Artery and Vein Catheterisation
|Reveiwed by Frank Bloomfield
Updated March 2013
also radiology images of UAC and UVC placement
- Umbilical vessels are relatively accessible in
the newborn infant, particularly the very small and very large
- As a general rule, infants less than 1000g
should have an umbilical venous catheter (UVC) inserted on day 1.
- An umbilical arterial catheter (UAC) may be
indicated if the infant has significant respiratory disease (ventilated or
>40% oxygen), close monitoring of blood pressure is desirable, the infant
is at high risk for complications even if reasonably stable on admission or
is likely to require significant blood sampling over the first few days of
- Larger infants with significant respiratory
distress may also require a UAC.
- Larger infants, especially sick infants,
should have a UVC inserted. A double-lumen catheter may be indicated if the
infant requires significant support (see Catheter Choice
Umbilical Venous Catheters
- The umbilical vein is 2-3cm long and 4-5mm in
- From the umbilicus, it passes cephalad and a
little to the right. It joins the left branch of the portal vein after
giving off several large intrahepatic branches.
- The ductus venosus arises from the point where the UV joins the left portal
vein and bypasses the liver, joining the inferior vena cava just distal to its
entry into the atrium atrium.
- The ideal position for a UVC is in the inferior vena cava, just outside
of right atrium-which correlates to the level of the diaphragm
- Position should be verified with anteroposterior and lateral
chest-and-abdominal radiographs or by echocardiography1,2
- It can be difficult to pass the catheter
through the ductus venosus. There are some manoeuvres that can assist
in placement. These include:
- pulling the catheter back to about 4-5cm,
then advancing the catheter whilst rotating the catheter clockwise
- passing another catheter down beside the
already mal-placed catheter. The path of the second catheter may
be through the ductus venosus.
- Do not force a catheter in if there
- In an emergency, a UVC that remains in the
portal circulation may be withdrawn until it lies in the umbilical
vein. Solutions which are not isotonic can be infused through this for
a short period of time until more suitable access is obtained.
- In a resuscitation situation, it is safe to advance a UVC whilst
aspirating frequently until blood return is seen. Inserting the catheter 1-2
cm beyond this point is an appropriate position for emergency use without
radiographic confirmation of position3.
- Any UVC pulled back after an X-ray should be re-X-Rayed to comfirm the
correct position or confirmed by bedside clinician performed ultrasound.
- Clearly document the line length, tip position and any adjustments made
to the line after X-Ray.
Duration of use
- Use of umbilical venous catheters for greater than 7 days is associated
with an increased risk of central line associated bloodstream infection (CLABSI)
compared with use less than 7 days4
- If it is anticipated that central venous access is likely to be
necessary for longer than 7 days, the UVC should be replaced with a PICC
line by 7 days of age.
Catheter size 5
For infants who are term or near-term and sick
enough to require central access (for example, sepsis,
PPHN), a 5F
double-lumen UVC should be inserted.
For infants <1000g, a 3.5F double-lumen
catheter should be considered if the infant is likely to need inotropes or
multiple infusions. This will be decided on an individual basis.
- If the shoulder-to-umbilicus distance
is measured, the catheter can be inserted the appropriate distance
according to the graph (right) 6.
- Remember to measure from the
skin at the base of the stump where it connects to the anterior
to add the length of
the umbilical stump to the distance inserted.
- Another method is to calculate the
distance according to the weight of the baby. See the
below to evaluate UVC position.
- An approximation of this is to use
the calculation of: UVC length (cm) = (1.5 x birthweight (kg)) +
or half the UAC length (calculated below) + 1cm 7
from UVC insertion include 4
||Catheter Malpostioned in the Heart and
Malpositioned in portal
- Pericardial effusion or cardiac tamponade
- Cardiac arrhythmias
- Thrombotic endocarditis
- Haemorrhagic pulmonary infarction
- Hydrothorax (UVC lodged in or perforating
- Perforation of peritoneum
- Obstruction of pulmonary venous return (in
infants with TAPVD)
- Plasticizer in tissues
- Portal hypertension
- Electrical hazard
(improper grounding of equipment, or conduction of current
through fluid filled catheter).
- Visceral laceration (hepatic)
Umbilical Artery Catheters
- The umbilical arteries are the direct
continuation of the internal iliac arteries.
- A catheter passed into an umbilical
artery will usually (but not always) enter the aorta via the internal iliac
- Its path is, therefore, initially inferior and lateral as it passes around
the bladder, before turning cephalad and medial to enter the aorta
- Occasionally it will pass into the femoral
artery via the external iliac artery or into the gluteal arteries.
- The femoral artery or gluteal artery are
unsuitable sites for sampling, infusion, or blood pressure monitoring.
- There are two potential positions for the
UAC. These are described as "high" or "low".
- The high position is at the level of
thoracic vertebral bodies T6-T9. 5 This position is above the
coeliac axis (T12), the superior mesenteric artery (T12-L1), and the
renal arteries (L1). This position is essentially "above the
- The low position is at the level of lumbar
vertebral bodies L3-L4. 5 This position is below the structures as
above, and is above the aortic bifurcation (L4-L5). The inferior
mesenteric artery arises from L3-L4. This position is essentially
"above the bifurcation".
- A high UAC position is associated with significantly lesser risks of
clinical vascular compromise and aortic thrombus formation
8 . This position should be used exclusively unless a low
position is the only position that can be obtained and a UAC is deemed
necessary for optimum patient care.
Catheter Size 5
|Never use an 8F UAC
- If you know the length of the infant,
you can refer to the graph on the right which relates UAC distance
to total body length.9
- This will result in placement at
- Note that of all the birth
measurements, length is the least reliable.
- Alternatively, the shoulder-to-umbilicus length can be used to
estimate catheter insertion distance according to the graph on the
- The average catheter distance is approximately 106% of the
shoulder-to-umbilicus distance. A rule-of-thumb is
shoulder-to-umbilicus distance + 2 cm allowing for the caveats below
- Remember to measure from the skin at the base of the stump where
it connects to the anterior abdominal wall.
- Remember to add the length of the umbilical stump to the
- Another option - and one which is particularly good if you forget
to measure the shoulder-to-umbilicus length - is to calculate the
insertion distance using the formula:
UAC distance (cm) = (birthweight (kg)
x4) + 710.
- It does no harm to insert the line a
centimetre further than calculated, as the line can be pulled back
slightly if needed. However, you should avoid inserting the
UAC so far that it needs to be removed from the carotid or
Complications from umbilical
catheterisation include 5
- Vessel perforation
- Refractory hypoglycaemia
(if catheter tip opposite coeliac axis)
- Peritoneal perforation
- False aneurysm
- Loss of extremity
- Heart failure (from aortic
- Air embolism
- Broken catheter
- Transection of catheter
- Plasticizer in tissues
- Improper grounding of electronic
- Conduction of current through
- Necrotising enterocolitis
- Intestinal necrosis or perforation
- Transection of omphalocoele
- Herniation of appendix through
- Cotton fibre embolus
- Wharton-jelly embolus
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