As the number of critical-care transport (CCT) programs has grown, they’ve begun to specialize into pediatric, neonatal and even high-risk obstetric/gynecological teams.1,2 Specialized pediatric education programs now exist for critical-care paramedics (CCPs), who require unique advanced skills. One of those is umbilical vein catheterization line placement, which involves placement of an intravenous line into the vein of the umbilical cord of a newborn following delivery. It’s not a difficult procedure, but it requires a review of the anatomy of the umbilical cord and the technique itself.
Umbilical Vein Catheterization
The umbilical cord is a baby’s lifeline in utero. It serves as a conduit for nutrients between the fetus and mother’s placenta. It consists of two (paired) thicker-walled arteries and one thinner-walled vein located at 12 o’clock (Figure 1) covered by a proteoglycan-rich matrix of connective tissue referred to as Wharton’s jelly. This covering not only protects the vessels but keeps the umbilical cord from twisting and cutting off fetal circulation.3 Once the baby is born, the umbilical arteries typically spasm shut, whereas the umbilical vein does not. (What we often refer to as a baby is more accurately described as a newborn for the first few hours following birth and then a neonate for the next 28 days.)
Umbilical vein catheterization (UVC) has been used by neonatal specialists for many years for central pressure monitoring, infusion of fluids, and administration of medications during and following neonatal resuscitation.4 Since the umbilical vein remains patent for up to one week after birth,4,5 it offers an effective route for vascular access in the neonate, and even more so in the premature neonate. The procedure does require specialized equipment, training and confirmation of correct placement by x-ray.3 Many organizations have begun looking at this option for vascular access in the depressed newborn.
One option for placing a UVC line is the Fast-Cath system developed by the OB department and pediatricians at Minnesota’s Lakeview Hospital. The Fast-Cath was designed for use by physicians, nurses and paramedics during the initial resuscitation of a depressed newborn. It places a traditional UVC line under sterile conditions for use in central venous pressure monitoring and infusion of fluids and medications.
The Fast-Cath technique utilizes equipment most physicians, nurses and paramedics use regularly and are familiar with. This provides an advantage over specialized kits in time-stressed environments6 and leads to higher success rates.7–9 The Fast-Cath utilizes a standard 14-gauge protective IV catheter inserted until it flushes easily. Other UVC line kits utilize a specialized umbilical vein catheter and require formulas for correct placement and radiographic confirmation.3 The Fast-Cath kit can be made by purchasing the various components and packaging them into a medium-size sealable plastic bag (Figure 2). For hospital-based services, the central supply department can sterilize and package all the components.
Insertion of the Fast-Cath is best accomplished by two clinicians: The primary clinician (PC) inserts the catheter, and the secondary clinician (SC) assists by stabilizing the umbilical cord. The PC opens the kit and lays out the components, verifying that all are present. The SC takes the Betadine swabs and paints the umbilical cord base and the cord itself. The SC then takes the umbilical tape and ties it at the base of the cord. It should be tied tightly enough to stop blood flow, but not so tight that you can’t pass the catheter through the vein. While the SC does this, the PC puts on sterile gloves, takes the 14-gauge angiocatheter and removes the needle. Next the PC connects the preloaded 10-ml syringe to the extension tubing and flushes it. Once the SC has an IV solution bag and administration set flushed and ready to go, placement of the UVC line can begin.