• Benjamin W Kozyak, María V Fraga, Courtney E Juliano, Shazia Bhombal, David A Munson, Erik Brandsma, Jason Z Stoller, Ankit Jain, Russell Kesman, Malorie Meshkati, Caroline Y Noh, Aaron G Dewitt, Andrew T Costarino, David A Hehir, and Alan M Groves.
• Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
• Pediatr Crit Care Me. 2022 May 1; 23 (5): e257-e266.

ObjectivesUmbilical venous cannulation is the favored approach to perinatal central access worldwide but has a failure rate of 25-50% and the insertion technique has not 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 with congenital heart disease, in whom umbilical access facilitates administration of inotropes and blood products while sparing vessels essential for later cardiac interventions. We sought to use real-time, point-of-care ultrasound to achieve central umbilical venous access in patients for whom conventional, blind placement techniques had failed.DesignMulticenter case series, March 2019-May 2021.SettingCardiac and neonatal ICUs at three tertiary care children's hospitals.PatientsWe identified 32 neonates with congenital heart disease, who had failed umbilical venous cannulation using traditional, blind techniques.InterventionsReal-time ultrasound guidance and liver pressure were used to replace malpositioned catheters and achieve successful placement at the inferior cavoatrial junction.Measurements And Main ResultsIn 32 patients with failed prior umbilical venous catheter placement, real-time ultrasound guidance was used to successfully "rescue" the line and achieve central position in 23 (72%). Twenty of 25 attempts (80%) performed in the first 48 hours of life were successful, and three of seven attempts (43%) performed later. Twenty-four patients (75%) were on prostaglandin infusion at the time of the procedure. We did not identify an association between patient weight or gestational age and successful placement.ConclusionsUltrasound guidance has become standard of care for percutaneous central venous access 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 markedly improve success of placement. This represents a significant advance in this core neonatal procedure.Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

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