April 6, 2010

Umbilical Venous Catheter

Ayman Abou Mehrem, MD, CABP

Neonatology Fellow

University of Manitoba

April 6, 2010

Case 1

• Mom:– 36 yr-old, G4 P3, uneventful pregnancy

– Presented in labour– Good CTG Sudden Fetal Bradycardia– Emergency LSCS

April 6, 2010

Case 1

• Baby:– Apnoeic, No Heart Beats– Resus: PPV, Chest Compression, ET Epi– Apgars: 0/1’, 4/5’, 4/10’, 4/20’– Cord pH: 6.9– Birth Weight: 4.260 kg

April 6, 2010

Case 1

Impression

Perinatal Asphyxia

April 6, 2010

Case 1

• Management:– Mechanical Ventilation– Body Cooling– Judicious Fluid Restriction– BC + Abx– Double lumen 4 Fr. UVC was inserted

Case 1 X-rays

April 6, 2010

Case 1

• UVC was pulled 1 cm.

• X-ray has not been repeated.

April 6, 2010

Case 1

• On day 4 of life:– HIE: Sarnat stage 3– Minimal ventilatory support– Normal blood gas– Never needed inotrops

April 6, 2010

Case 1

• Rapid deterioration within 3 hours:– Metabolic acidosis– Poor perfusion Fluid bolus– Desaturation– Bradycardia– Cardiac arrest

April 6, 2010

Case 1• Management:

– Standard resuscitation

– Epinephrine, NS bolus, NaHCO3

– After 15 min, empirical pericardiocentesis resulted in 30 ml of clear fluids.

– Heart started to beat, perfusion improved.

– Few hrs later, No metabolic acidosis.

April 6, 2010

Case 1

April 6, 2010

Case 1

• Biochemichal analysis– Glucose 80 mmol/L– Sodium 142 mmol/L,– Calcium 2.3 mmol/L– Protein undetectable– No organism

• Composition similar to the fluid infused through the UVC

April 6, 2010

Case 2

• Preterm baby boy 35 weeks

• Uneventful Pregnancy

• Referred from a secondary affiliating hospital

April 6, 2010

Case 2

• Multiple congenital anomalies:– Dandy Walker cyst– Brain atrophy– Large midline cleft palate– Micrognathia– Low set ears, low posterior hair line, webbed

neck.

April 6, 2010

Case 2

• On day 3 of life UVC + UAC were inserted.

• The position was confirmed by x-ray.

April 6, 2010

Case 2

• On day 13 of life cystoperitonial shunt was inserted

• Nine hours after operation:– Marked abdominal distension– Signs of dehydration several NS boluses– Hyponatremia and modest hyperglycemia

April 6, 2010

Case 2

• Abdominal US:– Massive ascites– Hypoechoic lesion in the right hepatic lobe

April 6, 2010

Case 2

• Paracentesis:– 100 ml of clear yellow fluids.– WBC 56/mm3– Glucose 77.6 mmol/L– Protein < 8 g/L– Gram stain showed no organisms

April 6, 2010

Case 2

• Water soluble contrast material (Lobitridol) was injected via UVC and x-ray showed 14 mm cavity in the right hepatic lobe with spillage to the peritoneum cavity

TPN ascites.

April 6, 2010

Case 2

• UVC was removed.

• Abdominal CT scan on day 23 of life:– cystic lesion in the liver was getting smaller

April 6, 2010

Case 3

• Mom:– 32 yr old, Primigravida– Primary infertility, paternal reason– IVF pregnancy Triplet– APH and PT labour LSCS @ 24 wks

April 6, 2010

Case 3

• All babies were intubated

• Prophylactic Surfactant

• UVC + UAC

• BC + Abx

April 6, 2010

Case 3

April 6, 2010

Case 3

April 6, 2010

Case 3

• Echocardiography:– UVC in Rt pulmonary vein!

April 6, 2010

Anatomy of The

Umbilical Vein

April 6, 2010

UVC Tip Placement

• In the IVC just below the junction of IVC and RA

• T-8 to T-9:– 90% of UVCs @ the IVC-RA junction

• T-7:– 80% of UVCs are in the RA

1. Bradshaw WT, Furdon SA. A nurse's guide to early detection of umbilical venous catheter complications in infants. Adv Neonatal Care. 2006 Jun;6(3):127-38.

2. Meerstadt PWD, Gyll C. Manual of Neonatal Emergency X-Ray Interpretation. London, UK: WB Saunders Co. Ltd; 2000:252.

April 6, 2010

UVC Tip Placement

3. Dunn P: Localisation of the umbilical catheter by post-mortem measurement. Arch Dis Child 1966; 41:69–75

April 6, 2010

UVC Tip Placement

• Lopriore E et al.

• Neonatology. 2008; 94(1):35-7.

• 101 pediatric professionals in the Netherlands

• The method used by the participants to measure the S-U length was highly inconsistent.

April 6, 2010

UVC Tip Placement

• Formula:

• UAC length = 3 x BW + 9

• UVC length = ½ UAC length + 1

5. Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child 1986; 140: 786-8.

April 6, 2010

UVC Tip Placement

• Radiography:– AP– Lateral or Cross-table

• Echocardiography:– Ades A, Sable C, Cummings S, Cross R,

Markle B, et al.– Echocardiographic evaluation of umbilical

venous catheter placement. J Perinatol. 2003;23:24 –28.

April 6, 2010

UVC Tip Placement

• 53 babies

• UVC assessed by:– CXR: AP, Lateral

– Venous PO2, and Saturation

– Echocardiography

• Sensitivity, Specificity, PPV, and NPV

April 6, 2010

UVC Tip Placement

• Catheters properly placed at the RA/IVC junction or in the inferior vena cava, as documented by echocardiography, were located at a wide range of vertebral bodies by CXR (T6–T11)

April 6, 2010

UVC Tip Placement

• AP CXR– Sensitivity of 32% and specificity of 89% in

assessing left atrial placement.

• Lateral CXR:– Sensitivity of 76% and specificity of 33%

• Venous PO2, and Saturation

– Sensitivity of 45% and specificity of 95%

April 6, 2010

UVC Tip Placement

April 6, 2010

Complications

• Blood loss

• Perforation of UV:– Hemoperitoneum– TPN/ IVF ascites7

– Retroperitoneal fluid extravasation: abdominal, genital, buttock, and thigh edema8

7. Mohan MS, Patole SK. Neonatal ascites and hyponatremia following umbilical venous catheterization. J Paediatr Child Health. 2002;38:612– 614.

8. Liao CH, Sy LB, Tsou KI. Umbilical vein catheter malposition: report of one case. Acta Paediatr Taiwan. 2003;44:38–40.

April 6, 2010

Complications

• Cardiac:– Dysrrhythmia:

• Atrial flutter reported in 2 cases 9, 10

– Tamponade: several case reports

9. Sinha A, Fernandes CJ, Kim JJ, Fenrich AL Jr, Enciso J. Atrial flutter following placement of an umbilical venous catheter. Am J Perinatol. 2005;22:275–277.

10. Leroy V, Belin V, Farnoux C, Magnier S, Auburtin B, Gondon E, Saizou C, Dauger S. Une observation de flutter auriculaire après pose de cathéter veineux ombilical. Arch Pediatr. 2002 Feb;9(2):147-50

April 6, 2010

Complications

• Pulmonary: – due to malposition 11

– Pulmonary edema, localized– Pulmonary hemorrhage– Pulmonary infarction ± hydrothorax– Possible systemic embolism

11. Björklund LJ, Malmgren N, Lindroth M. Pulmonary complications of umbilical venous catheters. Pediatr Radiol. 1995;25(2):149-52.

April 6, 2010

Complications

• Hepatic:– Necrosis– Calcification– Infusate encystment– Infusate ascites– Laceration– Biliary venous fistula formation– Abscess formation

April 6, 2010

Complications

12. Coley BD, Seguin J, Cordero L, Hogan MJ, Rosenberg E, et al. Neonatal total parenteral nutrition ascites from liver erosion by umbilical vein catheters. Pediatr Radiol. 1998;28:923–927.

April 6, 2010

Complications

13. Yiğiter M, Arda IS, Hiçsönmez A. Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review. J Pediatr Surg. 2008 May;43(5):E39-41

April 6, 2010

Complications

14. Levkoff AH, Macpherson RI. Intrahepatic encystment of umbilical vein catheter infusate. Pediatr Radiol. 1990;20:360 –361.

April 6, 2010

Complications

• Air embolism: iatrogenic

• Thrombosis:– Intimal damage– Bacterial colonization, slime-forming organisms– The low-flow nature of the venous system

April 6, 2010

Complications

• Thrombosis may lead to:– Occlusion– Portal vein thrombosis– Intracardiac thrombi– Renal vein thrombosis15

– Pulmonary and systemic embolism

15. Marks SD, Massicotte MP, Steele BT, Matsell DG, Filler G, et al. Neonatal renal venous thrombosis: clinical outcomes and prevalence of prothrombotic disorders. J Pediatr. 2005;146:811– 816.

April 6, 2010

Complications

• Infection:– Aseptic technique during insertion and care– Increased after 14 days: CDC– A study showed safety up to 28 days16

16. Butler-O'Hara M, Buzzard CJ, Reubens L, McDermott MP, DiGrazio W, D'Angio CT. 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.

April 6, 2010

Complications

• Recent study introduced a multimodal approach to reduce CR-BSI17:– 15/1000 to 10/1000 catheter-days

17. Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. Am J Infect Control. 2010 Feb 3. [Epub ahead of print].

April 6, 2010

Summary

• UV is good, easily accessible route for parenteral therapy and nutrition during neonatal period.

• Predicting the required length for insertion is not easy.

• Radiography is relatively unreliable in confirming the catheter tip position.

• Complications of malposition are devastating.

April 6, 2010

Recommendation

• Further studies are required to determine the required length of insertion.

• Repeated radiographs to ensure the tip in correct position. How frequent?

• Bedside echocardiography may be a useful tool to confirm the tip position.

• Strict infection control policies to reduce CR-BSI.

April 6, 2010