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Care of Umbilical Catheters (Arterial and Venous) (Pediatric) (1.48P)

Care of Umbilical Catheters (Arterial and Venous) (Pediatric) (1.48P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.48P

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
April 4, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.48P

Original
Revision

Page
1
of 6

Title: Care of Umbilical Catheters (Arterial and
Venous) (Pediatric)

I. PURPOSE

To provide guidance in the safe and effective use of umbilical catheters in neonates.

II. POLICY

A. Indications for umbilical arterial catheters (UACs) include:
1. Continuous monitoring of arterial blood pressure
2. Monitoring arterial blood gasses and other labs
3. Certain fluids and nutrition can be administered according to provider
order
B. Administration of medications, blood products, and vasopressors is not
recommended (can cause severe arterial constriction resulting in tissue necrosis)
C. Indications for umbilical venous catheters (UVCs) include:
1. Emergent intravenous access for resuscitation, fluids, and medications
2. Inability to establish peripheral access after several attempts
3. Need for multiple intravenous (IV) lines
4. Need for central access to administer glucose concentrations greater than
D12.5%W
5. Exchange transfusion
D. Contraindications for umbilical catheters include:
1. Omphalitis
2. Peritonitis
3. Omphalocele
4. Necrotizing entercolitis (NEC)
5. Vascular compromise in lower extremities/buttocks
E. Recommended maximum duration of catheter placement:
1. UAC: 7 days
2. UVC:
a. An appropriately positioned high lying UVC: 14 days
b. A low lying UVC: 48-72 hours
F. Radiographic confirmation of catheter placement must be confirmed prior to
catheter use, except in emergent situations, in which a low-lying venous catheter
(UVC) is preferred. Provider order is required to begin using umbilical catheters.
a. Additional radiographic confirmation is recommended within 48
hours of initial placement and a minimum of once every 7 days.
G. Catheter tips should be located as outlined below:
1. Low lying UAC: Between lumbar vertebrae L3 and L4. The tip should
be just above the aortic bifurcation.
2. High UAC: Between thoracic vertebrae T6 and T9. The tip should be
above the diaphragm but well below the curve of the aortic arch.

Page 2 of 6
3. High lying UVC: Above the diaphragm, in the inferior vena cava and at
or below the cavo-atrial junction.
4. Low lying UVC: Inserted 2-4 cm until free flow of blood can be
obtained with gently aspiration.
H. A trained registered nurse or provider can reposition a catheter by pulling the
catheter out a desired length to achieve optimal placement. A provider order is
required to reposition umbilical catheters.
I. Umbilical tape, also referred to as ties are placed around the umbilical stump
during umbilical line catheterization to help control bleeding. These ties can
remain in place up to 24 hours. If oozing persists at this time, notify the provider
prior to removing the umbilical tape.
J. A repeat x-ray is preferred to confirm proper catheter placement after a catheter
has been repositioned. A catheter should not be repositioned by advancement
(“pushed in”), except for rare circumstances by a provider under sterile
conditions.
K. Catheter position will be documented by centimeter (cm) marking with each
assessment.
L. UACs must be monitored via pressure transducer at all times with alarms always
turned ON. The UAC can never be capped off.
M. If a patient has both types of catheters (UAC and UVC), each catheter must be
clearly labeled in order to differentiate the catheters from each other.
N. Enteral feeding while umbilical catheters are in place:
1. UVC: Enteral feeding with an umbilical venous catheter:
a. Enteral feedings may be advanced as outlined in the Enteral
Nutrition – Neonatal – Inpatient Clinical Practice Guideline while
umbilical venous catheters are in place.
2. UAC: Enteral feeding with an umbilical arterial catheter:
a. Initiation of enteral feedings with an umbilical arterial catheter in
place should only occur after an assessment of patient’s
physiologic stability and assessment of potential compromise to
intestinal blood flow has occurred and deemed safe. In these cases,
feedings up to 30mL/kg/day can be initiated in patients with
umbilical arterial catheters in place. Under rare circumstances,
decision to exceed 30mL/kg/day can be made at the discretion of
the attending provider.
O. Documentation
1. Hourly documentation of site assessment is required for the duration of
umbilical catheter placement.
2. External centimeter (cm) marking should be documented a minimum of
every four (4) hours and with any catheter reposition. Notify provider
for any change in external cm marking.
3. Assessment of lower extremities should be documented with every
assessment, at least every four (4) hours while an umbilical arterial
catheter is in place.
P. A provider or trained registered nurse can remove an umbilical catheter upon
provider order. (See section V.)
Q. A provider should be present in the NICU/PICU during removal of umbilical
catheters.




Page 3 of 6
III. CARE OF UMBILICAL CATHETERS

A. Refer to Nursing and Patient Care Policy 1.56 AP, Central Vascular Access
Device Use, Maintenance and Removal (Adult & Pediatric) and Nursing and
Patient Care Policy 1.11 P, Arterial Catheter Set Up, Maintenance, Blood
Drawing and Discontinuation (Pediatric) for specific guidance on umbilical
catheter insertion, care and maintenance.
B. Umbilical catheters should be secured immediately after placement using the
following technique:
1. Perform hand hygiene according to UWHC Administrative Policy 13.08,
Hand Hygiene.
2. Apply Duoderm to abdomen
3. Secure catheter to Duoderm with transparent dressing, assure centimeter
markings are visible
4. Label catheter with appropriate sticker (UVC/UAC)
5. When securing lines, tape arterial lines above umbilicus in shape of an
“A” (A for arterial), tape venous lines below umbilicus in shape of a “V”
(V for venous) (Refer to image below.)



C. Take care not to allow air to enter the catheter. Check for air bubbles in the
catheter and all connections before flushing or starting infusions. Prime tubings
carefully to prevent air bubbles.
D. The minimum infusion rate for a UAC or UVC should be 0.5 mL/hour.
E. Refer to the Flushing/Locking of Venous Access Devices – Adult/Pediatric
Inpatient/Ambulatory Clinical Practice Guideline for specific infusion rates and
flushing/locking recommendations for umbilical catheters.
F. Notify the provider immediately if the infant’s toes, feet, legs or buttocks blanch
or become dusky, which suggests circulatory compromise.
G. Closely monitor for the development of peripheral and/or unilateral leg edema,
unequal femoral pulses, poor peripheral perfusion, cooler temperature,
diminished movement and respiratory distress which could indicate disturbances
in arterial blood flow to the lower extremities. Signs that may suggest thrombosis
and embolism formation include decreased urinary output, hematuria, abdominal
distention, and ileus.
H. No routine cleansing or dressing changes of the umbilical line or insertion site is
necessary.

Page 4 of 6
I. Monitor the umbilicus hourly for signs of infection and bleeding while catheter is
in place and for 12 hours after catheter removal. Signs of infection include
erythema and purulent drainage.
J. When accessing the line for labs, aspirate slowly, and flush slowly (at least over
5-10 seconds for every 0.5 mL of blood obtained).
K. Utilize normal saline pre-filled syringes for flushing.. Use the least amount
required to clear the line of blood.
L. After accessing the line, observe the line closely for any reflux of blood in the
line. If present, ensure the connections are correctly oriented and secure, and the
infusion has been resumed. Check the monitor for return of waveform.
M. Blood loss can occur quickly if there is a loose connection. Ensure all
connections are secure.
N. Blood return from an umbilical line should be instantaneous. If blood does not
return easily, there may be a clot. Notify the provider immediately.
O. Abdominal positioning should be used cautiously with umbilical lines as
accidental slipping, kinking or removal of the catheter(s) may occur without
being immediately apparent.
P. In the event of bleeding or oozing from umbilical site, tighten umbilical ties (if
present), apply pressure to the base of the umbilical stump until the oozing stops.
If lines have been removed, apply pressure dressing over umbilical stump, and
notify provider.
Q. Skin to skin or swaddle holding with umbilical catheters in place:
1. Direct visualization of the insertion site must be maintained at all times
when umbilical catheters are in place.
2. In general holding is contraindicated with umbilical arterial catheters
with exceptions outlined in Nursing Patient Care Policy 13.27, Skin-to-
skin holding (kangaroo care) of the neonate (Pediatric). A provider order
is required to facilitate holding with a UAC.
3. Skin to skin holding is the preferred method of holding while umbilical
venous catheters are in place. Patient should be positioned in an upright,
side-lying position so the insertion site can be directly visualized. Do not
place patient in the traditional prone position for skin-to-skin care while
umbilical catheters are in place.
4. If unable to perform skin to skin care, but holding is desired, place hat
on infant and loosely swaddle, leaving the insertion site visible for the
duration of holding. Monitor temperatures frequently as outlined in
Nursing Patient Care Policy 13.27 (referred to above).
5. An RN must be present in the patient’s room during holding while
umbilical catheters are in place.

IV. REPOSITIONING OF AN UMBILICAL CATHETER

A. Equipment:
1. Sterile gloves
2. Chlorhexadine swab
3. Sterile saline wipe
4. Sterile 4x4 gauze
5. Thumb tweezers
6. Umbilical ties
7. Restraints (optional)
B. A provider order is required to reposition catheter by pulling the catheter out a

Page 5 of 6
desired length. The order should specify exact length to pull out in centimeters.
C. Assemble necessary equipment.
D. Perform hand hygiene, don clean gloves and carefully remove the dressing from
the catheter to be pulled back. Discard dressing and remove gloves.
E. Perform hand hygiene.
F. Put on sterile gloves.
G. Cleanse umbilical site with chlorhexidine swab, allow to dry 30 seconds.
H. Wipe chlorhexidine from site with sterile saline wipes.
I. Support umbilical stump with one hand. With the other hand, use tweezers to
gradually pull back on the catheter with a gentle, steady pulling action to the
desired length.
J. If the catheter cannot be withdrawn using a gradual, steady continuous pulling
action, stop and notify the provider. Do not cut the sutures or catheter.
K. After pulling the catheter out to the desired length, re-dress the catheter as
outlined in section III, B.
L. Document procedure and new centimeter marking at insertion site in the clinical
record.

V. REMOVING AN UMBILICAL CATHETER

A. Equipment:
1. Suture removal kit or separate iris scissors and tweezers (“pickup”)
2. Sterile gloves
3. Hemostat (have available if needed)
4. Sterile 2x2
B. Procedure for Removal of UVC/UAC:
1. Gather supplies.
2. Verify order for removal.
3. Assure provider is present on unit.
4. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene.
5. Stop infusion of fluids and turn stopcock off to infant.
6. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene.
7. Put on sterile gloves.
8. Cut sutures carefully if necessary. May attempt to gently pull back on
catheter prior to cutting sutures. Some catheters will easily pull out
without cutting sutures.
9. Withdraw catheter to approximately 3-5 cm, wait five (5) minutes and
withdraw remainder of catheter slowly over 1-2 minutes and apply
pressure, watching for signs of bleeding. If patient is at risk for
bleeding due to a heparin infusion or coagulopathy, use caution when
withdrawing UAC and increase catheter withdrawal time to one (1)
hour.
10. Apply pressure to umbilical site with sterile 2x2 until hemostasis is
achieved.
11. Keep infant in supine position, undressed and unswaddled, in
warmer/crib for three (3) hours following removal and frequently
monitor for bleeding.
12. Notify provider for prolonged or excessive bleeding.
13. Document catheter removal in the patient’s clinical record.

Page 6 of 6


VI. UWHC CROSS REFERENCES

A. Enteral Nutrition – Neonatal – Inpatient Clinical Practice Guideline
B. Flushing/Locking of Venous Access Devices – Adult/Pediatric
Inpatient/Ambulatory Clinical Practice Guideline
C. Hospital Administrative Policy 7.31, Patient Identification
D. UWHC Administrative Policy 13.08, Hand Hygiene
E. Nursing Patient Care Policy 1.11, Arterial Catheter/Insertion, Maintenance, Blood
Drawing, and Discontinuation (Adults & Pediatric)
F. Nursing Patient Care 1.56 AP, Central Vascular Access Device Use, Maintenance
and Removal (Adult & Pediatric)
G. Nursing Patient Care Policy 13.27, Skin-to-skin Holding (Kangaroo Care) of the
Neonate (Pediatric)

VII. REFERENCES

A. American Academy of Pediatrics (2016). Textbook of Neonatal Resuscitation (7
th

ed.)
B. Association of Women’s Health, Obstetrics and Neonatal Nurses. (2013).
Neonatal Skin Care (3
rd
Ed.): Evidence-based Clinical Practice Guideline.
C. Centers for Disease Control and Prevention. (2011). Guidelines for the prevention
of intravascular catheter related infections. Retrieved from
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
D. Cooley, K. Grady, S. (2009). Minimizing catheter-related bloodstream infections.
Advances in Neonatal Care, 9(5), 209-226.
E. Furdon, S. A., Horgan, M. J., Bradshaw, W.T. & Clark, D. A. (2006). Nurses’
guide to early detection of umbilical arterial catheter complications in infants.
Advances in Neonatal Care, 6(5), 242-256.
F. Narang, S., Roy, J., Stevens, T., Butler-O'Hara, M., Mullen, C., D'Angio, C., & ...
D'Angio, C. T. (2009). Risk factors for umbilical venous catheter-associated
thrombosis in very low birth weight infants. Pediatric Blood & Cancer, 52(1), 75-
79. doi:10.1002/pbc.21714
G. Verklan, M. T., & Walden, M. (2015). Core curriculum for neonatal intensive
care nursing 5th Ed.). St. Louis, MO: Saunders Elsevier.

VIII. REVIEWED BY

Clinical Nurse Specialist, Neonatal Intensive Care Unit
NICU Medical Director
NICU Clinical Guidelines Committee, March 2017
Nursing Patient Care Policy and Procedure Committee, March 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive