MCH Techniques NICU Umbilical Venous Line

MCH NICU

UMBILICUS VENOUS LINE Insertion & Removal

Techniques

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Extract from Art Line Manual

Updated August 2015

Umbilical Venous Line INSERTION AND REMOVAL

Indications Administration of volume expanders (eg: blood, plasma) or medications to patients in shock in whom peripheral

lV's cannot be started. Delivery of dextrose solution > 15% in treatment of hypoglycemia and KCl > 60 mEq/l. Central venous pressure monitoring in sick neonate. Exchange transfusion. IV access (i.e. when peripheral IV route is impossible to obtain). Blood sampling is not routinely done via a UVL. Refer to Blood Sampling Guideline.

Contraindications Abdominal wall infections (i.e.: omphalitis, cellulitis) Suspected ischemic enteropathy (i.e.: necrotizing enterocolitis) Abdominal wall malformations (i.e.: gastroschesis, omphalocele). Infants > 3 days of life due to colonization of the umbilical cord and possibility of infection.

Procedure - Insertion

o Materials

Bring Interventional Cart to patient’s room (should be kept outside of room).

Gather appropriate tools as per plastified guide.

o Nurse’s role

Being at the bedside at the time of insertion aiding in the set-up and observing the baby's response to the procedure.

Ensure appropriate devices are place to keep line closed prior the end of the sterile procedure (2 microclaves for double lumen catheter; single purple clamp extension with microclave for single lumen catheter).

Accurate documentation of procedure and tolerance is essential. Call for X-Ray post insertion and before final securing to ensure proper catheter placement.

MCH NICU


Techniques

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Updated August 2015

o What to observe on X-Ray

The line will enter umbilical vein up through ductus venosus into inferior vena cava

The line will be placed just above the diaphragm The line SHOULD NOT be entering right atrium, portal vein, hepatic vein, or mesenteric vein

o Taping

1. A suture is placed in the cord and tied around the umbilical catheter. 2. The catheter must be secured with an umbilical vessel catheter anchor (“BRIDGE”). 3. It is important to leave umbilicus visible to watch for bleeding, oozing, discharge and to allow for cleaning of cord.

4. NOTE: If Surgicel or gauze used to stop bleeding, it must NOT be left in place for longer than 24 hours. Additionally, dried blood should be cleaned off gently with sterile normal saline, if dried blood persist may use appropriate disinfectant swab followed by normal saline rinse. Moreover, cord tie should be removed as soon as bleeding is controlled (no longer than 24 hours).

MCH NICU


Techniques

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Updated August 2015

Procedure – Removal

o When?

The central umbilical venous line may stay up to 10 days. However, if the patient requires long term intravenous access, earlier (3-5 days) PICC insertion should be considered to outweigh risks versus benefits.

Catheter is no longer needed. Catheter is obstructed. Septicemia (with suspected line source). Circulatory impairment to legs, buttocks, GI & GU systems. Severe condition such as pericardial tamponade, endocarditis, cardiac arrhythmias, and/or hydrothorax.

o Materials

Sterile sutures set removal kit Waterproof tape for compress dressing

o How?

Removal of the catheters should be done slowly to allow vessel spasm to occur at the catheter tip, thus reducing bleeding when the catheter is completely removed.

1. Turn off the pump. 2. Cut the suture (at the level of the skin to avoid catheter transection). 3. Remove the umbilical vessel catheter anchor (“BRIDGE”). 4. Pull the catheter out of the baby's umbilical vessel until 5 cm marking is visible, then pull it another 2 cm. (Length left to

be removed is actually 3 cm). 5. Pull the catheter 1 cm at a time every 5 minutes to minimize bleeding. 6. After catheter removal apply firm, constant pressure above the umbilicus for 5 minutes. If bleeding persists maintain

pressure for another 5 minutes. Notify physician if prolonged bleeding occurs and measure blood loss. 7. Apply compress dressing with a sterile 2" X 2" and waterproof tape for 24 hours, whether or not bleeding occurs at the

site.

o What to look for?

Watch for delayed bleeding especially with patient with thrombocytopenia and/or coagulopathy disorders.

MCH NICU

UMBILICAL ARTERIAL LINE

Insertion & Removal

Techniques

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Updated August 2021

Umbilical Arterial Line INSERTION & REMOVAL

Indications Continuous intra-arterial blood pressure monitoring Blood procurement

Contraindications Abdominal wall infections (i.e.: omphalitis, cellulitis). Abdominal wall malformations (i.e.: gastroschisis, omphalocele). Suspected ischemic enteropathy (i.e.: necrotizing enterocolitis). Infant > 3 days of life due to colonization of the umbilical cord and possibility of infection.

Procedure – Insertion

o Materials

Bring Interventional Cart to patient’s room (should be kept outside of room).

Gather appropriate equipment as per plasticized guide attached to cart.

o Nurse’s role

Setting-up all equipment with inserter. Being present at the bedside at the time of insertion, observing the baby's response to the procedure,

and adjusting care accordingly. Ensure appropriate device is placed to keep the line closed prior the end of procedure (microclave and

extension with red marvelous valve stopcock ). Accurate documentation of procedure and tolerance is essential. Call for X-Ray post insertion and before final securing to ensure proper catheter placement. There are two recommended positions for umbilical artery catheter tip placement (safest because they

are not near the vessels providing flow to vital organs). The physician will make the final decision on placement:

High catheter placement in the aorta at the level of the diaphragm; vertebral level T6-9 Low catheter placement: above the aortic bifurcation and below origin of renal arteries; vertebral level L3-

L4

MCH NICU


Insertion & Removal

Techniques

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Updated August 2021

o What to observe on X-Ray

The line will enter one of the two umbilical artery go down towards one of the two hypogastric aorta branches then up into the aorta. Tip of line should pass junction (around L5) to be placed just above at L3-4 or progress to diaphragm area between T6 – T9.

MCH NICU


Insertion & Removal

Techniques

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Updated August 2021

o Taping

1. A suture is placed in the cord and tied around the umbilical catheter. 2. The catheter must be secured with an umbilical vessel catheter anchor “BRIDGE”. 3. If patient less than 29 weeks, silicone tape layers (mepitac) should be placed under each side of umbilicus to avoid placing

Bridge directly on skin. 4. It is important to leave umbilicus visible to watch for bleeding, oozing, discharge and to allow for cleaning of cord.

MCH NICU


Insertion & Removal

Techniques

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Updated August 2021

NOTE: If Surgicel or gauze used to stop bleeding, it must NOT be left in place for longer than 24 hours. Additionally, dried blood should be cleaned off gently with sterile normal saline, if dried blood persist may use appropriate disinfectant swab followed by normal saline rinse. Moreover, cord tie should be removed as soon as bleeding is controlled (no longer than 24 hours).

o Risks and complications at insertion

Transient blanching or cyanosis of leg during or following catheterization, usually due to reflex arterial spasm. In such a case, a warm compress should be applied to the opposite limb for 10 minutes. This causes a reflex vasodilatation in the affected limb. If there has been no response to this treatment within half hour, the catheter should be removed.

Line may be diverted downward into femoral artery (via iliac artery) and thus impair circulation to the leg and/or buttock.

Line may perforate aorta or its branches.


o When?

Catheter is no longer needed Malfunctioning of the catheter (unable to withdraw) Septicemia (with suspected line source) Circulatory impairment to legs, buttocks, GI & GU systems Suspected thrombi emboli and air emboli

o Materials

Sterile sutures set removal kit Waterproof tape for compress dressing Sterile 2" X 2"

o How?

Removal of the catheters should be done slowly to allow vessel spasm to occur at the catheter tip, thus reducing bleeding when the catheter is completely removed.

1. Turn off the pump. 2. Cut the suture (at the level of the skin to avoid catheter transection). 3. Remove the umbilical vessel catheter anchor “BRIDGE”. 4. Pull the catheter out of the baby's umbilical vessel until 5 cm marking is visible, then pull it another 2 cm slowly.

(Length left to be removed is actually 3 cm). 5. Pull the catheter 1 cm at a time every 5 minutes to allow vessel to spasm and minimize bleeding. 6. After catheter removal apply firm, constant pressure below the umbilicus for 5 minutes. If bleeding persists maintain

pressure for another 5 minutes. Notify physician if prolonged bleeding occurs and measure blood loss. 7. Apply compress dressing with a sterile 2" X 2" and appropriate waterproof tape for 24 hours, whether or not bleeding

occurs at the site.

o What to look for?

Watch for delayed bleeding especially with patient with thrombocytopenia and/or coagulopathy disorders.

MCH NICU


Insertion & Removal

Techniques

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Updated August 2021

MCH NICU

PERIPHERAL ARTERIAL LINE Insertion & Removal

Techniques

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Updated August 2015

Peripheral Arterial Line

INSERTION AND REMOVAL

Indications Continuous intra-arterial blood pressure monitoring Blood procurement

Key points Peripheral arterial lines will be inserted instead of umbilical catheter in these situations:

Umbilical artery access is limited because the neonate is older more than 3 days old Umbilical artery catheterization has failed There is an infection of the abdominal wall

omphalitis

cellulitis

There is a known or suspected Ischemic enteropathy necrotizing enterocolitis (NEC)

In the presence of abdominal defects gastroschesis

omphalocele

severe umbilical hernia

Contraindications Failure of Allen’s test for radial artery line Poor arm perfusion

Procedure - Allen’s test

o Why?

To ensure that ulnar artery can adequately supply blood to the hand

o When?

Before the insertion of catheter into the radial artery

o How?

1. Gently squeeze hand to partially empty it of blood. 2. Apply pressure to both the ulnar and the radial arteries. 3. Then remove pressure from the hand and the ulnar artery. 4. If the entire hand flushes and fills with blood, the ulnar artery can supply the hand with blood and the radial artery can

be safely cannulated.

MCH NICU


Techniques

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Updated August 2015

Procedure - Insertion

o Who?

By the MD, Resident, Fellow, NNP & trained nurses (with the accord of MD)

o Material

Appropriate adhesive securement (Pink tape, foam tape) Sterile 2x2 gauze (for roll) Appropriate disinfecting agent Non-sterile gloves Catheter (Angiocath, Jelco or Insyte) of appropriate size Single IV extension ( T-piece ) Heparinized 1/2normal saline with appropriate heparin added according to weight 3 mL syringe filled with heparinized 1/2normal saline

o How?

1. The catheter is sutured when a cutdown is performed otherwise there is no need to suture the catheter 2. The catheter is connected to a T-piece connector and a 6 inch extension followed by a three-way stopcock. 3. The catheter is well secured with appropriate adhesive securement, leaving skin above catheter and fingers/toes exposed

o Positioning

The wrist of the baby should be restrained in a hyperextended position.

Place a cushion or a roll underneath the wrist.

Restrain the leg on a board in an abducted position.

Restrain the leg on a board. Place a cushion or a roll underneath the foot and

secure well with tape.

MCH NICU


Techniques

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Updated August 2015

What to look for?

o Signs

Perfusion / Blanching / Discoloration of fingers or toes Infiltration Discharge at the site

o Complications long term

Localized infection Small areas of skin necrosis Ischemic necrosis of fingertips or toes


o When?

Catheter is no longer needed Persistent skin blanching or erythema over the catheter tip Suspected thromboemboli; discoloration of the fingers or toes, clot formation manifested by inability to withdraw

blood or loss of the blood pressure tracing Leakage around insertion site Septicemia

o Materials

Sterile sutures set removal kit

Waterproof tape for compress dressing

o How?

1. Turn off the pump. 2. Apply firm, constant pressure with sterile gauze at the insertion site. 3. Pull the catheter out slowly while maintaining pressure at the insertion site for at least 5 minutes or until bleeding has

stopped. 4. Apply pressure dressing with a sterile 2" X 2" and waterproof tape for 24 hours site. If pressure is not maintained long

enough, a hematoma can result. 5. Notify physician if prolonged bleeding occurs and measure blood loss.

o By whom?

If a cut down was done, it has to be removed by surgery or the professional that inserted it. Resident, Fellow, NNP & MD. All RNs that reviewed the documentation and passed successfully the written and practical evaluation as per the

MCH-NICU protocol.

MCH NICU

SPECIAl considerations for UVL & UAL Potential problems & preventive interventions

Techniques

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Updated December 2019

Potential problems with umbilical arterial/venous line in situ and preventives nursing interventions

Potential Problems Preventives Nursing Interventions

Potential hemorrhage Unobstructed view

Verify all connections

Catheter well secured

Observe oozing and/or bleeding

Restrain infant PRN

Avoid prone position with umbilical arterial line

Observe signs of shock

Potential anemia hypovolemia Record blood in and out

Follow Hgb-Hct

Potential impairment of circulation Inquire position on X-ray with MD team


Unobstructed view

Verify color and warmth of buttocks and legs

Verify blood pressure and pulses

Observe abdominal distention

Record urine in and out

Potential infection Aseptic technique all the time, as protocol

Keep umbilicus clean

Site uncovered and unobstructed view

Observe signs of infection

Change syringe/ solution, as protocol

Do blood culture PRN, as ordered

Potential hypervolemia and/or hypernatremia

Arterial solution ordered must be included in daily fluid

Use minimal rate as ordered

Flush line with minimal amount for clean line

Record fluids / urine in and out

Record weight daily or as ordered

Observe for signs of fluid overload

UAL: Potential emboli or air clot Inquire position on X-ray with MD team


Verify all connections

Use heparinized solution appropriate for patient

Clear line effectively after blood sampling

Verify and record blood pressure tracing and vital signs

UVL: if advanced too far, the line may pass into the right atrium or even into the left atrium and may cause cardiac arrhythmias, pericardial tamponade, endocarditis, hydrothorax.

Inquire position on X-ray with MD team

Record vital signs

Observe for cardiac rhythm

Observe for respiratory changes

Observe for increase FiO2 needs

Observe for signs of sepsis

Techniques

Arterial Line Set-Up, priming &

Intra-arterial blood pressure

monitoring



MCH NICU

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Arterial Line Set-Up, Priming & Intra-

arterial blood pressure monitoring Materials

chlorhexidine 0.5% and alcohol 70% swabs (CHG/alcohol swab)

one alcohol antiseptic-cap

50-60 ml syringe with appropriate arterial heparinized solution 0.5 unit /1ml (baby < 1500g)

1 unit/1ml (baby > 1500g)

Microclave

Macrobore extension set

Arterial tubing with transducer and pre-attached “flush syringe”

Extension with red marvelous valve stopcock (only UAL – if radial, already in place at insertion)

Syringe Pump

Blood pressure monitoring cable & BP block

Transducer holder & White plaque

white sterile field

Level

non-sterile gloves

Procedure ( P=Patient & S=Solution)

1. Preparation & setting-up

Proceed with hand hygiene Gather all equipment needed Disinfect metal table & let it dry Proceed with hand hygiene Open packages in an aseptic way and

connect all tubings and extensions as shown in picture on the right

You are ready to PRIME

Extension with

red marvelous

valve stopcock

Techniques



monitoring



MCH NICU

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2. “Flush syringe” is full of air and must be emptied.

• Close top stopcock (attached to flush syringe) toward heparinized solution and push the air from the syringe into the line.

• This is completed prior to priming the line.

3. Close top and bottom stopcocks toward patient.

4. Open blue cap (“zeroing” cap). This cap can be twisted open but cannot (and should not) be removed. It prevents contamination of tubing during manipulation.

5. Prime “zeroing” stopcock by squeezing the yellow tabs and flushing the solution until you see a drop coming out of the blue cap and no air is left in the tubing.

6. Twist blue cap back into closed position.

7. Close stopcock toward blue cap.

8. Prime “flush syringe” by squeezing the yellow tabs and flushing the solution until “flush syringe” is full. There will be air trapped in the syringe.

9. Close top stopcock toward yellow tabs and push air out of “flush syringe” and into tubing toward patient.

10. Keep pushing solution until a maximum of 8ml is left in the “flush syringe”.

S

Techniques



monitoring



MCH NICU

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11. Close top stopcock toward “flush syringe”.

12. Prime the rest of the tubing with solution, making sure that no air is left in tubing.

13. Insert transducer in white support plaque and connect transducing moniyot cable to white “telephone style” cable hanging under yellow tabs.

14. A. Connecting to patient with UAL Proceed with hand hygiene Don non-sterile gloves Close sample port stopcock towards

patient If arterial line tubing already in place,

disconnect old set from UAL – LEAVE MICROCLAVE IN PLACE

Disinfect UAL Microclave for 15 sec & allow to dry

Connect primed system Place 50-60 mL syringe in pump, set

appropriate rate and START pump Remove gloves and wash hands

15. B. Connecting to patient with Radial Arterial Line

Proceed with hand hygiene Don non-sterile gloves Close sample port stopcock toward

patient Disconnect heparinized syringe or old

system Disinfect open hub of sample port

stopcock for 15 sec & allow to dry Connect primed system (Ensure no air is

present at the connection) Place 50-60 mL syringe in pump, set

appropriate rate and START pump

Techniques



monitoring



MCH NICU

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Remove gloves and Proceed with hand hygiene

16. Zeroing the system: Ensure that system is leveled

between mid-chest & mid–transducer at blue cap

Close the bottom stopcock (with blue cap) toward patient

Open blue cap to air without removing it completely

Press “zero” on monitor under Art line tracing & maintain until a “0” appears at the pressure reading (until you hear second beep)

Close blue cap & close bottom stopcock toward blue cap

Open sample port (“Off” position placed opposite to sample port)

17. End result once system is in place Extension with marvelous valve stopcock Attached to microclave on the UAL OR Extension with marvelous valve stopcock Attached directly to radial arterial catheter

OR

Techniques



monitoring



MCH NICU

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18. Marvelous valve stopcock No need to discard blood No need to use syringes to flush Can use in-line flushing No residual blood left after procedure Attach a new alcohol Swabcap on

marvelous valve https://www.youtube.com/watch?v=0X-

PLyKAiHw

Solution change 60 ml syringe Q 24 hrs Transducer, tubing and “marvelous” valve Q 96 hrs (unless radial art line –

“marvelous” valve stays on for the life of the radial line)

Calibration and leveling

o When?

Q 12 hrs PRN if mobilizing baby and transducer doesn’t follow in this mobilization PRN if change in BP quality tracing or readings Always follow same steps as in procedure step 13.

Quality tracing

o Definitions

The upstroke of the pressure wave formed during systole ascends steeply and correlates with the QRS complex of ECG

The notch in the downstroke is the "dicrotic notch" and represents closure of aortic valve

The highest point on pressure wave represents systolic pressure The diastolic pressure is the lowest point just before the next systole

o Troubleshooting a change in tracing quality

Calibrate your system Level your transducer Verify for any leaks, blood in line or air bubbles

If air bubbles, can flush out (not to patient)

If blood in line, try to flush back in (do not flush against high resistance as you may dislodge a clot)

Pull back some blood and verify patency of system (immediately flush)

Good blood return?

Resistance upon flushing?

Blanching of limb when you flush?

https://www.youtube.com/watch?v=0X-PLyKAiHw

https://www.youtube.com/watch?v=0X-PLyKAiHw

Techniques

ARTERIAL BLOOD SAMPLING UAL and Peripheral Art Line



MCH NICU

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Arterial blood sampling UAL and Peripheral Art Line

Materials chlorhexidine 0.5% and alcohol 70% swabs (CHG/alcohol swab)

one alcohol antiseptic-cap

arterial blood gas syringe (if ordered)

3 or 5ml syringe (depending on volume needed & minimize entry into system)

sampling tubes

labels

non-sterile gloves

Procedure ( P=Patient & S=Solution)

1. Proceed with hand hygiene.

2. Close top stopcock (attached to “flush syringe”) toward heparinized solution. DO NOT STOP YOUR PUMP.

3. Keep sample port open (“Off” position placed opposite to sample port).

4. Make sure “flush syringe” contains at least 2ml of heparinized solution. Otherwise follow procedure to refill if volume is less than 2ml (see below).

S

Techniques




MCH NICU

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5. Using “flush syringe”, gently withdraw blood up to the black line on the tubing.

6. Close sample port stopcock toward heparinized solution.

7. Proceed with hand hygiene and don non-sterile gloves.

8. Remove alcohol antiseptic-cap from sample port. Allow to dry.

9. If taking a sample for blood gas, prepare blood gas syringe by pushing down plunger to the 0.5ml mark. Connect blood gas syringe by inserting tip into sample port and twisting the syringe clockwise by ¼ turn. Ensure that syringe is well secured. Blood gas sampling should always be done first and collected directly using the arterial blood sample syringe. Collect 0.5ml of blood for your specimen by letting the blood flow into the syringe on its own. Remove syringe, place tip in filter cap and push plunger to fill cap with blood.

10. If other samples are needed, scrub the sample port with a new CHG/alcohol swab for 15 sec and allow to dry. Connect the appropriately sized syringe, gently withdraw the amount of blood needed and remove syringe.

Techniques




MCH NICU

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11. Once the blood is collected, open the sample port (“Off” position placed opposite to sample port).

12. Holding the “flush syringe” in an upright position (keeping air out of the line) flush the line slowly with the heparinized solution using the stop-and-go technique until the line is properly cleared of blood (approximately 1.0 to 1.5 ml).

13. Once line is cleared, close top stopcock toward “flush syringe”.

14. Place a new alcohol antiseptic-cap on the sample port. Remove any blood present with a CHG/alcohol swab on the sample port prior placing the cap.

Procedure to refill flush syringe

1. Close top stopcock toward patient 2. Stop infusion pump and remove the 50-60ml syringe containing the heparinized solution

from syringe driver. 3. While squeezing the yellow flaps just below the transducer, flush heparinized solution

from big syringe into the “flush syringe” up to 8ml mark (maximum). 4. Replace the 50-60ml syringe onto the pump and restart the infusion. 5. Close top stopcock toward “flush syringe”.

Documents

MCH Techniques NICU Umbilical Venous Line