Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
Title:
Version:
Ratification Date:
Review date:
Approval:
Authors:
Job title:
Consultation:
Umbilical venous and arterial catheters
3 (Vs 1: May 1999, Vs 2: July 2005)
July 2015 (reviewed by D Sharkey, minor changes)
July 2017
Neonatal Guidelines Meeting July 2015
Don Sharkey
Consultant Neonatologist
Nottingham Neonatal Service Staff and Clinical
Guideline Meeting
Guideline Contact: Dr Shalini Ojha, Guideline Coordinator and
Consultant Neonatologist, C/O Stephanie Tyrrell,
Nottingham Neonatal Service
[email protected]
Target Audience: Staff of the Nottingham Neonatal Service
Patients to whom Patients of the Nottingham Neonatal Service who fit
this applies:
the inclusion criteria of the guideline below
Distribution:
Neonatal Intensive Care Units
Risk Managed:
Safe placement and use of umbilical catheters
Evidence used:
The contemporary evidence base has been used to
develop this guideline. References to studies
utilised in the preparation of this guideline are given
at its end.
Clinical guidelines are guidelines only. The interpretation and
application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague. Caution is
advised when using guidelines after a review date. This guideline has
been registered with the Nottingham Hospitals NHS Trust.
Key points
 Umbilical lines are crucial in the management and care of
very sick or very premature newborn babies
 The greatest risks with these lines includes infection,
thrombosis, ischaemia and bleeding
 It is essential to ensure the line tips are located outside the
heart to reduce the risk of pericardial effusion and
subsequent tamponade
 Documentation is important. Whenever a line is repositioned
it must be X-rayed again to check position
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
1.
Guideline G5
Introduction
Umbilical venous (UVC) and arterial (UAC) catheters are central lines which can be
inserted up to one week of age. Care must be taken in their use to prevent
complications. These lines should be inserted with an aseptic technique and have
many advantages over peripheral lines. The insertion of umbilical lines can greatly
reduce handling and skin damage to extremely preterm infants in trying to obtain
peripheral access and blood sampling. Invasive blood pressure monitoring can help
guide management of the sick newborn.
2.
Patient Group/Indications
2.1
UVC
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2.2
UAC
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2.3
Required for arterial blood sampling especially in babies requiring ventilation
Frequent blood sampling, in particular extremely preterm infants or those
requiring significant intensive care
Exchange transfusion
Invasive blood pressure monitoring
Cautions/contraindications

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3.
UVCs are usually used in the emergency situation during resuscitation of the
newborn infant at birth
For parenteral nutrition
Where peripheral IV access has been unsuccessful
Exchange transfusion
Venous access in the first few days of life in babies of <28 weeks gestation
where minimal handling is required
For intravenous drugs requiring central administration such as inotropic
infusions or solutions containing >12.5% dextrose
In persistent pulmonary hypertension of the newborn (PPHN) where multiple
drug infusions are likely to be required
To measure central venous pressure – tip must lie 1cm above diaphragm
(rarely used in the NICU)
Localised infection at insertion site
Evidence or risk of lower limb/buttock vascular compromise when inserting
UAC
Surgical condition likely to need correction at site of insertion i.e. abdominal
wall defects
Evidence of significant gut hypoperfusion/compromise e.g. necrotising
entercolitis
Identification of umbilical vessels
Within the umbilical cord there are usually two arteries and one vein. The vein is
easily identifiable against the arteries as it has a thin wall and a large lumen. The
arteries are typically thick muscular walled vessels.
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
4.
Management
4.1
General Patient Management
Guideline G5
All umbilical lines must be inserted by those competent to do so and who have read
the relevant guidelines and completed the learning package linked with this.
There have been a large number of attempts to identify the best insertion length
calculation for umbilical lines. The previous Nottingham guideline used Dunn’s
measurements/methods1.
However, a recent audit (Sharkey and Lok 2013) of
Nottingham babies <1500g demonstrated only 35% of UACs and 40% of UVCs were
in the correct position at first insertion (n=20 per line type) using this method. A
recent study2 with 170 UVCs and 125 UACs has developed a more reliable and
simpler measurement formula that works well across all gestations/birth weights
compared with other previously published measures. This is discussed later in the
guideline along with the anatomical measures.
4.1.1
Insertion of a UVC or UAC (refer to learning package for detailed
illustrations)
Equipment
Clean dressing trolley prepared with the following:
Sterile gown and towel pack
Sterile gloves, surgical mask and hat
Sterile umbilical catheterisation pack
0.5% chlorhexidine solution
Sterile umbilical tie
Sterile gauze
Appropriate catheter(s):
For the UVC - 5 or 6F single lumen catheter (for resuscitation purposes,
exchange transfusion) or 4F double lumen (particularly infants <28 weeks
gestation ± inotrope infusion)
For the UAC - usually a 3.5-5F single lumen catheter (use smaller lumen for
babies <1500g to prevent occlusion/thrombosis in vessel)
IV bungs (for each UVC lumen)
3-way tap if inserting UAC (often in catheter pack)
10ml syringe (one per lumen)
Blunt needle (drawing up saline flush)
0.9% Sodium Chloride for priming and flush
Non-dissolvable sutures
Scalpel
Roll of sleek tape
Tape measure
Appropriate giving sets
UAC only Heparinised Saline (1 unit/ml) and transducer set
Blood bottles if taking samples at time of insertion
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
Procedure
1. Ensure there are no contraindications to insertion of umbilical lines (section 2.3).
If inserting a UAC check and document lower limb perfusion/pulses are normal.
2. The baby must have respiratory (pulse oximetry) and cardiovascular monitoring
(ECG, if >27 weeks gestation) on when inserting umbilical catheters. This is
essential as the baby will be covered in a sterile dressing and if the line
inadvertently enters the heart it could result in disturbances of heart rate/rhythm.
3. Measure the distances required to insert the lines (see Figure 1 in appendix).
The two measures (cms) are: umbilical base to the nipple (umbilical-nipple
distance, UN); and umbilical base to the symphysis pubis (umbilical-symphysis
pubis distance, USp). You can then use the formula below to work out the
insertion distances required.
4. distance
required.
Formula
for measuring
UVC and UAC lengths in all babies2
UN = measure from base umbilicus to nipple
USp = measure from base of umbilicus to symphysis pubis
UVC length (cms) = UN – 1
UAC length (cms) = (UN – 1) + (2 x USP)
For both measures you will need to add on any umbilical cord remnant
5. The attending clinical and nursing team will discuss on the length of time the
procedure will normally take to avoid any excess stress for the baby. This will
guide the number of attempts, and by whom, based on how difficult/critical the
line is. The delivery of maintenance fluids, and hence glucose, needs to be
considered to avoid any prolonged hypoglycaemic risk.
6. An aseptic technique should be used and is undertaken by a member of the
medical team or an advanced neonatal nurse practitioner trained to do this (see
self-directed learning package on technique for umbilical line insertion). In
particular, double gloving when preparing the sterile field should occur in all
instances. All equipment should be prepared using this technique and the
Neonatal CVC Insertion Checklist (Figure 2 in appendix) followed, completed and
filed in the patient’s notes. Isolation screens should be placed around the
patient’s space to minimise the risk of interruptions, inadvertent desterilisation of
equipment and privacy.
7. The umbilicus and anterior abdominal wall should be cleaned using the antiseptic
solution. Once the skin is cleaned the solution should be allowed to dry. Care
must be taken with babies <28 weeks gestation due to the risk of chemical burns
especially from pooling of cleaning solution in the flanks3. For these babies
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
there should be a second ‘wash’ with sterile water or normal saline to
reduce the risk of skin injury.
8. Prime the catheters with normal saline. Do not leave the catheter open to the
atmosphere because negative intrathoracic pressure could cause an air embolus.
For the single lumen catheters it is essential to prime the 3-way tap and attach it
to the catheter as there are no clamps to occlude them once in.
9. Once sterile drapes are in place, loosely tie umbilical tie around the base of the
cord in case of excessive bleeding. The umbilical cord should be cut
approximately to a length of 1-1.5cm.
10. Identify the vessels (there are two arteries and one vein). The vein has a thin wall
and a large lumen when compared to the arteries. If inserting a UAC it is
preferable to start with this as it is often more difficult. If the vessels are still
oozing blood, making it difficult to visualise them, it can help if you press gently
on the abdominal wall just above (for vein) or below (arteries) the umbilical stump
to slow the flow of blood. Gently tightening the cord tie will also help but care
needs to be taken not to occlude the vessel lumen.
11. The umbilical stump should be fixed using the appropriate clamps in the insertion
pack (see umbilical line learning package).
12. If inserting a UAC it is useful to dilate the artery using the dilator or fine tooth
forceps in the insertion pack.
13. Insert the catheter(s) to the desired length and check blood flows easily when
aspirating. If it does not aspirate, assume it is not in the correct location or has
created a false track. Occasionally the umbilical vein is kinked and advance of
the catheter is blocked at 1-2cm beyond the abdominal wall. Gentle traction on
the cord usually relieves this. If obstruction occurs at more than 2 cm and only
partly gives way to pressure the catheter is probably either wedged in the portal
system or coiled up in the portal sinus. Withdraw the catheter part way and
reinsert. It is common to feel slight resistance when inserting the UAC as it curls
back around the internal iliac arteries.
14. In the resuscitation situation, tighten the cord tie around the umbilical cord to
keep UVC in place. For longer use, suture the lines in place using nonabsorbable silk sutures. It is important to do this securely to avoid any migration
of the lines (in or out) once sited (see umbilical line learning package). The long
ends of the sutures should be secured to the catheter immediately distal to the
umbilical stump using sleek tape. If both a UAC and UVC are used then these
should be sutured separately to allow them to be removed independently.
15. Once the UVC is secure it can be used to put up initial starter parenteral nutrition
or other maintenance fluids whilst waiting for the X-ray (which should be
requested immediately after insertion). For inotropic infusions it is preferable to
check the position on the X-ray prior to commencing unless the clinical situation
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
dictates otherwise. For the UVC, locate the catheter tip in the inferior vena cava
just at/above the diaphragm (see Figure 3 in appendix). If the catheter will not
pass through the ductus venosus locate the tip below the liver. Do not leave a
UVC kinked in the portal sinus or wedged in a portal vein. The patency of the
UAC must be maintained with heparinised saline (1unit/ml) running at 0.5ml/hr
and a blood pressure transducing kit set up.
16. The position of the catheter(s) should be confirmed on X-ray. The tip of the UVC
should lie at or immediately above the diaphragm (Figure 3). The catheter tip
MUST lie outside the cardiac silhouette to minimise the risk of extravasation into
cardiac structures. If the tip is lying within the liver it must be withdraw so the tip
lies below liver. In an emergency do not delay the administration of drugs
before the X-ray is available. The UAC should ideally be a high one (T8 to T10)
just above the diaphragm (Figure 3 in appendix)5. A low lying UAC tip (L3-L4) is
acceptable but requires close observation for vascular compromise. If the UAC
tip is between T10-L2 it must be withdrawn to a low lying position. ALL lines that
are repositioned require repeat X-rays (ideally within 2 hours) to confirm
the new position and this requires documentation.
17. The medical staff/ANNPs should document position of lines carefully in notes and
clarify what infusions/drugs may be given via the line (depends on position- see
section 4.2). Complete the central line documentation (see Figure 2 in appendix).
4.1.2
Catheter removal
If long-term central venous access is required then a longline will need inserting.
This should ideally been performed within 7 days of UVC insertion. There is a
greater risk of complications/infection if the UVC remains in for more than 7 days
although there is evidence they can stay in longer (typically up to 14 days)4. Only
after discussion with the duty Neonatal Consultant can it remain in for longer.
The UAC should be removed when no longer clinically required for intensive
monitoring or sampling. Any concerns regarding complications (see sections 4.2-4.4)
should result in a review of the line and removal if warranted.
Catheter removal may be undertaken by either a doctor or ANNP trained to do so. It
is important to ensure and document removal of the whole line. The tip should only
be sent for culture if there are concerns about infection.
Equipment:
Dressing pack
Sterile gloves
Hand towels
Sterile scissors/stitch cutters
Specimen pot (if sending tip)
Gauze
Cord tie if required
1. Document baseline observations prior to the procedure
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
2. Turn off any 3-way taps or clamp extension sets to the baby and stop the flow of
any infusions
3. A full aseptic technique is employed
4. Remove tape and sutures around the catheter
5. Withdraw the catheter slowly and gently (UAC usually over 5 minutes to allow
muscular contraction and minimise blood loss)
6. If resistance is felt, stop and identify the cause before continuing. If no obvious
cause, seek assistance
7. If bleeding slightly, pull the umbilical cord tie around the base of the umbilical
stump tight
8. If bleeding continues, it may be necessary to use haemostat (e.g. Oxycel) gauze
to stem the flow. Occasionally surgical input is required.
9. Place the tip of the catheter into the sterile specimen pot and send for culture and
sensitivity only if there are concerns of infection
10. Cover the umbilical stump with a small gauze dressing to detect any bleeding
after the procedure. The baby should be nursed supine/lateral position for 24
hours with the umbilical stump observed for any delayed bleeding
11. Document the removal of the catheter in the medical notes (central line yellow
sheet) and on the observation charts.
4.2
Specific Issues

Never leave an umbilical line open to the atmosphere as there is a risk
of air embolus. Always clamp off line when removing/attaching
infusions/bolus drugs. Check infusions/bolus drugs carefully for air
bubbles. If air is seen in line, clamp immediately, stop infusion and call
for medical assistance.

UVCs can be used to administer both continuous infusions and bolus drugs.
These drugs should be given in an aseptic manner and as described in
guideline D12 Administration of intravenous drugs and fluids to neonates and
guideline G3 Management of a baby with a central venous catheter.

All IV drugs/infusions can be given through a UVC when its tip is lying in the
inferior vena cava at or above the diaphragm. Do not use UVCs for drugs
(either bolus or infusion) if tip lying within the liver except in emergency, life
saving situation. A low lying UVC below the liver should be used with caution.

Necrotising enterocolitis has been associated with umbilical line usage with
the greatest risk from the UAC6. Consider immediate removal if any
suggestion of NEC. If the line is vital discuss with consultant. The
commencement of enteral feeds whilst umbilical lines are in-situ is a
consultant decision.

There is the risk of hepatic necrosis/portal hypertension if hyperosmolar fluids
(>300mosmol/kg H2O) e.g. parenteral nutrition or inotropes, are infused into
the liver.
4.3
Observation and monitoring

Nurse the baby on an open nappy in a supine or lateral position
Author D Sharkey
Page 7 of 13
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5

The baby may be nursed prone, to facilitate breathing, 24 hours after the
catheter has been inserted following discussion with a doctor/ANNP. This
should be documented in the medical and nursing notes

Observe the umbilicus for signs of bleeding and infection

Review the infusion fluids as for Nottingham Neonatal Service - clinical
Guideline D12 - Administration of intravenous drugs and fluids to neonates

Record the type and amount of each fluid being infused hourly on the fluid
chart

Observe the site of insertion and monitor and record the pressure in the line
hourly

Incompatibilities between drugs and fluids can cause precipitation and
inactivation. This is not always visible. Compatibility should always be
checked using the drug information folder. If in doubt contact drug
information/pharmacist.
4.4
Complications of umbilical catheters
It is important to monitor the lines for complications and address these in a timely
manner along with appropriate documentation. Important complications to consider
for umbilical catheters include:

With any central line there is the risk of infection. The longer the line stays in
the greater the risk.

Bleeding from the umbilical stump can occur. It is essential to keep the baby
under observation for this especially in the early insertion period (first 24
hours).

Thrombosis/occlusion can occur and this risk tends to increase the longer the
catheter is in. Documentation of initial pump pressures should be made in the
nursing notes. Significant increases in the line pressure or ‘backing’ off of
infusions sometimes give clues to this (the pressure ‘limit’ is dependent on
many factors such as lumen diameter, flow rate and so it is not possible to
define a set pressure, typically they are >100mmHg but the overall
change/pattern is more important). In such cases there needs to be a careful
evaluation of the line and consideration for removal if significant concerns.

Air embolus, especially with the UAC, is a real risk and the line should never
be open to the air. When accessing the lines it is important to ensure all air
bubbles are removed especially when giving intravenous fluids.

The tip of the catheter can cause erosion in blood vessel walls. Again, this
should be considered in any baby who deteriorates especially when the
cause is unclear. Careful consideration needs to be given to leakage of the
solution being delivered particularly into the peritoneal or pleural cavities.

Acute deterioration with a line in could be caused by a number of factors. In a
baby with a UVC the attending team must consider, and if necessary exclude,
Author D Sharkey
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Nottingham Neonatal Service – Clinical Guidelines
Guideline G5
a line related cardiac problem. This is most commonly from a line tip in the
heart (either during placement or due to migration) resulting in cardiovascular
problems such as arrhythmia or cardiac tamponade due to extravasation. In
this situation it is important to check the position of the line (consider a chest
X-ray as this will give important information of position, lung fields and cardiac
shape). Consideration should also be given to obtaining an ECHO to exclude
a pericardial effusion and evolving cardiac tamponade.

Leaking lines can occur often from a fracture or break at some point in the
line or giving set. If a baby has an unexplained low blood sugar always check
the line for any leaks.
5.
Audit points
5.1
Routine Data Collection


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
6.
Number of umbilical lines used
Correct placement of lines
Indication for use
Complications
Documentation
References
1. Dunn PM. Localisation of the umbilical catheter by post mortem measurements.
Arch Disc Child. 1966; 41:69
2. Gupta AO, Peesay MR, Ramasethu J. Simple measurements to place umbilical
catheters using surface anatomy. J Perinat. 2015; 35(7): 476-80
3. Lashkari HP, Chow P, Godambe S. Aqueous 2% chlorhexidine-induced chemical
burns in an extremely premature infant. Arch Dis Child FN Ed 2012; 97:F64
4. Butler-O’Hara M, Buzzard C, Reubens L, McDermott M, DiGazio W, D’Angio C.
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; 118(1): e25-e35
5. Barrington KJ. Umbilical artery catheters in the newborn: effects of position of the
catheter tip. Cochrane Database Syst Rev 2000; (2):CD000505.
6. Rand T, Weninger M, Kohlhauser C, Bischof S, Heinz-Peer G, Trattnig S, Popow
C, Salzer HR. Effects of umbilical arterial catheterization on mesenteric
hemodynamics. Pediatr Radiol. 1996; 26(7):435-8
Author D Sharkey
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Guideline G5
Appendix
Figure 1. Anatomical landmarks to measure for UVC and UAC lengths (adapted from
Gupta et al 20152)
Formula for measuring UVC and UAC lengths in all babies
UN = measure from base umbilicus to nipple
USp = measure from base of umbilicus to symphysis pubis
UVC length (cms) = UN – 1
UAC length (cms) = (UN – 1) + (2 x USP)
For both measures you will need to add on any umbilical cord remnant
Author D Sharkey
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Guideline G5
Figure 2. Documentation proforma for central line placement
Author D Sharkey
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Author D Sharkey
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Guideline G5
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Guideline G5
Figure 3. X-ray for line positions (see text for ideal tip location)
Author D Sharkey
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