Unique to the neonate, lifesaving central access can be achieved through catheterization of the umbilical vessels. Umbilical artery catheterization can routinely be performed in newborns up to 24 hours old and occasionally in those up to 1 week old. Umbilical vein catheterization is feasible up to 2 weeks of age.¹

Indications for central access include volume expansion, blood transfusion, infusion of resuscitative medications, administration of hypertonic solutions including parenteral nutrition, and frequent laboratory draws. Peripheral access should be attempted first but should not delay central access in a critically ill infant.

Arterial catheters are indicated in newborns requiring frequent arterial blood gases and/or invasive blood pressure monitoring. An umbilical artery catheter has the advantage of rapid insertion and may also be used to deliver fluids, medications, and blood products.

Overlying soft tissue infection (e.g. omphalitis), peritonitis, possible necrotizing enterocolitis, and abdominal anomalies (e.g. omphalocele) are contraindications to placing an umbilical vessel catheter.² Umbilical lines should not be placed in infants greater than 2 weeks of age and should be avoided in patients with known thrombotic disease. Finally, one must remember that these are central lines and are not placed for routine blood sampling or administration of fluids or medications.

NONSTERILE

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  Radiant warmer with light source

  
  
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  Cardiorespiratory monitor

  
  
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  Pulse oximeter

  
  
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  Measuring tape

  
  
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  Surgical mask with face shield, surgical cap

  
  
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  D5W, D10W, or 0.45% NaCl infusion setup with heparin 1 unit/mL (unless medications are incompatible with heparin)

  
  
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  Soft infant restraints

  
  
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  Adhesive tape

STERILE

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  Povidone–iodine solution

  
  
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  Sterile drapes, gauze, gloves, gown

  
  
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  Scalpel (number 11 or 15)

  
  
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  Curved hemostats (2)

  
  
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  Straight forceps

  
  
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  3-0 silk suture

  
  
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  Needle driver

  
  
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  Scissors

  
  
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  Umbilical tape

  
  
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  Umbilical catheters (3.5, 5, or 8 French with end hole)

  
  
  
  
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    Umbilical vein catheter size = 5 Fr (3.5 Fr if <500 g)

    
    
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    Umbilical artery catheter size = 5 Fr if >1500 g; 3.5 Fr if <1500 g

  
  
  
  
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  Three-way stopcock

  
  
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  Curved, toothless forceps or pointed, solid metal dilator

  
  
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  10-mL syringe filled with sterile normal saline (with heparin 1 unit/mL if available)

PREPARATION

Arrange the materials and warmer before the patient’s arrival, if feasible. Address any cardiorespiratory issues before the procedure. Determine the length of the catheter. Venous catheter placement can be estimated by measuring the shoulder to umbilicus length in centimeters and multiplying by 0.6 (Figure 193-1). For arterial catheter placement, an estimated length can be calculated using the formula (birth weight (kg) × 3) + 9 cm. Recent data suggest that the Wright formula (birth weight (kg) × 4) + 7 cm is a more accurate estimate, especially in very low birth-weight infants, but may result in under-insertion of the catheter.^3,4 Venous catheter diameters are typically 5 French unless the infant is <1000 grams. Arterial catheters are 5 French for infants weighing more than 1.5 kg and 3.5 French for smaller infants.

Place the infant in a radiant warmer with the arms and legs restrained in the supine, frog-leg position (see Figure 193-1). Attach cardiorespiratory, temperature, and oxygen saturation monitors, and don appropriate surgical wear. Attach the three-way stopcock to the umbilical catheter, and flush both ports and the catheter with sterile solution. Turn off the stopcock to all ports.