Intravascular Catheters
Umbilical Catheterisation

Authorised by:
Charge Nurse - Newborn

May 2006

Insertion of UAC/UVC	Large branches of the aorta	Placement of UVC	Securing of catheters in infants <1500g
Gate strapping of umbilical catheters	Management of a UAC/UVC	Removal of a UAC/UVC	Blood pressure monitoring
Blood pressure monitoring via transducer	Assembling/priming blood pressure tranducing set	Transducer set up	How to zero calibrate
Monitoring HR without using ECG leads

Insertion of a UAC/UVC

Steps	Action
1	Specific equipment required: Sterile umbilical artery pack Umbilical catheter size 3.5 or 5.0 Satane 3.0 silk and needle 3 way tap, 10ml syringe, filter needles Ampoule of 0.9% NaCl Ampoule of heparinised saline (10 units per ml) Appropriate disinfectant for infant's gestational and postnatal age. Term infants should have a double lumen catheter.
2	Observe baby carefully for any bruising on buttocks, toes and feet and document carefully.
3	Ensure baby has been measured from umbilicus to shoulder to give approximate catheter placement.
4	Secure baby’s limbs (see Restraint guideline). After insertion ascertain from NS-ANP/Medical staff which catheter is a UAC and UVC and label clearly.
5	A radiograph is used to confirm correct position of UAC/UVC. UAC fluids and blood pressure measuring can be commenced before the radiograph is taken.
6	Do not lie baby prone for at least 4 hours after insertion. Do not lie baby prone unless UAC/UVC lines are secured using the Gate Strapping method.

Aorta showing large artery branches

Placement of catheter inserted into umbilical vein (UVC)

Securing of Umbilical Catheters in Babies under 1500g

Step

Action

1
To secure catheter wrap one suture thread around the catheter x 2 firmly and close to the base. Double knot and repeat.

2
Take a 5cm length of elastoplast. Attach to the catheter – close to the base. Position the threads along the length of the catheter and wrap half the tape around and around.

3
Fold back the thread lengths and continue wrapping the tape around catheter, catching the threads again.

4
At the end, turn under the last bit of tape to make a tag.

Securing of UAC/UVC – Gate strapping

Gate strapping using sleek plaster with duoderm as a base tape, must be used on all babies over 1500grams and also on babies under 1500grams from day 4 (or earlier) if condition of cord is giving concern.

Steps

Action

1
Place duoderm base tapes lengthwise on the baby’s abdomen, one on either side of the umbilicus. Then apply sleek gates on top of duoderm. Size of gate should be relevant to size of infant.

2
Until a radiograph for catheter position is performed, secure catheter with a temporary crossbar using leucoplast.

3
After the radiograph, the catheter may need repositioning. Once this has been done restrap, using sleek as the crossbar to secure.

N.B.:

Please ensure purse string suture is neither cut nor caught in crossbar. This must be free to be tightened in an emergency.

If taping UVC as well as UAC cut strips of plaster longer to make 2 flaps

Management of UAC/UVC

Steps	Action
1	A nurse is always present in the room. Alarm limits are set appropriately including mean blood pressure alarm.
2	The catheter is secured as per baby’s weight criteria. Check security of gate at the commencement of each duty. Retape or apply a sleek gate immediately if concerned about dislodgement.
3	Connections are checked at beginning of each shift to ensure they are secure and there are no kinks in the lines.
4	Booties are not worn. The toes, feet and legs are checked frequently for changes in colour and circulation. Buttocks are checked for patchy discolouration and signs of blanching. Cyanosis of toes/feet/buttock discoloration are reported to doctor/NS-ANP immediately.
5	Napkins must not be fastened in such a manner as to obscure view of the umbilical stump.
6	Babies total fluids must not be infused via a UAC with a blood pressure transducer in situ as the flush device has a minimum flow rate.
N.B.:	On the rare occasion that fluids are infused via the UAC, place on 3-way tap closest to Baby so as maintenance fluids are not infused through the transducer.

Removal of UAC/UVC

Steps	Action
1	Cut stitches between catheter and knot of purse string.
2	Withdraw catheter slowly until 3cm remains in UAC/UVC.
3	Retape catheter at that position.
4	Turn 3 way tap off to catheter.
5	Turn off infusion pump.
6	Leave for 30 minutes.
7	Remove catheter completely.
N.B.:	Have sterile gauze handy to apply pressure if bleeding occurs.
8	Do not lie baby prone for at least 4 hours after removal of UAC/UVC. Check frequently for ooze.
9	Ensure napkin is secured below the umbilicus.

RBP: Blood pressure monitoring

Steps	Action
1	Ensure there is no blood present in the blood pressure line causing damping of the reading.
2	Calibration checks are performed - at the beginning of each shift or if having problems with the readout of blood pressure.

Blood Pressure monitoring via Blood Pressure Transducer

Blood pressure may be measured directly by attaching a blood pressure transducer set to an umbilical or peripheral arterial line.
The transducer is a very sensitive device, which responds to a change in pressure and converts these changes to a digital display on the monitor.

Equipment required

Blood pressure transducer set and
Cable fitting that joins to the monitor
500ml bag of sodium chloride 0.9% (or 0.45% for babies under 1000g) with 250 units heparin added (0.5 unit/ml).
Giving set and pall filter

Assembling/Priming Blood Pressure Transducer Set

Steps	Action
1	Attach blood pressure transducer set to giving set.
2	Plug cable from monitor into BP transducer set. A labelled pressure waveform is displayed when the cable is connected
3	Prime giving set.
4	Squeeze lever on flush device and prime BP set.
5	Turn stopcock off to flushing line and syringe.
6	Remove the 10ml syringe, draw up 10mls NaCl with Heparin from IV Bag, replace and prime flushing line to the end of transducer set.
Note:	Peripheral arterial line. Prime line as above, then remove syringe and attach luerlock bung.
7	Turn stop cock off to the flushing line and syringe. Check that there are no air bubbles present in transducer line and flushing line.
Note:	Transducer must have a zero calibration performed prior to commencement of BP monitoring. A zero calibration is required once per shift.

Transducer Set Up

To Zero Calibrate

Follow the steps below to perform zero calibration (performed prior to commencement of BP monitoring and then once per shift).

Steps

Action

1
Ensure transducer placed appropriately at level of mid-axilla of baby.

2
Close the 3-way tap closest to the baby.

3
Open the venting stopcock on the transducer to air.

4
Press the "Zero all" button on the keypad

5
Verify that zero reference has been established (watch the pressure parameter window for messages)

6
Close the venting stopcock.

7
Open the 3 way tap to baby. Within seconds, pressure numerics should be displayed in the pressure parameter window.

Monitoring Heart Rate without ECG Electrodes

Heart rate can be monitored as a 'pulse' through the umbilical arterial line by the GE-Marquette monitors.
It should be considered for all Infants <26 weeks on assisted ventilation.
Be Aware:
- Not for babies on Hudson CPAP or babies on high frequency ventilation.
- If umbilical line is not functioning well and a good pulse rate is not picked up, revert to chest electrodes. SpO₂ heart rate monitoring is not sufficient in itself.
Procedure
Monitoring <1000g babies without ECG (via the GE-Marquette monitors).
- Must have umbilical arterial line.
- To change alarm capability from HR (taken from ECG) to pulse (taken from umbilical or arterial line).

Disconnect ECG Leads
↓
Discharge Baby from Monitor
↓
Re-admit baby to Monitor
(Monitor will set up automatically)

If you cannot see an index above, please press the "Refresh" button of your browser.

Step	Action
1	To secure catheter wrap one suture thread around the catheter x 2 firmly and close to the base. Double knot and repeat.
2	Take a 5cm length of elastoplast. Attach to the catheter – close to the base. Position the threads along the length of the catheter and wrap half the tape around and around.
3	Fold back the thread lengths and continue wrapping the tape around catheter, catching the threads again.
4	At the end, turn under the last bit of tape to make a tag.

Steps	Action
1	Place duoderm base tapes lengthwise on the baby’s abdomen, one on either side of the umbilicus. Then apply sleek gates on top of duoderm. Size of gate should be relevant to size of infant.
2	Until a radiograph for catheter position is performed, secure catheter with a temporary crossbar using leucoplast.
3	After the radiograph, the catheter may need repositioning. Once this has been done restrap, using sleek as the crossbar to secure.
N.B.:	Please ensure purse string suture is neither cut nor caught in crossbar. This must be free to be tightened in an emergency. If taping UVC as well as UAC cut strips of plaster longer to make 2 flaps

Steps	Action
1	Ensure transducer placed appropriately at level of mid-axilla of baby.
2	Close the 3-way tap closest to the baby.
3	Open the venting stopcock on the transducer to air.
4	Press the "Zero all" button on the keypad
5	Verify that zero reference has been established (watch the pressure parameter window for messages)
6	Close the venting stopcock.
7	Open the 3 way tap to baby. Within seconds, pressure numerics should be displayed in the pressure parameter window.

Intravascular Catheters Umbilical Catheterisation

Insertion of a UAC/UVC

Aorta showing large artery branches

Placement of catheter inserted into umbilical vein (UVC)

Securing of Umbilical Catheters in Babies under 1500g

Securing of UAC/UVC – Gate strapping