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Umbilical Artery Catheterization

Indications

  • acid-base and oxygen monitoring
  • blood sampling for other investigations
  • continuous arterial blood pressure monitoring

Equipment

Arterial tray

  • 1 scalpel blade handle
  • 2 probes: fine and medium
  • 4 mosquito artery forceps: 2 curved, 2 straight
  • 2 pair dissecting forceps: toothed, non-toothed
  • 2 iris forceps
  • 1 pair vein scissors
  • 1 pair suture scissors
  • 1 needle holder
  • 2 bowls
  • cotton wool swabs
  • gauze swabs
  • tape measure

Other equipment

  • surgical mask
  • sterile gown and gloves
  • 1 plastic drape (sterile)
  • 1 scalpel blade No. 11
  • 1 umbilical artery catheter
    • Fg 3.5 < 1250g baby
    • Fg 5 > 1250g baby
  • 1 blood pressure monitoring kit
  • 1 disposable luer lock 3-way tap
  • 1 x 5ml syringe and 18G needle
  • 1 x 10ml ampoule 0.9% saline
  • 1 packet 3/0 black silk suture
  • Skin preparation solution
  • Parenteral administration set
  • Infusion pump
  • Ordered parenteral solution
  • 1ml ampoule heparin 1,000 units/ml
  • drug additive label
  • 1cm wide leukoplast for taping of catheter

Procedure

  • estimate the position of catheter tip
    • the correct position is in the descending aorta above the origin of the mesenteric and renal arteries (to avoid occlusion in these vessels)
    • the catheter length may be calculated from the formula [ Weight (kg) x 3] + 9cm
    • remember to add the length of the cord stump

 

  • consider the use of appropriate measures to relieve distress including
    • use or oral sucrose (link to section)
    • containing the infant by holding
    • securing the catheter as soon as possible
    • avoidance of placing clamps or sutures on the skin

 

  • flush the selected catheter via the 3-way tap with normal Saline. Leave the syringe of saline attached to 3-way tap throughout the procedure

  • clean the umbilical stump and surrounding 3-4cm of abdomen with a chlorhexidine based solution. Wait 2 minutes. Clean the area with aqueous chlorhexidine

  • drape around the umbilical stump with sterile towels

  • tie a short piece of umbilical tape around the base of the cord. It should be secure enough to maintain haemostasis but not too tight to prevent passage of the catheter

  • with a pair of straight forceps, grasp the end of the cord clamp and pass the forceps to the assistant. Whilst the assistant applies gentle upward traction, slice the cord with the scalpel, 1-1.5cm from the skin margin. An alternative method is to leave the cord long and cannulate the artery from the side. This method should be left to experienced operators only
  • when the cut surface is blotted dry, the umbilical vessels can be identified
    • the single thin walled umbilical vein
    • two smaller thick walled round arteries, generally constricted so that their lumen appear pinpoint. They often protrude from the cut surface of the umbilical cord

  • to insert the arterial catheter the orifice of the artery is gently opened with fine forceps. . Initially 1 tip and then both tips of the iris forceps should be gently inserted into the artery. The tips should be allowed to spring apart. The tips should be gradually advanced to the curve of the forceps. Then the vessel may be cannulated. Obstruction may be encountered at the anterior abdominal wall or bladder. This can usually be overcome by 30-60 seconds of gentle, steady pressure. Avoid excessive pressure or repeated probings. If unsuccessful, seek advice from a more experienced person. The most common error arises after cannulating the layer between the vascular intima and the muscle. This usually occurs if dilatation of the artery in the cord has been inadequate

  • ensure patency of catheter by checking for easy withdrawal of blood and "pulsation" of blood/saline in the catheter

  • secure catheter with 3/0 black silk suture by placing a purse string suture (use several small bites) around the base of the cord. Do not include the skin. Commence the suture close to the catheter so that the first knot lies at the base of the catheter. Tighten the purse string and knot securely. Tie the purse string around the catheter tightly. Strp with goal post strapping. Label line clearly (in order to distinguish from an umbilical venous catheter)

  • connect catheter to infusion fluid

  • confirm the position of catheter by X-ray - initial caudal route of catheter before ascending aorta will distinguish from umbilical vein catheterisation, tip of catheter above  level of T10

  • check for arterial waveform on arterial transducer after it is connected and calibrated

Ongoing Management

  • observe skin colour
    Note any skin blanching or bruising of limbs, toes or buttocks prior to procedure, during and following the procedure, and at any time that catheter is in situ. Report immediately.
    If one limb is involved, warm opposite limb to induce reflex vasodilation of affected limb.
    If physical therapy fails, the catheter may be withdrawn 0.5 - 1cm and observe.
    Remove catheter if blanching persists >30 minutes.

  • maintain infant supine or in lateral position for 24 hours post procedure to observe for haemorrhage from umbilical stump

  • keep catheter and infusion line clear of blood as blood clots may form. Remove all air bubbles in the infusion line and catheter. Interruption to infusion must be for as short a time as possible. Do not flush catheters quickly

  • filters are not used for IA lines. All connections must be luer lock

Complications

  • bleeding due to accidental disconnection or dislodgement, or from open connections

  • vasospasm of the femoral artery causing blanching of toes and foot is less common with high than low catheters. The opposite limb may be warmed with a warm moist towel. If blanching persists, the catheter must be removed

  • embolisation from blood clot or air in the infusion system

  • thrombosis - may invlove
    • femoral artery resulting in limb ischaemia, gangrene
    • renal artery resulting in hypertension, haematuria, renal failure
    • mesenteric artery resulting in gut ischaemia, necrotising enterocolitis

  • vascular perforation of the umbilical arteries, haematoma formation and retrograde arterial bleeding

  • infection - prophylactic antibiotics are not required

Catheter Removal

  • equipment required
    • alcohol swab
    • sterile stitch cutter (optional)
    • sterile blade
    • specimen container
    • tapes

  • the procedure is performed by medical staff

  • clean the stump with an alcohol swab

  • turn infusion pump off and clamp infusion line

  • remove sutures and withdraw catheter to within 3-4cm of skin

  • tape catheter to skin and maintain infant supine

  • wait for pulsation in catheter to stop (this usually takes 10-20 minutes)

  • remove rest of catheter. If any bleeding is noted, apply positive pressure below level of stump

  • only send tip for culture and sensitivity if infection is suspected

  • do not nurse infant prone for 4 hours following removal. Observe for bleeding

References

Umbilical Artery Catheterisation Protocol, Southern Health Care Network -Monash Medical Centre, Newborn Services

Updated 04/06/2009

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