Umbilical Venous Catheter

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  • Many thanks for the reference quoted that support the use of UVC till day 28. With appreciation.
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Umbilical Venous Catheter

  1. 1. Umbilical Venous Catheter Ayman Abou Mehrem, MD, CABP Neonatology Fellow University of Manitoba
  2. 2. Case 1 <ul><li>Mom: </li></ul><ul><ul><li>36 yr-old, G 4 P 3 , uneventful pregnancy </li></ul></ul><ul><ul><li>Presented in labour </li></ul></ul><ul><ul><li>Good CTG  Sudden Fetal Bradycardia </li></ul></ul><ul><ul><li>Emergency LSCS </li></ul></ul>
  3. 3. Case 1 <ul><li>Baby: </li></ul><ul><ul><li>Apnoeic, No Heart Beats </li></ul></ul><ul><ul><li>Resus: PPV, Chest Compression, ET Epi </li></ul></ul><ul><ul><li>Apgars: 0/1’, 4/5’, 4/10’, 4/20’ </li></ul></ul><ul><ul><li>Cord pH: 6.9 </li></ul></ul><ul><ul><li>Birth Weight: 4.260 kg </li></ul></ul>
  4. 4. Case 1 <ul><li>Impression </li></ul><ul><li>Perinatal Asphyxia </li></ul>
  5. 5. Case 1 <ul><li>Management: </li></ul><ul><ul><li>Mechanical Ventilation </li></ul></ul><ul><ul><li>Body Cooling </li></ul></ul><ul><ul><li>Judicious Fluid Restriction </li></ul></ul><ul><ul><li>BC + Abx </li></ul></ul><ul><ul><li>Double lumen 4 Fr. UVC was inserted </li></ul></ul>
  6. 6. Case 1 X-rays
  7. 7. Case 1 <ul><li>UVC was pulled 1 cm. </li></ul><ul><li>X-ray has not been repeated. </li></ul>
  8. 8. Case 1 <ul><li>On day 4 of life : </li></ul><ul><ul><li>HIE: Sarnat stage 3 </li></ul></ul><ul><ul><li>Minimal ventilatory support </li></ul></ul><ul><ul><li>Normal blood gas </li></ul></ul><ul><ul><li>Never needed inotrops </li></ul></ul>
  9. 9. Case 1 <ul><li>Rapid deterioration within 3 hours: </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Poor perfusion  Fluid bolus </li></ul></ul><ul><ul><li>Desaturation </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Cardiac arrest </li></ul></ul>
  10. 10. Case 1 <ul><li>Management: </li></ul><ul><ul><li>Standard resuscitation </li></ul></ul><ul><ul><li>Epinephrine, NS bolus, NaHCO 3 </li></ul></ul><ul><ul><li>After 15 min, empirical pericardiocentesis resulted in 30 ml of clear fluids. </li></ul></ul><ul><ul><li>Heart started to beat, perfusion improved. </li></ul></ul><ul><ul><li>Few hrs later, No metabolic acidosis. </li></ul></ul>
  11. 11. Case 1
  12. 12. Case 1 <ul><li>Biochemichal analysis </li></ul><ul><ul><li>Glucose 80 mmol/L </li></ul></ul><ul><ul><li>Sodium 142 mmol/L, </li></ul></ul><ul><ul><li>Calcium 2.3 mmol/L </li></ul></ul><ul><ul><li>Protein undetectable </li></ul></ul><ul><ul><li>No organism </li></ul></ul><ul><li>Composition similar to the fluid infused through the UVC </li></ul>
  13. 13. Case 2 <ul><li>Preterm baby boy 35 weeks </li></ul><ul><li>Uneventful Pregnancy </li></ul><ul><li>Referred from a secondary affiliating hospital </li></ul>
  14. 14. Case 2 <ul><li>Multiple congenital anomalies: </li></ul><ul><ul><li>Dandy Walker cyst </li></ul></ul><ul><ul><li>Brain atrophy </li></ul></ul><ul><ul><li>Large midline cleft palate </li></ul></ul><ul><ul><li>Micrognathia </li></ul></ul><ul><ul><li>Low set ears, low posterior hair line, webbed neck. </li></ul></ul>
  15. 15. Case 2 <ul><li>On day 3 of life UVC + UAC were inserted. </li></ul><ul><li>The position was confirmed by x-ray. </li></ul>
  16. 16. Case 2 <ul><li>On day 13 of life cystoperitonial shunt was inserted </li></ul><ul><li>Nine hours after operation: </li></ul><ul><ul><li>Marked abdominal distension </li></ul></ul><ul><ul><li>Signs of dehydration  several NS boluses </li></ul></ul><ul><ul><li>Hyponatremia and modest hyperglycemia </li></ul></ul>
  17. 17. Case 2 <ul><li>Abdominal US: </li></ul><ul><ul><li>Massive ascites </li></ul></ul><ul><ul><li>Hypoechoic lesion in the right hepatic lobe </li></ul></ul>
  18. 18. Case 2 <ul><li>Paracentesis: </li></ul><ul><ul><li>100 ml of clear yellow fluids. </li></ul></ul><ul><ul><li>WBC 56/mm3 </li></ul></ul><ul><ul><li>Glucose 77.6 mmol/L </li></ul></ul><ul><ul><li>Protein < 8 g/L </li></ul></ul><ul><ul><li>Gram stain showed no organisms </li></ul></ul>
  19. 19. Case 2 <ul><li>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 </li></ul><ul><li> TPN ascites. </li></ul>
  20. 20. Case 2 <ul><li>UVC was removed. </li></ul><ul><li>Abdominal CT scan on day 23 of life: </li></ul><ul><ul><li>cystic lesion in the liver was getting smaller </li></ul></ul>
  21. 21. Case 3 <ul><li>Mom: </li></ul><ul><ul><li>32 yr old, Primigravida </li></ul></ul><ul><ul><li>Primary infertility, paternal reason </li></ul></ul><ul><ul><li>IVF pregnancy  Triplet </li></ul></ul><ul><ul><li>APH and PT labour  LSCS @ 24 wks </li></ul></ul>
  22. 22. Case 3 <ul><li>All babies were intubated </li></ul><ul><li>Prophylactic Surfactant </li></ul><ul><li>UVC + UAC </li></ul><ul><li>BC + Abx </li></ul>
  23. 23. Case 3
  24. 24. Case 3
  25. 25. Case 3 <ul><li>Echocardiography: </li></ul><ul><ul><li>UVC in Rt pulmonary vein! </li></ul></ul>
  26. 26. Anatomy of The Umbilical Vein
  27. 27. UVC Tip Placement <ul><li>In the IVC just below the junction of IVC and RA </li></ul><ul><li>T-8 to T-9: </li></ul><ul><ul><li>90% of UVCs @ the IVC-RA junction </li></ul></ul><ul><li>T-7: </li></ul><ul><ul><li>80% of UVCs are in the RA </li></ul></ul><ul><li>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. </li></ul><ul><li>Meerstadt PWD, Gyll C. Manual of Neonatal Emergency X-Ray Interpretation . London, UK: WB Saunders Co. Ltd; 2000:252. </li></ul>
  28. 28. UVC Tip Placement <ul><li>Dunn P: Localisation of the umbilical catheter by post-mortem measurement. Arch Dis Child 1966; 41:69–75 </li></ul>
  29. 29. UVC Tip Placement <ul><li>Lopriore E et al. </li></ul><ul><li>Neonatology . 2008; 94(1):35-7. </li></ul><ul><li>101 pediatric professionals in the Netherlands </li></ul><ul><li>The method used by the participants to measure the S-U length was highly inconsistent. </li></ul>
  30. 30. UVC Tip Placement <ul><li>Formula: </li></ul><ul><li>UAC length = 3 x BW + 9 </li></ul><ul><li>UVC length = ½ UAC length + 1 </li></ul><ul><li>Shukla H, Ferrara A. Rapid estimation of insertional length of umbilical catheters in newborns. Am J Dis Child 1986; 140: 786-8. </li></ul>
  31. 31. UVC Tip Placement <ul><li>Radiography: </li></ul><ul><ul><li>AP </li></ul></ul><ul><ul><li>Lateral or Cross-table </li></ul></ul><ul><li>Echocardiography: </li></ul><ul><ul><li>Ades A, Sable C, Cummings S, Cross R, Markle B, et al. </li></ul></ul><ul><ul><li>Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol . 2003;23:24 –28. </li></ul></ul>
  32. 32. UVC Tip Placement <ul><li>53 babies </li></ul><ul><li>UVC assessed by: </li></ul><ul><ul><li>CXR: AP, Lateral </li></ul></ul><ul><ul><li>Venous PO 2 , and Saturation </li></ul></ul><ul><ul><li>Echocardiography </li></ul></ul><ul><li>Sensitivity, Specificity, PPV, and NPV </li></ul>
  33. 33. UVC Tip Placement <ul><li>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) </li></ul>
  34. 34. UVC Tip Placement <ul><li>AP CXR </li></ul><ul><ul><li>Sensitivity of 32% and specificity of 89% in assessing left atrial placement. </li></ul></ul><ul><li>Lateral CXR: </li></ul><ul><ul><li>Sensitivity of 76% and specificity of 33% </li></ul></ul><ul><li>Venous PO 2 , and Saturation </li></ul><ul><ul><li>Sensitivity of 45% and specificity of 95% </li></ul></ul>
  35. 35. UVC Tip Placement
  36. 36. Complications <ul><li>Blood loss </li></ul><ul><li>Perforation of UV: </li></ul><ul><ul><li>Hemoperitoneum </li></ul></ul><ul><ul><li>TPN/ IVF ascites 7 </li></ul></ul><ul><ul><li>Retroperitoneal fluid extravasation: abdominal, genital, buttock, and thigh edema 8 </li></ul></ul><ul><li>Mohan MS, Patole SK. Neonatal ascites and hyponatremia following umbilical venous catheterization. J Paediatr Child Health . 2002;38:612– 614. </li></ul><ul><li>Liao CH, Sy LB, Tsou KI. Umbilical vein catheter malposition: report of one case . Acta Paediatr Taiwan . 2003;44:38–40. </li></ul>
  37. 37. Complications <ul><li>Cardiac: </li></ul><ul><ul><li>Dysrrhythmia: </li></ul></ul><ul><ul><ul><li>Atrial flutter reported in 2 cases 9, 10 </li></ul></ul></ul><ul><ul><li>Tamponade: several case reports </li></ul></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>
  38. 38. Complications <ul><li>Pulmonary: </li></ul><ul><ul><li>due to malposition 11 </li></ul></ul><ul><ul><li>Pulmonary edema, localized </li></ul></ul><ul><ul><li>Pulmonary hemorrhage </li></ul></ul><ul><ul><li>Pulmonary infarction ± hydrothorax </li></ul></ul><ul><ul><li>Possible systemic embolism </li></ul></ul><ul><li>Björklund LJ, Malmgren N, Lindroth M. Pulmonary complications of umbilical venous catheters. Pediatr Radiol. 1995;25(2):149-52. </li></ul>
  39. 39. Complications <ul><li>Hepatic: </li></ul><ul><ul><li>Necrosis </li></ul></ul><ul><ul><li>Calcification </li></ul></ul><ul><ul><li>Infusate encystment </li></ul></ul><ul><ul><li>Infusate ascites </li></ul></ul><ul><ul><li>Laceration </li></ul></ul><ul><ul><li>Biliary venous fistula formation </li></ul></ul><ul><ul><li>Abscess formation </li></ul></ul>
  40. 40. Complications <ul><li>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. </li></ul>
  41. 41. Complications <ul><li>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 </li></ul>
  42. 42. Complications <ul><li>Levkoff AH, Macpherson RI. Intrahepatic encystment of umbilical vein catheter infusate. Pediatr Radiol. 1990;20:360 –361. </li></ul>
  43. 43. Complications <ul><li>Air embolism: iatrogenic </li></ul><ul><li>Thrombosis: </li></ul><ul><ul><li>Intimal damage </li></ul></ul><ul><ul><li>Bacterial colonization, slime-forming organisms </li></ul></ul><ul><ul><li>The low-flow nature of the venous system </li></ul></ul>
  44. 44. Complications <ul><li>Thrombosis may lead to: </li></ul><ul><ul><li>Occlusion </li></ul></ul><ul><ul><li>Portal vein thrombosis </li></ul></ul><ul><ul><li>Intracardiac thrombi </li></ul></ul><ul><ul><li>Renal vein thrombosis 15 </li></ul></ul><ul><ul><li>Pulmonary and systemic embolism </li></ul></ul><ul><li>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. </li></ul>
  45. 45. Complications <ul><li>Infection: </li></ul><ul><ul><li>Aseptic technique during insertion and care </li></ul></ul><ul><ul><li>Increased after 14 days: CDC </li></ul></ul><ul><ul><li>A study showed safety up to 28 days 16 </li></ul></ul><ul><li>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. </li></ul>
  46. 46. Complications <ul><li>Recent study introduced a multimodal approach to reduce CR-BSI 17 : </li></ul><ul><ul><li>15/1000 to 10/1000 catheter-days </li></ul></ul><ul><li>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]. </li></ul>
  47. 47. Summary <ul><li>UV is good, easily accessible route for parenteral therapy and nutrition during neonatal period. </li></ul><ul><li>Predicting the required length for insertion is not easy. </li></ul><ul><li>Radiography is relatively unreliable in confirming the catheter tip position. </li></ul><ul><li>Complications of malposition are devastating. </li></ul>
  48. 48. Recommendation <ul><li>Further studies are required to determine the required length of insertion. </li></ul><ul><li>Repeated radiographs to ensure the tip in correct position. How frequent? </li></ul><ul><li>Bedside echocardiography may be a useful tool to confirm the tip position. </li></ul><ul><li>Strict infection control policies to reduce CR-BSI. </li></ul>
  49. 49. THANK YOU

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