Indian J Pediatr DOI 10.1007/s12098-014-1377-8

SCIENTIFIC LETTER

Umbilical Venous Catheter Insertion in Gastroschisis Suhasini Gazula

Received: 4 December 2013 / Accepted: 12 February 2014 # Dr. K C Chaudhuri Foundation 2014

To the Editor: Gastroschisis and Omphalocele have always been considered contraindications to inserting umbilical vascular catheters without any concrete evidence. This is a uniform finding across neonatology textbooks, guidelines, residenthandbooks and anesthesia manuals [1, 2]. Despite being an easy central venous access compared to jugular/subclavian/ femoral cannulations, umbilical venous catheter (UVC) is avoided in gastroschisis/omphalocele due to fear of interfering with surgery, infection or umbilical hernia. Exhaustive literature search revealed only two reports of umbilical artery catheter (UAC) insertion in gastroschisis [3, 4]. We report the first case of successful insertion of UVC within native umbilicus in gastroschisis and propose that with concerted efforts of the neonatologist and neonatal surgeon, the umbilical vein can be reasonably easy and useful central venous access even in gastroschisis. One-hour-old term neonate (Weight=2,500 g) with gastroschisis was admitted and given initial care. Intraoperatively, bowel was assessed, replaced in abdomen and primary repair planned. Umbilical cord was freshened to 2 cm length, vein identified and 3Fr-10 cm double-lumen-catheter was introduced till its hub. Good backflow of blood was aspirated and proximal suture was tied snugly around umbilical stump. Catheter was fixed to the stump and the abdominal skin. Abdominal wall was closed snugly around umbilicus after minimally separating falciform ligament attachment. Caution was exercised to ensure UVC is not injured by needle or constricted while tying sutures. Radiograph showed UVC was tip at right atrial-inferior venacava junction. UVC was

S. Gazula (*) Department of Pediatric Surgery, Employees State Insurance (ESI) Corporation Superspeciality Hospital, Sanathnagar, Hyderabad, Andhra Pradesh 500038, India e-mail: [email protected]

used to provide parenteral nutrition for 7 d, venous access for another 4 d and removed on 12th d. In omphalocele/gastroschisis, if arterial access is required and cannot be obtained percutaneously, Filston et al. has described translocating umbilical arteries to lower abdominal wall to remove them from the surgical field [3]. This would however, require vascular surgeons, added time and may have complications. Greenberg et al. described the only report of using UAC within native umbilicus in gastroschisis [4]. Using UVC in gastroschisis will require neonatal surgeon to ensure that it is not injured by suture needle or constricted during abdominal closure. Our case had no omphalitis, central-line sepsis or hernia. While rare cases of small umbilical hernia have been reported following umbilicus-preserving surgeries in gastroschisis [5], closing abdomen snugly around umbilical stump may decrease risk of a wide defect. Prospective studies are necessary to analyze feasibility of UVCs in gastroschisis; nevertheless, we support Greenberg et al. that in view of readily accessible cord, and difficulty in central vein and peripheral artery catheterization because of dehydration secondary to third-space losses in gastroschisis, using umbilical vessels provides ready access [4]. Contribution Dr R. D. Ojha, MS, ESIC Superspeciality Hospital, Sanathnagar, will act as guarantor for the paper. Conflict of Interest None. Role of Funding Source None.

References 1. Anderson J, Leonard D, Braner DA, Lai S, Tegtmeyer K. Videos in clinical medicine. Umbilical vascular catheterization. N Engl J Med. 2008;359:e18.

Indian J Pediatr 2. Anderson J, Leonard D, Braner DA, Lai S, Tegtmeyer K. Umbilical vein catheterization. In: MacDonald MG, Ramasethu J, eds. Atlas of Procedures in Neonatology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2002. pp. 174–82. 3. Filston HC, Izant RJ. Translocation of the umbilical artery to the lower abdomen: An adjunct to the postoperative monitoring of arterial blood gases in major abdominal wall defects. J Pediatr Surg. 1975;10:225–9.

4. Greenberg M, Hilfiker M, Bickler SW. Preoperative placement of umbilical artery catheter for use during umbilical sparing gastroschisis repair. Internet J Surg. 2006;7:doi:10.5580/eb2. 5. Nagaya M, Ando H, Tsuda M, Hiraiwa K, Akatsuka H. Preservation of the umbilical cord at the primary fascial closure in infants with gastroschisis. J Pediatr Surg. 1993;28: 1471–2.