Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length?

Selahattin Akar; Celal Varan

doi:10.4103/jcn.JCN_85_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 9 | Issue : 4 | Page : 276-279

Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length?

Selahattin Akar¹, Celal Varan²
¹ Department of Neonatology, Training and Research Hospital, Adıyaman University, Adıyaman, Turkey
² Department of Pediatric Cardiology, Training and Research Hospital, Adıyaman University, Adıyaman, Turkey

Date of Submission	06-Jun-2020
Date of Decision	10-Jul-2020
Date of Acceptance	27-Jul-2020
Date of Web Publication	01-Oct-2020

Correspondence Address:
Dr. Selahattin Akar
Yunus Emre Mah., 1164. Sk. No: 13,02200, Ziyaretpayamli, Adiyaman
Turkey

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcn.JCN_85_20

Abstract

Objective: Umbilical venous catheter is a commonly used intervention for total parenteral nutrition, antibiotic therapy, and investigations, especially in very low birth weight infants hospitalized in neonatal intensive care units. Catheter length can be calculated using several methods such as Dunn's method, Shukla–Ferrara's formula, and revised Shukla's formula. In this study, we evaluated with echocardiography whether the length of umbilical venous catheter inserted by measuring the upper limit of the xiphoid process and the lower limit of the umbilical ring is appropriate.Materials and Methods: A total of 12 premature infants with a birth weight ≤1500 g with umbilical venous catheter inserted were included in the study. The length of the umbilical venous catheter was determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring. Evaluation was performed first by chest X-ray followed by echocardiography. Results: On chest X-ray, the tip of the catheter appeared longitudinal below the diaphragmatic level in all infants. In none of the cases was the umbilical venous catheter found intracardiac when evaluated by echocardiography. The catheter tip was localized in the cavoatrial junction in four infants, thoracic inferior vena cava in five infants, and ductus venosus in three infants. Conclusion: In our study, we found that the length of umbilical venous catheter determined by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring did not lead to overadvancement, and this method can be used in practice. However, further studies with larger series are needed to draw more definitive conclusions on this issue.

Keywords: Echocardiography, preterm, umbilical venous catheter

How to cite this article:
Akar S, Varan C. Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length?. J Clin Neonatol 2020;9:276-9

How to cite this URL:
Akar S, Varan C. Evaluation of the distance between the xiphoid process and the umbilicus: Is it appropriate for the measurement of the umbilical venous catheter length?. J Clin Neonatol [serial online] 2020 [cited 2021 Jan 28];9:276-9. Available from: https://www.jcnonweb.com/text.asp?2020/9/4/276/297010

Introduction

Umbilical venous catheter is a commonly used intervention for total parenteral nutrition, antibiotic therapy, and investigations, especially in very low birth weight infants hospitalized in neonatal intensive care units. Several complications have reported including pericardial effusion, arrhythmias, cardiac tamponade, pleural effusion, thrombosis, endocarditis, hepatic hematoma, hepatic necrosis, and portal hypertension when the position and length of the umbilical vein catheter are not appropriate.^{[1],[2],[3],[4],[5],[6],[7],[8]} Catheter length can be calculated using several methods such as Dunn's method, Shukla–Ferrara's formula, and revised Shukla's formula. However, studies have increasingly reported that these methods lead to overadvancement of the catheter in preterm infants and that ultrasonography and echocardiography are ideal methods for appropriate position and length.^{[9],[10],[11]} In this study, we evaluated with echocardiography whether the length of umbilical venous catheter determined by measuring the upper limit of the xiphoid process and the lower limit of the umbilical ring is appropriate.

Materials and Methods

A total of 12 premature infants with a birth weight ≤1500 g with umbilical venous catheter inserted in our neonatal intensive care unit between September 1, 2019, and November 30, 2019, were included in the study. An umbilical venous catheter was inserted under sterile conditions by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring. Evaluation was performed first by chest X-ray followed by echocardiography. On chest X-ray, we evaluated whether the catheter tip was above or below the diaphragmatic level. Anatomic localization with the tip of the umbilical venous catheter was noted on echocardiography. Infants diagnosed with congenital malformation, gastrointestinal system anomalies, and congenital cardiac disease were excluded from the study. The study was approved by the institutional review board. The parents of the infants included in the study provided written consent.

Results

On chest X-ray, the tip of the catheter appeared longitudinal below the diaphragmatic level in all infants. None of the cases were intracardiac at the echocardiographic evaluation. The catheter tip was localized in the cavoatrial junction in four infants, thoracic inferior vena cava in five infants, and ductus venosus in three infants [Table 1]. At clinical follow-up, no catheter-related complication was observed.

Table 1: Infants' birth weight, length of the xiphoid-umbilicus distance, localization of catheter tip on chest X-ray, and echocardiography

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In an infant with 1140 g birth weight, catheter position calculated using the length between the xiphoid process and the umbilicus on chest X-ray and its appearance on echocardiography are shown in [Figure 1], [Figure 2], [Figure 3].

Figure 1: Measuring the length between the xiphoid process and the umbilicus with the orogastric tube

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Figure 2: Appearance of a catheter of 6.5 cm length calculated according to the length between the xiphoid process and the umbilicus for an infant with 1140 g birth weight. Catheter seen on the chest X-ray at the level of T9-T10 vertebrae

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Figure 3: Evaluation of the same catheter in Image 2 with echocardiography. End of the catheter is seen within the ductus venosus

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Discussion

Shukla's formula ([3 × kg + 9]/2 + 1), which is calculated based on birth weight, and Dunn's method (based on the distance between the umbilicus and shoulder) have been the most commonly used methods for catheter insertion for a long time.^[12],[13] However, it has been reported that both methods lead to overadvancement, and these methods are not suitable for determining the optimal position of the catheter.^[14] It has been stated that “revised Shukla's formula” developed by decreasing 1 cm in the formula reduced overadvancement without increasing the incidence of lower localized catheters.^[15]

There is no consensus reported on the most ideal position of the umbilical vein catheter. Limited studies in the literature have reported the right atrium as an appropriate position for these catheters.^[16],[17] However, it should be remembered that intracardiac catheter may lead to life-threatening complications such as thrombus, arrhythmias, endocarditis, and pericardial effusion. In addition, a catheter in the right atrium may pass into the left atrium through the foramen ovale, increasing the risk of hemodynamic impairment. It has been reported that the incidence of complications increases when umbilical venous catheter is not in a proper position. In our clinical practice, we do not use intracardiac localized umbilical vein catheters. We use the catheter after establishing the localization in inferior vena cava right atrium (IVC-RA), inferior vena cava, or ductus venosus under the guidance of echocardiography or ultrasonography.

In our study, umbilical venous catheter inserted by measuring the distance between the xiphoid process and umbilical ring was below the diaphragmatic level on chest X-ray in all the 12 infants. The catheter tip was localized in the cavoatrial junction in four infants, thoracic inferior vena cava in five infants, and ductus venosus in three infants. In our study, the catheters were not intracardiac or too lower localized, showing that the xiphoid–umbilicus distance is a practicable method when inserting umbilical venous catheter. In our study, no catheter-related complication was observed at clinical follow-up.

The most accepted anatomic localization as the ideal location of the catheter tip is IVC-RA junction.^[9],[18] Ades et al. reported that IVC-RA differed between the 6^th and 11^th thoracic vertebrae on chest X-ray and stated that ultrasonography findings were weakly correlated with X-rays.^[19] Michel et al. evaluated the position of umbilical venous catheter with chest X-rays and ultrasonography in preterm infants of 34.7 ± 4.2 gestational weeks and reported that ultrasonography gave more accurate results in showing catheter position. Again in the same study, sensitivity of chest X-ray in showing catheter position decreased as birth weight decreased.^[20] Karber et al. evaluated 51 preterm infants with umbilical venous catheter and reported that the location of the catheter on echocardiography was not compatible with the localization of the umbilical catheter, which was evaluated according to the chest radiograph.^[21] In a prospective study by Franta et al., umbilical venous catheter was inserted in 65 preterm infants with a mean birth weight of 808 ± 289 g. The authors reported that catheter localization was appropriate only in 25 (38.5%) infants on ultrasonographic examination. In that study, catheter position extending to the left atrium was reported as the most common malposition.^[22]

Today, the use of echocardiography or ultrasonography in neonatal intensive care units is becoming increasingly common. The greatest advantage of echocardiography includes being performed at any time at the bedside, with no radiation, and the ability to be simultaneously carried out with the intervention performed. However, its most important disadvantage is the inability to reach pediatric cardiologist at any time. Physicians working in neonatal intensive care units can decrease their dependency on radiologist or pediatric cardiologist by receiving training in echocardiography.

Conclusion

In our study, we found that the length of the umbilical venous catheter inserted by measuring the distance between the upper limit of the xiphoid process and the lower limit of the umbilical ring did not lead to overadvancement, and this method can be used in practice. However, further studies with larger series are needed to draw more definitive conclusions on this issue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for images and other clinical information to be reported in the journal. The parents understand that names and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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