Real-time Ultrasound Guidance to Increase Success of Umbilical Venous Cannulation

Background: Central venous access is essential to the resuscitation of critically ill neonates. Umbilical venous cannulation is the most widely practiced approach to perinatal central access worldwide, but has a success rate of only 50-75% and the insertion technique has not meaningfully evolved in decades. Improving the success of this procedure would have broad implications, particularly where peripherally inserted central catheters are not easily obtained and in neonates undergoing cardiac surgery, in whom it facilitates administration of inotropes and blood products while sparing other vessels that may be essential for later cardiac interventions. Point of care ultrasound has been described in the assessment of UVC tip position, but its use in real-time image guidance is a new and emerging technique with the potential to improve the rate of procedural success.

Methods:

Objective: We sought to use real-time, point-of-care ultrasound to achieve successful central umbilical venous cannulation in patients for whom traditional blind placement techniques had failed.

Design: Case series. March 2019-May 2021.
Setting: Multicenter. Cardiac and Neonatal Intensive Care Units at three tertiary care children’s hospitals.
Participants: Thirty-two neonates with critical congenital heart disease, who had failed umbilical venous catheter placement attempts using traditional, “blind” techniques.
Interventions: Real-time ultrasound guidance and liver pressure were used to replace malpositioned umbilical venous catheters and achieve successful placement at the inferior cavoatrial junction.
Main Outcomes and Measures: Rate of successful central umbilical venous cannulation, impact of postnatal age on placement success, procedural complications.

Results: In 32 patients with failed prior umbilical venous catheter (UVC) placement, real-time ultrasound guidance was utilized to successfully “rescue” the line and achieve central position in 23 (72%). Earlier attempts appeared more likely to more successful, with 20 of 25 (80%) patients achieving successful placement in the first 48 hours of life. After 48 hours, only 3 of 7 (43%) of attempts were successful. Prostaglandin (PGE1) therapy also appeared to be associated with a higher rate of procedural success. There was no association between patient weight or gestational age and successful UVC placement.

Conclusion: Ultrasound guidance has become standard of care for central venous line placement in children outside the neonatal period, but is a new and emerging technique for umbilical vessel catheterization. In this early experience, we report that point-of-care ultrasound, together with liver pressure, can be used to rescue failed UVCs with a high rate of success, and has the potential to markedly improve the overall success rate of this core neonatal procedure.