Untitled.pdf

VoL.

120,

No.

2

NORMAL AND ABNORMAL POSITION OF THE BILICAL ARTERY AND VENOUS CATHETER THE ROENTGENOGRAM AND REVIEW OF COMPLICATIONS* By

ALFRED

L. WEBER, and DANIEL BOSTON,

M.D., SALVATORE C. SHANNON,

American Journal of Roentgenology 1974.120:361-367.

the introduction of intravascular catheters via the umbilical vein for exchange transfusion by Diamond in 1947,8 and measurement of blood gases and pH by James in 1959,” these catheters have been employed with increasing frequency, and recording of their exact position has become most important in order to prevent complications and false measurements. Catheters are now used in acutely ill infants for the above applications, as well as for hyperalimentation, and the measurement of pressures, electrolytes and blood

of the

Departments

of

METHOD

Radiology

and

open

for

a longer

period

of

time,

as

infant where catheterization of the umbilical vessels was carried out ii days after birth. The ideal location for the occurred

Pediatrics,

we

Umbilical catheterization usually can be performed in the first days of life. In hypoxic infants, the umbilical vessels may

The catheters should be soft, small, and rigid enough to negotiate the vascular channels. At the present time, nonwettable, polyvinyl chloride catheters are in use. We employ a 3.5 French catheter in infants up to 1.5 kg. in weight, and a No. 5 for larger infants. The catheter should be radiopaque with an acceptable dead space of less than 0.5 ml. For prevention of clot formation, the catheter should have an end hole with no side holes, and the end should be rounded to prevent damage or perforation of the vascular wall. Localization can be achieved by image intensification fluoroscopy or by anteroposterior (AP) and lateral roentgenographic examination of the chest and abdomen. In the Newborn Intensive Care Unit From the Massachusetts.

Hospital,

unit.’

remain

*

General

i/is

values.

AND

Massachusetts

have a General Electric portable I 10 volt roentgenographic unit. For the AP view, the factors are io ma., 6o kvp., with an exposure time of 1/12 to seconds. An additional io kvp. is added for the lateral projection. To reduce radiation exposure to the infant, paraspeed or highspeed films are used. The gonads are shielded unless the pelvic area also needs to be demonstrated on the examination. Rapid evaluation of the position of the catheter can also be obtained with the use of Polaroid film which is developed in a rapid processing

The purpose of this paper is to discuss the methods and materials used, the normal and abnormal position of catheters, and the complications. MATERIAL

M.D.,

M.D.

MASSACHUSETTS

S INCE

sugar

DELUCA,

UMON

tip

of

in

the

I

umbilical

artery

catheter

is

at

about the 3rd lumbar vertebra, between the origin of the renal and superior mesenteric arteries and the bifurcation of the aorta. Another desirable location is in the descending aorta at the D6-7 level, where rapid flow gives good mixing and dilution of injected fluids. The catheter should be repositioned to prevent air embolism to vital structures when placed in the left common carotid artery, the innominate artery,

the

external

artery, or the via the ductus The technique eterization

Harvard

361

Medical

is the School

and

iliac

artery,

the

femoral

pulmonary artery (reached arteriosus). of umbilical venous cathsame

Massachusetts

as

that General

used Hospital,

for

ar-

Boston,

A. L. \Veber,

362

S. DeLuca

and

D.

C.

Shannon

A separate and

through

of the

these pressure

can

third

stopcock

most

Photograph catheter, millipore .

of stopcock system filter, and tubing

(Fig.

with arterial to pump.

stopcock

for

terial

catheterization.

inserted right

into atrium

ductus

serted, order

The

the

inferior after

venosus.

to

American Journal of Roentgenology 1974.120:361-367.

contamination,

air

formation. tion cocks

A useful

of three-way locked

FIG.

separate to each

other

(A)

Anteroposterior

2.

catheter

is

is

demonstrating

millipore

the

pump

in-

tamination

or is the

in clot

disposable

stop-

with

clips.

metal

sion

if

an

containing

the or

of

fluids.

used

placed last air

of

intravenous i

proximal

blood

samples

source of injecting or air bubbles. the

stopcock injection will

flushed continuously. If the infant’s

of

conthe

infu-

of

the

be

insignificant

catheter solution

heparin

condition

A

infusion

prevents during

maintenance unit

gauge

the

between

days

by

manometer

Thrombosis

for 5-7

a

infant

strain

per requires

(B) lateral roentgenograms of the chest and abdomen course and position of umbilical venous catheter.

and

normal

and

when

applica-

potential old blood

filter

the

calibrated

withdrawing

a

contaminated

the

important disconnection,

embolization, method

be

near

through

the

handling accidental

should

cava

passage Once

careful prevent

tip

vena

to

use

The

through

a fluid-filled a

eliminates

be handled

stopcocks.

distal

Restricting

I).

can

be monitored

either

preferably,

1974

withdrawing

as

catheters,

individual

blood connecting

FIG.

such

operation,

flushing

or,

FEBRUARY,

ml.

is con-

VOL.

120,

tinued safely site for gases, a 20-22

No.

Normal

2

and

Abnormal

Position

of the

monitoring, a catheter can be used for as long as I week. If an alternate monitoring arterial blood pressures, and electrolytes becomes necessary, gauge teflon-covered cannula can

be placed in a radial, poral artery.

dorsalis

pedis,

soon

as

American Journal of Roentgenology 1974.120:361-367.

catheter

is in

genograms should tion.3”6

the of

be

the

obtained In the

tric

artery

AP

and

abdomen for

or lateral and

accurate

Anteroposterior

demonstrating

the

to

ductus

venosus

The

then

anterior

and

B).

catheter,

which

can

PASSAGE

OF

OR

CATHETERS

prevent

complications

or

position

technique,

positioned

measure

in

central

is a reflection of

of the portal

is always pressure, and for

cular

status.2

position

the

lumbar

of

gentle

ma-

of the catheter, and flushing should be strictly adhered

used

roentgenograms

within

of the

accurate

Measurement however, venous

artery

inferiorly, and the hypogas-

ARTERY

sterile

A catheter

cava

into

umbilical

ascends

and

measurements,

neuvering the catheter

and

363

FOLLOWING

order

false

localiza-

course

and

to the left (Fig. 3, 4

VENOUS

chest

(B) lateral

cava.

arteries,

In

roent-

and

the

vena

UMBILICAL

venous

normal

through

COMPLICATIONS

view the venous catheter ascends to the right at the level of the ductus (Fig. 2, A’ and B). In the lateral view, the catheter ascends beneath the rectus muscle posteriorly within

3. (A)

Artery

passes medially, a ioop before entering

aorta

or tem-

AP slightly

FiG.

inferior

spine

umbilical place,

liver

the

catheter forms

In view of the relatively slow flow in a peripheral artery, no medications, hypertonic solutions, or albumin should be injected. The same sampling, pressure monitoring, and flushing procedures can be employed as described above. With careful handling, the peripheral artery can be expected to remain serviceable for 5 to 7 days. As

the

Umbilical

evaluating

of

of arterial

the

vascular venous

higher therefore the

the chest catheter.

inferior

venous

of to. vena

pressure volume. pressure,

than

general

and abdomen

central cannot be cardiovas-

364

A. L. \Veber,

S. DeLuca

and

D.

tem

C.

(Fig.

Shannon

6,

tip

should

ing

the

head,

7,

1 and

B;

inal

aorta

teric

or

A’ and

not

neck, and

may

damage of the

to cardiac myocardium’2

with

with

American Journal of Roentgenology 1974.120:361-367.

in

of

suffering

from

reported

an

4.

Anteroposterior

roentgenogram

including

the

upper

umbilical

vein

catheter

The

abdomen in portal

tip

of

the

located in or extrahepatic

the

umbilical portal

5, ii

and

catheter

the

of the

showing

venous

chest

coiling

of

vein, systems cardiopulmonary

in the (Fig.

not

be

intra;

thrombosis

ensue

if strict

or

if an

and

bicarbonate

sys-

tion

infusion

frequency

(

per

20

of of

is given. is occlusion of

cent

cases),

compli-

thrombosis with

the

system

portal

hypertonic

or

FIG.

5. (A) Anteroposterior and (B) lateral roentgenograms of the abdomen umbilical vein catheter coiled at the level of ductus venosus.

the

and subse-

is not

technique

B),

sysperi_

cases),

(6

Phlebitis

A

cases

syndrome,

the venous consisted of

emboli

sterile

200

stress in

the

Scott,’7

among

of

cases).

of to

catheter.

respiratory

yes-

forma-

related

autopsies

pulmonary

quent

or portal in the

and

incidence

(

vein

often

hemorrhage

cases),

infection

vein.

should

(6

perforation

thrombus

cations from catheters tem. The complications FIG.

cath-

arrhythmias,

indwelling 92

mesen-

hemorrhage

degree

of the

a review

(Fig.

mid-abdom-

and 9).

without

the

supply-

superior

umbilical

formation

duration

the

valves, (Fig.

or

catheter

Intracardiac

caused

thrombus

in

cardiac

in the

1974

extremities

of the

produce

have

tion

or

level

the

in arteries

arteries.

Catheters

Also,

and

8),

at the renal

Sel wall

B).

be located

eters

system

FEBRUARY,

solutions

delayed

portal

may

used or

complica-

venous

showing

sys-

VOL.

American Journal of Roentgenology 1974.120:361-367.

I iG.

120,

6. (A)

Normal

2

No.

and

catheter tern

with formation

ensuing

intrahepatic

portal in

branches

the

can

and

FIG.

ing

hepatic

after

vein lead

veins.’7

7. (A) Anteroposterior the umbilical vein

to

and catheter

of the chest

change

or

its liver

ex-

Umbilical

through

passage

have folthe portal

Following

of the

roentgenograms

hypertension.’4 portal

necrosis.’9 Pulmonary emboli lowed thrombus formation in system

Position

and (B) lateral in the left atrium

Anteroposterior

Clot

Abnormal

patent

365

Artery

revealing foramen

transfusion

the tip of umbilical ovale. through

the

portal

venous

the

bowel,

most

a

system, often

vein

in

catheter

perforation

of

the

colon,

of

from

underlying infarction has been reported.6’#{176}” The underlying mechanism is not known, but

increased

(B) lateral roentgenograms in the left lugular vein

pressure

of the chest after crossing

in

the

portal

including neck showthe right atrium.

circu-

A. L. Weber,

366

S. DeLuca

and

D. C. Shannon

blanching

of

during

the

artery drawal

lower

extremities

introduction

of

an

acidosis may

or

relieve

1974

occurs umbilical

catheter, partial or complete is indicated. Correction of

metabolic ever,

the

FEBRUARY,

witheither

hypovolemia,

the

how-

blanching.

DISCUSSION

Umbilical has

tion

agement

weight, a variety

American Journal of Roentgenology 1974.120:361-367.

future

8. Anteroposterior showing the umbilical axillary artery. Note

membrane

proved

and

venous

of great

benefit

of newborn

respiratory of other developments

catheteriza-

infants

distress diseases. in

with

in the

man-

low

birth

syndrome, It

is hoped

noninvasive

and that moni-

roentgenogram of the chest artery catheter in the left nasogastric tube and severe

FIG.

hyaline

artery

disease.

lation secondary to obstruction by the catheter or retrograde microemboli is thought to be responsible. Complications following umbilical artery catheterization have occurred at a rate of 4.6 to 10.4 per cent. Among 387 infants investigated

cations eters

by

blanching

in

arteritis,

or

postmortem Thrombosis aorta, monary

the

infants and inflammation

13

other

examination has also

from

cent

the

thrombosis, noted

glucose

artery, with vaginal-bladder hemiparesis

edema, catheter

of the

umbilical

peritoneal

artery, cavity

the

of a right right

per

40

umbilical large rectopyonephro-

leg,

right

muscle necrosis.4 manipulated perforation may

pulhave (tris-

and

into

result fistula,

and gluteal is forcefully

and

of THAM

nomethan)

solution the

at

in i8 infants. been reported in the

infusion

ylami

compli-

artery cathtemporary

renal, celiac, splenic, arteries. Severe complications

hydroxymeth

the

et al.,7

iliac,

resulted

sis,

Cochran

related to umbilical were vasospasm and

occur.’8

labial If the through into

the When

9. Anteroposterior roentgenogram of the chest and abdomen demonstrating the umbilical vein catheter perforating through the right atrium following passage through the right atrium, left atrium, left ventricle, and right ventricle.

FIG.

VOL.

No.

120,

Normal

2

toring techniques to manage these curate

importance

and

obtain

We

recommend

grams correct

the prevent and

chest

intensive

care

in unit

unit

conventional magnification

film

arterial

of

can

also

the be

lung,

allows

technique, and cath-

artery table.

catheter

the

a built-

unit

and vein For rapid

alone,

Polaroid

localization of of thermocouples,

tubes,

and

can the

vascular

evaluation

of

the

in

the

structures aorta

lungs,

head

for

and

branches,

and

vessels

neck.

10.

and

placement

arterial

suring infusion

blood of

AP

often

of

thrombosis

mandatory catheters.

and

handling

and

complications,

with

resultant

of Radiology

Massachusetts

General

intensive

Radiology, 2.

ARCILLA, ENSHIP,

born BAKER,

R. L’E.,

ORME,

bowel

in

i6.

R. A., OH, W. Portal period. Acta D. B.,

newborn.

I., after En-

aspects

and

S. M. Perforation complication of cxM. 7., 1968, 4, 349-

EADES,

newborn

as

Brit.

L. K. of umbilical

ALLEN,

DIAMOND,

Pediatrics,

catheterization.

R., of

and umbilical

correct

vascular 3967,

Radiology,

M. S., and catheterization

ROSEN,

R.

LOWMAN,

3!,

1963,

M. Roentgen catheterization 89, 874-877.

S. B. Umbilical venin newborn: identification

REICH,

Radiology,

positioning.

radiography

J. M. latrogenic

SCOTT,

ing umbilical vein Childhood, 1965, 40,

M. Advantages room.

i8.

119-121.

W., LIND, and atrial

BERDON,

colon New

95,

1970,

335-340.

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LIDSKY,

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104,

R. M.,

796-797.

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F. R.,

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scandinav.,

W. E., and

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BLANCKin

JAMES,

L. S.

of

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lesions in babies followcatheterization. Arch. Dis.

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426-429. PATNEY, M. Complicavessel catheterization: Pediatrics, 1969, 44,

1028-1030.

new-

1966,55,

6i 5-625. 3.

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for

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W. 0., JR. Erythroblastosis with exchange transfusion. Med., 1951, 224, 39-49. FRIEDMAN, A. B., ABELLERA, and LUBERT, M. Perforation

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venous for

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Improper

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is important

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catheters

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& 68-76. 6. CASTOR, W. R. Spontaneous perforation of bowel in newborn following exchange transfusion. Canad. M. A. 7., 1968, 99, 934-939. 7. COCHRAN, W. D., DAVIS, H. T., and SMITH, C. A. Advantages and complications of urnbilical artery catheterization in newborn. Pediatrics, 1968, 42, 769-777. 8. DIAMOND, L. K. Erythroblastosis foetalis or haemolytic disease ofnewborn. Proc. Roy. Soc. Med., ‘947, 40, 546-550.

electrocardiographic The catheters material into

umbilical arterial lateral roentgenograms.

of

by

43, 34-39.

1969,

NUCLEAR

9.

vascular naso-

leads can be determined. be used to inject contrast heart,

catheters

AM.

used.

In addition to catheters, positions tracheal

in

but

latter

localization

venous

umbilical

or venous

is adequate, The

5.

assure

machine

of the umbilical roentgenographic

localization

4.

367

Artery

Proper

Annual Pediatric

roentgenoto

Umbilical

Pediatrics,

complications

roentgenographic studies of the

eterization on the

of the

measurements.

x-ray

is preferable.

risk. Acis of ut-

abdomen

of the

A portable

Position

physician

less

lateral

and

localization

the

catheters

blood

AP

the

catheter.

American Journal of Roentgenology 1974.120:361-367.

of to

accurate

of

Abnormal

will permit infants with

placement

most

and

19.

WIGGER,

W. A. infants

H. J., BRANSILvER, B. R., and Thromboses due to catheterization and’children. 7. Pediat., 1970,76,

BLANC,

in I-I

I.