Chapter 31 ■ Peripheral Arterial Cannulation 187

medially by the extensor pollicis longus and extensor pollicis brevis muscles (Fig. 31.8A).

e. The artery becomes superficial immediately after

passing the extensor pollicis longus and before passing beneath the first dorsal interosseous muscle.

f. The point for cannulation is located at the junction of

a line drawn along the medial aspect of the extended

thumb and another line drawn along the lateral

aspect of the extended index finger (Fig. 31.8B).

Posterior tibial Artery Cannulation by a

Cutdown Procedure

1. Prepare as for percutaneous method.

2. Put on mask.

3. Tape foot to footboard in equinovarus position (see

Chapter 4).

4. Scrub and prepare as for major procedure (see Chapter

5).

5. Infiltrate incision site with 0.5 to 1 mL of 0.5% lidocaine (Fig. 31.4).

k. Remove stylet and advance cannula to hub (Fig.

31.7F).

l. Remove ligature.

m.See percutaneous method under E (Standard

Technique, steps 7 to 11) for fixation and care of

cannula.

The incision can usually be kept small enough so

that the hub of the cannula fills it and no closing

suture is needed.

2. Technique II: Cannulation at anatomic snuffbox

a. Described by Amato et al. (26)

b. May be used in infants who have undergone previous arterial cutdown at wrist

c. Should not be a primary approach to radial artery

(particularly if cannulation is achieved by cutdown)

(1) Site is not easy to expose.

(2) Scar tends to be more disfiguring than at wrist.

d. The radial artery passes dorsally at the wrist and traverses the anatomic snuffbox, which is bounded

A B

C D

Fig. 31.6. A: Puncture artery directly at angle of 10 to 15 degrees to skin, with needle bevel down.

B: Advance slowly. C: Withdraw needle stylet, allow for blood return, and advance cannula into artery.

D: Attach cannula firmly to T connector.

 

186 Section V ■ Vascular Access

a. Prepare as for percutaneous procedure (Standard

Technique, steps 1 to 3).

b. Scrub and prepare as for major procedure (see

Chapter 5).

c. Infiltrate site of incision (point of maximum pulsation just proximal to proximal wrist crease) with 0.5

to 1 mL of lidocaine.

d. Wait 5 minutes for anesthesia.

e. Make a 0.5-cm transverse skin incision (Fig. 31.7A).

f. Deepen incision into subcutaneous tissue by blunt

longitudinal dissection with curved mosquito hemostat (Fig. 31.7B).

g. Use curved mosquito hemostat to dissect artery free.

Be gentle, to avoid arteriospasm.

h. Elevate artery with hemostat or nerve hook (Fig.

31.7C).

i. Loop ligature (5-0 silk) around artery for traction

purposes (Fig. 31.7D). Do not tie ligature.

j. Advance cannula stylet into artery with bevel down,

until cannula is clearly within vessel lumen (Fig.

31.7E).

Fig. 31.4. A: Anatomic relations of posterior

tibial artery, showing site of incision for cutdown.

B: Cannulation of posterior tibial artery; cannula

is attached to a transducer for continuous blood

pressure monitoring.

A

B

Fig. 31.5. A: Cannulation of artery using Method A (see text).

B: Cannulation of artery using Method B (see text). (Redrawn

from Filston HC, Johnson DG. Percutaneous venous cannulation

in neonates and infants: a method for catheter insertion without

“cutdown.” Pediatrics. 1971;48:896, with permission of the

American Academy of Pediatrics.)

B

A

 

6. Accomplish cannulation of artery (Fig. 31.5).

Method A (Preferred for Small Premature

Neonates) (Fig. 31.6)

a. Puncture artery directly at an angle of 10 to

15 degrees to the skin, with the needle bevel down.

b. Advance slowly. There will be arteriospasm when

the vessel is touched, and blood return may be

delayed.

c. Withdraw needle stylet (blood should appear in the

cannula) and advance cannula into artery as far as

possible.

Method B (Fig. 31.5B)

a. Pass needle stylet (with bevel up) and cannula

through artery at 30- to 40-degree angle to skin.

b. Remove stylet and withdraw cannula slowly until

arterial flow is established.

c. Advance cannula into artery.

The inability to insert the cannula into the lumen

usually indicates failure to puncture the artery centrally. This often results in laceration of the lateral

wall of the artery with formation of a hematoma,

which can be seen on transillumination.

7. Attach cannula firmly to T connector and gently flush

with 0.5 mL of heparinized solution, observing for evidence of blanching or cyanosis.

8. Apply iodophor ointment (optional) to puncture site.

9. Suture cannula to skin with 5-0 nylon suture if desired.

Fig. 31.2. Anatomic relations of the

major arteries of the wrist and hand.

Chapter 31 ■ Peripheral Arterial Cannulation 185

This step may be omitted as long as cannula is

securely taped (Fig. 27.4); use of sutures may produce a

more unsightly scar.

10. Secure cannula as done with peripheral IV line, as

shown in Fig. 27.4. Transparent semipermeable dressing may be used in place of tape to allow continuous

visualization of skin entry site. Guarantee that all digits

are visible for frequent inspection.

11. Maintain patency by attaching T connector to extension

tubing or arterial pressure line to run 0.5 to 1 mL/h of

heparinized flush solution by constant infusion pump.

12. Change IV tubing and flushing solution every

24 hours.

Radial Artery Cutdown

Cutdown technique may be required for the very small neonate, because trauma to the artery causes vasospasm, which

makes percutaneous cannulation of a small vessel very difficult.

1. Technique I: Cutdown at wrist

The artery is initially exposed by cutdown, and a

catheter is inserted under direct vision.

Fig. 31.3. A: Anatomic relations of

dorsalis pedis artery. B: White arrow

shows anatomic location of dorsalis

pedis artery.

A

B

 

E. Technique

Standard Technique for Percutaneous

Arterial Cannulation

1. Choose a site for cannulation and secure the appropriate limb.

a. Radial artery: This is the most routine site for cannulation (15,21). The infant’s forearm and hand can

be transilluminated with the wrist in extension 45 to

60 degrees (Fig. 31.1), making sure that fingers are

visible to monitor distal perfusion. The artery can

be palpated proximal to the transverse crease on the

palmar surface of the wrist, medial to the styloid process of the radius, and lateral to the flexor carpi radialis (Fig. 31.2).

b. Ulnar artery: In a small number of infants, the ulnar

artery may be easier to locate than the radial artery

(22). If an Allen test indicates that the collateral blood

supply is adequate, the ulnar artery may be cannulated using the same method as for a radial artery.

The ulnar artery runs along the palmar margin of the

flexor carpi ulnaris, radial to the pisiform bone.

Fig. 31.1. Transillumination of the radial artery.

184 Section V ■ Vascular Access

Caution is necessary when cannulating the ulnar

artery because it runs next to the ulnar nerve and is

smaller in caliber than the radial artery (Fig. 31.2).

c. Dorsalis pedis artery: The dorsalis pedis artery can

be found in the dorsal midfoot between the first and

second toes with the foot held in plantar flexion

(Fig. 31.3). It should be noted that the vascular anatomy of the foot is variable and the dorsalis pedis

artery may be absent in some patients (23), whereas

it may provide the main blood supply to the toes in

others (24).

d. Posterior tibial artery: The posterior tibial artery runs

posterior to the medial malleolus with the foot held

in dorsiflexion (Fig. 31.4).

2. Identify artery by

a. Palpation (see anatomic landmarks as described

above or individual arterial sites)

b. Transillumination (see Fig. 13.1 and Chapter 13) (25)

c. Doppler ultrasound (9–11)

3. Scrub and put on gloves.

4. Prepare skin over site with antiseptic (e.g., an iodophor).

5. Make small skin puncture with venipuncture needle over

site (optional; to ease passage of cannula through skin

and reduce chances of penetrating the posterior wall of

the vessel, especially when using a larger-gauge cannula).

3. When performing radial or ulnar cannulation, avoid

excessive hyperextension of wrist, because this may

result in occlusion of artery and a false-positive Allen

test (18) and has been associated with median nerve

conduction block (19).

4. Leave all fingertips/toes exposed so that circulatory status may be monitored. Examine limb frequently for

changes in perfusion.

5. Never ligate artery.

6. Take care not to introduce air bubbles into cannula while

assembling infusion system or taking blood samples.

7. Make sure that a continuous pressure waveform tracing

is displayed on a monitor screen at all times.

8. Be aware that the blood pressure measured in the lower

extremity may be 5 to 20 mm Hg higher than in the

upper extremity, and the reading may be delayed by

one tenth of a second (17).

9. Do not administer a rapid bolus injection of fluid via

line, because there is a danger of retrograde embolization of clot or air (20). Flush infusion after sampling

should be:

a. Minimal volume (0.3 to 0.5 mL)

b. Injected slowly

10. To reverse arteriospasm, see Chapter 34.

11. Use cannula for sampling only; no fluids other than

heparinized saline flush solution should be administered via cannula.

12. Remove cannula at first indication of clot formation or

circulatory compromise (e.g., dampening of waveform

on monitor). Do not flush to remove clots.

13. Inspect cannula insertion site at least daily.

a. If signs of cellulitis are present, remove the cannula

and send the cannula tip for culture. Also, send a

wound culture if there is inflammation at the cutdown site.

b. Obtain a blood culture from a peripheral site if signs

of sepsis are present.

c. Inspect the area distal and proximal to the insertion

site for blanching, redness, cyanosis, or changes in

temperature or capillary refill time.

14. Remove cannula as soon as indications no longer exist. 

 

24-gauge × 0.75-inch, or 24-gauge × 0.56-inch tapered

or nontapered cannula with stylet for larger to smaller

neonates, respectively

8. Antiseptic ointment (optional)

9. Arterial pressure transducer and extension tubing (see

Chapter 9)

10. 5-0 nylon suture with curved needle (optional)

11. Needle holder (optional)

12. Suture scissors (optional)

13. T connector primed with heparinized flush solution

14. Transparent, semipermeable dressing

Nonsterile

1. Equipment for transillumination (see Chapter 13) or

Doppler ultrasound

Use of Doppler ultrasound for localization of the

artery (9,10) and assessment of the adequacy of the palmar circulation has been described (11,12)

2. 0.5-inch, water-resistant adhesive tape

3. Materials for forearm restraint (see Chapter 4) for radial

or ulnar cannulation

4. A constant-infusion pump capable of delivering flush

solution at rate of 0.5 to 1 mL/h against back pressure

Chapter 31 ■ Peripheral Arterial Cannulation 183

Additional Equipment Required for

Cutdown Procedure

All equipment except mask must be sterile.

1. Gown and mask

2. 0.5% lidocaine hydrochloride in labeled 3-mL syringe

3. No. 11 scalpel and holder

4. Two curved mosquito hemostats

5. Nerve hook

6. 5-0 nylon suture

D. Precautions

1. When performing radial artery cannulation, always

check ulnar collateral circulation using the Allen test

(13–15) prior to undertaking the procedure. This test is

recognized to have limitations regarding accuracy and

interrater reliability (16), so careful observation for

signs of impaired distal perfusion is still required during

and after the procedure. Doppler ultrasound (11,12)

may also be useful in assessing collateral circulation.

2. When performing dorsalis pedis or posterior tibial cannulation, a modified Allen test can be performed by

raising the foot, occluding the dorsalis pedis and posterior tibial arteries, releasing pressure over one, and

monitoring for tissue perfusion within 10 seconds,

although this technique is less reliable than testing in

the hand (17).

 

182

An N. Massaro

Khodayar Rais-Bahrami

31 Peripheral Arterial Cannulation

Arterial access is often needed in the care of the sick neonate for continuous hemodynamic monitoring and blood

sampling. For various technical or clinical reasons, catheterization of the umbilical artery is not always possible.

Therefore, peripheral arterial cannulation may be required.

As a general rule, the most peripheral available artery

should be used, to reduce the potential sequelae from any

associated vascular compromise or thromboembolic event.

The artery chosen should be large enough to measure blood

pressure without occlusion, have adequate collateral circulation, be at a site with low infection risk, and be in an area

that can be easily monitored and cared for by nursing staff.

Common sites for peripheral arterial cannulation include

the radial, ulnar, dorsalis pedis, and posterior tibial arteries.

Although cannulation of the axillary (1,2) and brachial (3)

arteries have been described, these sites are not recommended because of the limited collateral blood flow and

high potential for ischemic complications. Cannulation of

the temporal artery should likewise be avoided due to

potential adverse neurologic sequelae (4,5).

A. Indications

1. Monitoring of arterial blood pressure

2. Frequent monitoring of blood gases or laboratory tests

(e.g., sick ventilated neonates or extremely lowbirthweight premature infants)

3. When preductal measurement is required (e.g., with

persistent pulmonary hypertension) (right upper

extremity cannulation)

B. Contraindications

1. Bleeding disorder that cannot be corrected

2. Pre-existing evidence of circulatory insufficiency in

limb being used for cannulation

3. Evidence of inadequate collateral flow (i.e., occlusion

of the vessel to be catheterized may compromise perfusion of extremity)

4. Local skin infection

5. Malformation of the extremity being used for cannulation

6. Previous surgery in the area (especially cutdown)

C. Equipment

Sterile

1. Gloves

2. Antiseptic solution (e.g., iodophor, chlorhexidine)

3. 4- × 4-inch gauze squares

4. 0.5 to 0.95 normal saline (NS) with 1 to 2 U/mL heparin

Although hypernatremia has been reported in very

small premature infants who received excess sodium in

flush solution (6), in our experience 0.5 NS has been

used without complications at infusion rates of 0.5 to

1 mL/h. Using heparinized saline has been shown to

maintain line patency longer than hypotonic solutions

such as heparinized 5% dextrose water (7) or unheparinized NS (8).

5. 3- or 5-mL syringe

6. 20-gauge venipuncture needle (if using larger-sized

22-gauge cannula)

7. Appropriate-sized cannula: 22-gauge × 1-inch (2.5-cm),

 

Chapter 30 ■ Umbilical Vein Catheterization 181

32. Lauridsen UB, Enk B, Gammeltoft A. Oesophageal varices as a

late complication of neonatal umbilical vein catheterization. Acta

Paediatr Scand. 1978;67:633.

33. Johnson DE, Bass JL, Thomson TR, et al. Candida septicemia

and right atrial mass secondary to umbilical vein catheterization.

Am J Dis Child. 1981;135:275.

34. Crie JS, Hajar R, Folger G. Umbilical catheter masquerading at

echocardiography as a left atrial mass. Clin Cardiol. 1989;12:728.

35. Welibae MA, Moore JH. Digital ischemia in the neonate following intravenous therapy. Pediatrics. 1985;76:99.

36. Long WA. Pneumopericardium. In: Long WA, ed. Fetal and

Neonatal Cardiology .Philadelphia: WB Saunders; 1990:382.

 

26. Venkatavaman PS, Babcock DS, Tsang RC, et al. Hepatic injury: a

possible complication of dopamine infusion through an inappropriately placed umbilical vein catheter. Am J Perinatol. 1984; 1:351.

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

28. Nakstad B, Naess PA, Lange C, et al. Complications of umbilical

vein catheterization: neonatal total parenteral nutrition ascites

after surgical repair of congenital diaphragmatic hernia, J Pediatr

Surg. 2002;37:1.

29. Yigiter M, Arda IS, Hicsonmez A. Hepatic laceration because of

malpositioning of the umbilical vein catheter: case report and literature review. J Pediatr Surg. 2008; 43:E39.

30. Kanto WP, Parrish RA. Perforation of the peritoneum and intraabdominal hemorrhage. Am J Dis Child. 1977;131:1102.

31. Hillman LS, Goodwin SL, Sherwin WR. Identification and measurement of plasticizer in neonatal tissues after umbilical catheters and blood products. N Engl J Med. 1975;292:381.

A B

Fig. 30.7. A: Hepatic infarction (darkened areas on anterior aspect of liver) related to umbilical vein

catheter. B: Section through inferior aspect of liver to show internal appearance of infarcted areas (arrow).

 

17. Sarrut S, Alain J, Allison F. Early complications of umbilical vein

perfusion in the premature infant. Arch Fr Pediatr. 1969;26:651.

18. Thomson TL, Levine M, Muraskas JK, et al. Pericardial effusion

in a preterm infant resulting from umbilical venous catheter

placement. Pediatr Cardiol. 2010;31:287.

19. Sehgal A, Cook V, Dunn M. Pericardial effusion associated with

an appropriately placed umbilical venous catheter. J Perinatol.

2007;27:317.

20. Egan EA, Eitzman DV. Umbilical vessel catheterization. Am J

Dis Child. 1971;121:213.

21. Symchych PS, Krauss AN, Winchester P. Endocarditis following

intracardiac placement of umbilical venous catheters in neonates.

J Pediatr. 1977;90:287.

22. Kulkarni PB, Dorand RD. Hydrothorax: a complication of intracardiac placement of umbilical venous catheters. J Pediatr. 1979;

94:813.

23. Livaditis A, Wallgren G, Faxelius G. Necrotizing enterocolitis

after catheterization of the umbilical vessels. Acta Paediatr Scand.

1974;63:277.

24. Shah KJ, Corkery JJ. Necrotizing enterocolitis following umbilical vein catheterization. Clin Radiol. 1978;29:295.

25. Friedman A, Abellera R, Lidsky I, et al. Perforation of the colon

after exchange transfusion in the newborn. N Engl J Med.

1970;282:796.

 

2. Kitterman JA, Phibbs RH, Tooley WH. Catheterization of umbilical vessels in newborn infants. Pediatr Clin North Am.

1970;17:895.

3. Oestreich AE. Umbilical vein catheterization—appropriate and

inappropriate placement. Pediatr Radiol. 2010;40:1941.

4. Dunn P. Localization of the umbilical catheter by post-mortem

measurement. Arch Dis Child. 1966;41:69.

5. Mandel D, Mimouni FB, Littner Y, et al. Double catheter technique for misdirected umbilical vein catheter. J Pediatr.

2001;139:5.

6. Baker DH, Berdon WE, James LS. Proper localization of umbilical arterial and venous catheters by lateral roentgenograms.

Pediatrics. 1969;43:34.

7. Weber AL, Deluce S, Shannan DL. Normal and abnormal position of the umbilical artery and venous catheter on the roentgenogram and review of complications. AJR. 1974;20:361.

8. Fleming SE, Kim JH. Ultrasound-guided umbilical catheter

insertion in neonates. J Perinatol. 2011;31:344.

9. Ades A, Sable C, Cummings S, et al. Echocardiographic evaluation of umbilical venous catheter placement. J Perinatol. 2003;

23:24.

10. Anagnostakis D, Kamba A, Petrochilou V, et al. Risk of infection

associated with umbilical vein catheterization: a prospective study

in 75 newborn infants. J Pediatr. 1975;86:759.

11. Brans YW, Ceballos R, Cassady G. Umbilical catheters and

hepatic abscesses. Pediatrics. 1974;53:264.

12. Centers for Disease Control. Guidelines for prevention of intravascular device-related infections, parts 1 and 2. Am J Infect

Control. 1996;24:262.

13. Raad II, Luna M, Kaliel S-AM, et al. The relationship between

the thrombotic and infectious complications of central venous

catheters. JAMA. 1994;271:1014.

14. Williams JW, Rittenberry A, Dillard R, et al. Liver abscess in the

newborn: complication of umbilical vein catheterization. Am J

Dis Child. 1973;125:111.

15. Noel GJ, O’Loughlin JE, Edelson PJ. Neonatal staphylococcus

epidermitis right sided endocarditis: description of five catheterized infants. Pediatrics. 1988;82:234.

16. Oski FA, Allen DM, Diamond LK. Portal hypertension—a complication of umbilical vein catheterization. Pediatrics. 1963;

31:297.

 

178 Section V ■ Vascular Access

A B

C D

Fig. 30.6. Spectrum of malpositions of umbilical venous catheters (UVCs) (A–C). A: UVC in right

portal vein with secondary air embolization into portal venous system. B: UVC in splenic vein. UAC catheter in good position with its tip at T7. C: UVC extending through heart into the superior vena cava.

D, E: Spectrum of malpositions of UVCs. The anteroposterior film (D) shows an indeterminate position

of the UVC. The right atrium, the right ventricle, and the left atrium are all possibilities.

Chapter 30 ■ Umbilical Vein Catheterization 179

I

H

G

F

E

Fig. 30.6. (continued) The lateral film (E) shows its posterior position, confirming its presence in the

left atrium. The lateral film is particularly important in making this distinction. Measurement of the PO2

in blood from the catheter will be diagnostic of misplacement, unless the infant has severe persistent pulmonary hypertension or other cause of severe intracardiac shunting. F–I: Spectrum of malpositions of

UVCs. Series of radiographs demonstrating various malpositions of a venous catheter: right pulmonary

artery (F), left main pulmonary artery (G), main pulmonary artery (H), and right ventricle (I).

180 Section V ■ Vascular Access

References

1. Nickerson BG, Sahn DJ, Goldberg SJ, et al. Hazards of

inadvertent venous catheterization in a patient with anomalous

pulmonary venous drainage: a case report. Pediatrics. 1979;

63:929.

 

Chapter 30 ■ Umbilical Vein Catheterization 177

Fig. 30.5. A: Radiograph showing venous catheter that has crossed the ductus arteriosus into the thoracic aorta. B: In this situation, the arterial pressure markings were not helpful because the presence of

pulmonary hypertension in the patient rendered the tracings from the pulmonary artery and descending

aorta virtually identical.

B

A

d. Hemorrhagic infarction of lung (7)

e. Hydrothorax (catheter lodged in or perforated pulmonary vein) (22)

4. Catheter malpositioned in portal system

a. Necrotizing enterocolitis (23,24)

b. Perforation of colon (25)

c. Hepatic necrosis (thrombosis of hepatic veins or

infusion of hypertonic or vasospastic solutions into

liver tissues) (Fig. 30.7) (11,12,17,26)

d. Hepatic cyst (27)

e. Ascites (secondary to extravasation of fluid through

malpositioned catheter) (28)

f. Hepatic laceration (29)

5. Other

a. Perforation of peritoneum (30)

b. Obstruction of pulmonary venous return (in

infant with anomalous pulmonary venous drainage)

(1)

c. Plasticizer in tissues (31)

d. Portal hypertension (16,32)

e. Electrical hazard (see Chapter 29, J3c) (2)

f. Fungal mass in right atrium (33)

g. Pseudomass in left atrium (34)

h. Digital ischemia (35)

i. Pneumopericardium (36)

 

Fig. 30.4. Venous and arterial pressure tracings may be used to facilitate placement and detect misplacement. A: The catheter has been pulled back through the ductus venosus, and the tip lies in the portal

system. The portal venous pressure is higher than the central venous pressure, there are no venous pressure waves, and there is a small positive deflection during inspiration. B: Tip of catheter in the superior

vena cava near the right atrium shows a deflection of more than 4 mm Hg during spontaneous inspiration

(I) and a large negative deflection of more than 15 mm Hg during a sigh (S). Atrial tracing shows an AC

and a V wave. AC wave occurs with atrial contraction and closure of atrioventricular valve after P wave of

ECG. V wave occurs with ventricular contraction near T wave of electrocardiogram. (Based on data from

Kitterman JA, Phibbs RH, Tooley WH. Catheterization of umbilical vessels in newborn infants. Pediatr

Clin North Am. 1970;17:895, with permission.) C: Pressure tracing from right ventricle and pulmonary

artery. Right ventricular pressure tracing shows a single large rise and fall, beginning just after onset of

QRS complex. Pulmonary artery tracing usually shows a dicrotic notch at end of T wave. Diastolic pressure is higher than that in right ventricle. Pulmonary capillary wedge tracing should resemble atrial tracing, inasmuch as it reflects left atrial pressure transmitted to the catheter tip when anterograde pulmonary

arterial flow is occluded. Note: The marked negative deflection in the right atrial tracing would be more

typically seen in infants who are receiving mechanical ventilation and, thus, have a positive airway pressure that exceeds ventricular filling pressures during each inspiration. In a spontaneously breathing

neonate, positive airway pressure occurs only during expiration and never exceeds ventricular filling pressures. There are extremely small changes in cardiac pressures (i.e., on inspiration: right atrial [RA] mean

pressure ↑, 1 mm Hg; left atrial [LA] mean pressure ↓ 1 mm Hg; on expiration: RA pressure ↓ 1 mm Hg;

LA pressure ↑ 1 mm Hg) during the respiratory cycle as a result of changes in venous filling or preload.

Right and left atrial pressures remain approximately equal in both inspiration and expiration (36).

 

Chapter 30 ■ Umbilical Vein Catheterization 175

Fig. 30.3. Anteroposterior (A) and lateral (B) radiographs demonstrating the normal

course of an umbilical venous catheter, with an umbilical artery catheter (arrows) in position for comparison. Note how the venous catheter swings immediately superior from the

umbilicus, slightly to the right as it traverses the ductus venosus into the inferior vena cava

(IVC). The distal tip of this line is just superior to the right atrial–IVC junction, and it

might optimally be pulled back slightly into the IVC. Note how the thinner umbilical

artery catheter (arrows) heads inferiorly as it proceeds to the iliac artery and then ascends

posteriorly and to the left until it reaches the level of T7.

A B

imaging techniques may provide a more accurate

assessment of catheter location.

12. Secure catheter as for umbilical artery catheter (see

Chapter 29, E).

There may be more bleeding from the umbilical

vein than from the umbilical artery because the vein is

not a contractile vessel. Local pressure is usually sufficient to stop oozing. For care of an indwelling catheter,

sampling technique, and removal of a catheter, see

Chapter 29.

F. Complications

1. Infections (6,10–15)

2. Thromboembolic (10,13,16,17)

Emboli from a venous catheter may be widely distributed. If the catheter tip lies in the portal system and

the ductus venosus has closed, emboli will lodge in the

liver. If the catheter has passed through ductus venosus,

emboli will go to the lungs or, because of right-to-left

shunting of blood through foramen ovale or ductus

arteriosus in sick newborn infants, emboli may be distributed throughout entire systemic circulation. These

emboli may be infected and, therefore, may cause

widespread abscesses.

3. Catheter malpositioned in heart and great vessels (Figs.

30.5 and 30.6)

a. Pericardial effusion/cardiac tamponade (cardiac perforation) (3,18,19)

b. Cardiac arrhythmias (20)

c. Thrombotic endocarditis (21)

176 Section V ■ Vascular Access

A

B

C

 

174 Section V ■ Vascular Access

and left lobes of the liver in the median sagittal plane of the

body, at a level between the 9th and 10th thoracic vertebrae; it terminates in the inferior vena cava along with

hepatic veins, as shown in Fig. 30.1.

1. Make necessary measurements to determine length of

catheter to be inserted, adding length of umbilical

stump (Figs. 30.1 and 30.2) (4).

2. Prepare for procedure as with umbilical artery catheter

(see Chapter 29, E).

3. Identify thin-walled vein, close to periphery of umbilical stump (Fig. 30.2).

4. Grasp cord stump with toothed forceps.

5. Gently insert tips of iris forceps into lumen of vein and

remove any clots.

6. Introduce fluid-filled catheter, attached to the stopcock

and syringe, 2 to 3 cm into vein (measuring from anterior abdominal wall).

7. Apply gentle suction to syringe.

a. If there is not easy blood return, the catheter may

have a clot in the tip. Withdraw the catheter while

maintaining gentle suction. Remove clot and reinsert catheter.

b. If there is smooth blood flow, continue to insert

catheter for full estimated distance.

Fig. 30.1. Anatomy of the umbilical and associated veins, with

reference to external landmarks.

Fig. 30.2. The umbilical stump. Vein is indicated with an arrow.

8. If catheter meets any obstruction prior to measured distance

a. It has most commonly

(1) Entered portal system, or

(2) Wedged in an intrahepatic branch of portal vein

b. Withdraw catheter 2 to 3 cm, gently rotate, and reinsert in an attempt to get tip through ductus venosus.

9. If the catheter is in the portal circulation, leave the misdirected catheter in its place. Pass a new 3.5- or 5-Fr

catheter into the same vessel. Once the catheter is in a

good position, remove the misdirected catheter. This

procedure has a 50% success rate (5).

10. Obtain radiographic verification of catheter position. A

lateral radiograph will aid in exact localization (Fig.

30.3) (6,7). The desired location is T9 to T10, just

above the right diaphragm. The catheter tip position

may be estimated clinically by measurement of venous

pressure (1) and observation of waveform (Figs. 30.4

and 30.5). The catheter has crossed the foramen ovale

if the blood obtained is bright red (arterial in appearance). In this case, pull the catheter back.

a. As soon as the catheter has been advanced 2 to 3 cm

into the vein, have an assistant connect it to a pressure-monitoring system (see Chapter 9).

b. While continuing to advance the catheter, measure

venous pressure and note pressure changes with respiration (Fig. 30.4). The ideal position is with the

catheter tip at the junction of the inferior vena cava

and the right atrium, although placement in ductus

venosus is acceptable for purposes other than measurement of central venous pressure.

11. Other modalities to evaluate catheter placement

include ultrasound (8) and echocardiography (9).

These techniques may require fewer manipulations

during catheter placement and reduce the number of

x-rays a patient receives. Additionally, these types of