett, 2011.
6. Amedi A, Malach R, Hendler T, Peled S, Zohary E. Visuo-haptic object-related activation in the ventral visual pathway. Nat Neurosco, 2001 Mar; 4(3): 324–30.
7. Lederman SJ, Klatzky RL. Hand movements: a window into haptic object recognition. Cogn Psychol, 1987 Jul; 19(3): 342–68.
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9. Cannon-Bowers J, Salas E. Making Decisions Under Stress: Implications for Individual and Team Training. Washington, DC: American Psychological Association, 1998.
10. www.uihealthcare.com/depts/med/pediatrics/iowaneonatologyhandbook/procedures/insertionumbilicalvessel.html.
11. www.cvc-partner.com/index.cfm?7F880D3CB24B4A6586A771F17149822C.
12. Schwartz AJ, Jobes DR, et al. Carotid artery puncture with internal jugular cannulation using the Seldinger technique: incidence, recognition, treatment, and prevention. Anesth, 1979; 51(3): 161.
13. Kliman HJ. The Umbilical Cord, https://info.med.yale.edu/obgyn/kliman/placenta/articles/EOR_UC/Umbilical_Cord.html.
14. Ellemunter H, Simma B, Trawoger R, Maurer H. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed, 1999 Jan; 80(1): F74–75.
15. Fisher R, Prosser D. Intraosseous access in infant resuscitation. Arch Dis Child, 2000 Jul; 83(1): 87.
Scott Tomek, MA, EMT-P, has been in EMS for the past 29 years. He oversees quality improvement, safety and risk management at Minnesota’s Allina Health Medical Transportation, and serves a faculty member with the Century College paramedic program and a subject-matter expert on prehospital airway management.
