Overview
Definition:
Umbilical venous catheterization (UVC) is a procedure to insert a catheter into the umbilical vein, typically within the first few days of life, for vascular access
The umbilical vein is a direct conduit to the portal circulation and ultimately to the inferior vena cava, providing a route for rapid fluid, medication, and blood product administration, as well as for monitoring central venous pressure and obtaining blood samples in neonates.
Epidemiology:
UVC is commonly used in critically ill neonates requiring intensive care, including premature infants, those with birth asphyxia, sepsis, or surgical conditions
Its use is indicated in approximately 5-15% of all neonates admitted to NICU, with higher rates in extremely premature infants.
Clinical Significance:
UVC provides a reliable and readily accessible route for central venous access in the immediate neonatal period, which is crucial for managing unstable neonates
It allows for precise administration of vasoactive drugs, fluid resuscitation, parenteral nutrition, and chemotherapy, and facilitates hemodynamic monitoring, thereby improving outcomes in critically ill newborns
Expertise in its placement and management is essential for all pediatric residents and DNB/NEET SS candidates.
Indications For Placement
Emergencysituations:
Rapid administration of emergency medications (e.g., epinephrine, sodium bicarbonate, volume expanders) during resuscitation
Need for frequent blood sampling in unstable neonates.
Hemodynamicinstability:
Inotropic or vasoactive support for conditions like shock, sepsis, or congenital heart disease
Need for invasive hemodynamic monitoring (e.g., central venous pressure).
Nutritional Support:
Initiation of parenteral nutrition (TPN) when enteral feeding is not feasible or sufficient, especially in premature infants or those with gastrointestinal anomalies
Long-term venous access requirements for prolonged treatment.
Specificneonatalconditions:
Meconium aspiration syndrome requiring aggressive respiratory and circulatory support
Neonates with congenital anomalies requiring complex medical or surgical management
Severe anemia requiring blood transfusions.
Contraindications
Absolute Contraindications:
Absent umbilical cord stump (rare)
Omphalitis or severe abdominal wall infection at the insertion site
Known congenital anomalies of the portal system or liver.
Relative Contraindications:
Disseminated intravascular coagulation (DIC) or severe coagulopathy
Congenital abdominal wall defects (e.g., gastroschisis, omphalocele) may require alternative access methods due to contamination risk or altered anatomy
Previous abdominal surgery involving the umbilical area.
Considerations At Time Of Insertion:
The presence of infection at the insertion site is a relative contraindication
sterile technique is paramount
The duration of UVC use should be minimized to reduce complications.
Procedure Steps
Preparation:
Gather all necessary equipment: UVC kit (catheter, guidewire, syringe, antiseptic solution, sterile drapes, gloves, mask, gown, sterile saline, gauze, tape, sterile scissors or scalpel)
Ensure proper lighting and a sterile field
Identify the umbilical cord and its vessels (two arteries and one vein).
Insertion Technique:
Cleanse the umbilical stump and surrounding skin with antiseptic solution and allow to dry
Ligate the umbilical cord approximately 1-2 cm from the abdominal wall using umbilical tape or a clamp
Gently cut the cord distal to the ligature, exposing the umbilical vessels
Identify the umbilical vein (larger, thinner-walled, and centrally located)
Gently dilate the umbilical vein with a blunt-tipped instrument or by gentle manipulation of the catheter.
Catheter Insertion And Advancement:
Insert the UVC catheter, bevel up, into the umbilical vein
Advance the catheter slowly and smoothly until resistance is met, typically when it reaches the level of the diaphragm or the hepatic vasculature
For optimal placement above the diaphragm and within the inferior vena cava, the catheter is typically advanced to a depth of approximately 7-10 cm for a term infant and 4-6 cm for a preterm infant, or until pulsations are felt or blood return is easily aspirated.
Confirmation Of Placement:
Aspirate blood to confirm venous return and check for absence of air
If resistance or difficulty is encountered, or if air is aspirated, withdraw the catheter slightly and reattempt
Once placement is confirmed, secure the catheter to the abdominal wall with sterile tape or a purse-string suture
A chest X-ray (anteroposterior view) is mandatory to confirm the catheter tip position
The tip should ideally be located in the distal inferior vena cava, at the level of the diaphragm or slightly above, and not in the hepatic circulation or right atrium.
Postprocedure Care:
Administer intravenous fluids and medications as prescribed
Monitor the infant closely for signs of complications
Limit the duration of UVC use (ideally < 7-14 days) to minimize risks
Perform daily site care and dressing changes using aseptic technique
Remove the catheter promptly when no longer indicated.
Complications
Early Complications:
Hemorrhage from the insertion site or catheter dislodgement
Air embolism due to faulty technique or catheter disconnection
Thrombosis of the umbilical vein or portal vein
Infection (local or systemic)
Bowel or bladder perforation if the catheter is advanced too far or malpositioned
Arrhythmias if the catheter tip irritates the heart
Necrosis of the umbilical stump.
Late Complications:
Portal vein thrombosis leading to portal hypertension
Liver abscess or intrahepatic calcifications
Embolic phenomena (rare)
Prolonged UVC use may increase the risk of catheter-related bloodstream infections (CRBSIs) and thrombotic events.
Prevention And Management:
Strict aseptic technique during insertion and catheter care
Confirm correct tip placement with X-ray before use
Secure the catheter properly to prevent dislodgement
Monitor for signs of infection or thrombosis
Limit UVC duration to the shortest possible time
Remove the catheter as soon as it is no longer needed
Use prophylactic antibiotics judiciously based on institutional guidelines.
Key Points
Exam Focus:
UVC is a life-saving intervention in neonates requiring central venous access
The primary indication is hemodynamic instability or need for rapid, accurate medication delivery
Confirmation of tip placement via X-ray at the level of the diaphragm or suprahepatic IVC is crucial.
Clinical Pearls:
Always use a sterile technique and prepare the site meticulously
Have a reliable assistant for the procedure
If resistance is met, do not force the catheter
withdraw and reposition
For prolonged use, consider other venous access options if feasible
The risk of portal vein thrombosis increases with duration of catheterization.
Common Mistakes:
Incorrect catheter tip positioning (too high in the right atrium or too low in the hepatic circulation)
Failure to confirm tip placement with an X-ray before use
Inadequate securing of the catheter leading to dislodgement or air embolism
Poor aseptic technique leading to infection
Forcing the catheter, which can cause perforation.