Updated: Sep 9, 2019
When you see a pediatric patient on the board, do you get palpitations?
What about a lethargic neonate?!
BUT WAIT IT'S A LETHARGIC PREMIE THAT MOM JUST GAVE BIRTH TO AT HOME?!?!?!?!?
WHAT THE $@!%!?!?!?
Is your heart racing yet?! Because mine was when the sim faculty threw the sim neonate in my arms and told me.... "He's blue and barely breathing doctor! Save my baby!"
This was an amazing sim experience as it not only had us running a code on a neonate with our pediatric code cart and warmer but also got us experience with a very rare procedure...
umbilical vein catheterization.
Umbilical Vein Catheterization
Uses: 1) Emergency resuscitation and stabilization of neonates 2) Exchange transfusions 3) Short term central venous access in newborns
Contraindications: 1) Omphalitis 2) Peritonitis 3) Necrotizing enterocolitis 4) Intestinal hypoperfusion
Complications: 1) Air Embolism 2) Hemorrhage 3) Infection 4) Injection of sclerotic agents into liver causing hepatic necrosis 5) Catheter tip embolism 6) Vessel Perforation
Technique: 1) Scrub the umbilical stump and cord upright with bactericidal solution 2) Drape the umbilical area in sterile fashion (leave head uncovered for monitoring) 3) Place loop of umbilical tape (or sterile suture or sterile iodoform) for hemostasis and to anchor your line 4) Flush the umbilical catheter - 3.5 Fr for preterm infants and 5.0 Fr for term infants. Attach a 3 way stop cock. 5) Cut the cord leaving approximately 3-4 cm of stump 6) Locate the vein. *PEARL* Remember there is one vein and two arteries. The vein is normally at the 12 o'clock position and has a thin wall and the largest lumen. 7) Have an assistant use Kellys to open the cord along the lateral edges to better visualize the vasculature 8) Place the catheter into the lumen of the umbilical vein and gently advance while withdrawing using a syringe 9) Once blood return is obtained advance 1-2 cm further *PEARL* This is normally about 4-5 cm in a term sized infant. Less in a premie! 10) Xray to confirm placement 11) Make sure to tighten your loop of umbilical tape to keep the catheter in place!
If you cannot find a 5 Fr umbilical catheter what would you do?! Don’t panic! MacGyver it!
*PEARL* While this is certainly not the recommended move or the technique in Roberts and Hedges you can also use a 5 Fr Dobhoff or a 14 g angiocath! BUT be very careful with these alternatives though as there will be a higher risk of air embolism with these. Also remember that if you use the Dobhoff you cannot attach the three way stop cock recommended by Roberts and Hedges.
Our crafty sim faculty created a model in which they used various sized tubing to replicate the umbilical cord so we could practice following this technique.
What you will need for simulation:
¼ inch tubing
1/8 inch tubing
Hollow foam tube
Hot glue gun
Umbilical vein access materials
Directions: Hot glue gun a 6 inch piece of ¼ inch tubing with two pieces of 1/8 inch tubing. Glue this to the inside of the hollow foam tube. Cut a similar size hole through the umbilicus of the plastic baby and hot glue the umbilical vein to the inside of the plastic baby! While this may not be the most advanced simulation it certainly helped all of us at least walk through the steps once or twice in order to practice a very rare procedure so when the time comes we are ready!
Custalow, Catherine B., et al. Roberts and Hedges Clinical Procedures in Emergency Medicine. Elsevier/Saunders, 2014 pg 160-161.
Author: Sarah Rubin, PGY4 EM
Residency: Jefferson Northeast