Umbilical Catheter Placement Procedure Note (UAC/UVC)

Date/Time of Procedure: [Start date/time – End date/time]

Location: [NICU / delivery room / OR / other]

Patient: [Identifiers per local policy]

Gestational Age: [weeks + days]

Birth Weight: [grams]

Procedure Performed: UAC: [placed / attempted but not placed / not attempted]; UVC: [placed / attempted but not placed / not attempted]

Operator: [Name, credentials]

Assistants: [Names and roles] (Omit if none)

(Document only catheters that were actually attempted—omit all sections for lines not attempted. For required safety fields, if information is unavailable, enter "Unknown / not documented at time of note" with brief explanation. Never infer consent, time-out, sterile compliance, or tip position.)

Indication and Urgency

• UAC: [Indication: continuous arterial BP monitoring / frequent blood gas sampling / inability to obtain peripheral arterial access / other]. Urgency: [elective / urgent / emergent]. [Precipitating circumstance if emergent]. (Include only if UAC was attempted.)
• UVC: [Indication: central venous access for vasoactive medications / TPN / fluids / difficult peripheral access / other]. Urgency: [elective / urgent / emergent]. [Precipitating circumstance if emergent]. (Include only if UVC was attempted.)

Consent and Pre-Procedure Verification

Consent: [Informed consent obtained from parent/guardian (relationship: mother / father / legal guardian / other) with discussion of risks, benefits, and alternatives / Emergency exception applied — rationale].

Time-out: [Performed immediately prior to procedure verifying correct patient and procedure].

Analgesia and comfort measures: [Sucrose / swaddling / local anesthetic / sedation — agent, dose, route / none — rationale if emergent].

Sterile Technique

Asepsis attestation: [Hand hygiene performed; maximal sterile barrier precautions used (cap, mask, sterile gown, sterile gloves, full drape)].

Antiseptic: [Agent: chlorhexidine / povidone-iodine / other]; adequate dry time observed: [yes / no].

Deviations: [None / Break in sterile technique — describe deviation, corrective action taken, and plan for reassessment].

Equipment

• UAC: French size: [3.5 / 5.0 / other]; single lumen; flush solution: [specify]. (Include only if UAC was placed.)
• UVC: French size: [3.5 / 5.0 / other]; lumen: [single / double]; flush solution: [specify]. (Include only if UVC was placed.)

Procedure Details — UAC

(Include only if UAC was attempted. If not successfully placed, document the attempt and outcome; omit Tip Position Confirmation and Utilization Plan for UAC.)

• Number of attempts: [#]
• Insertion depth: [cm]; target depth estimation method: [formula / chart / other]
• Arterial placement confirmation: [Pulsatile flow / pressure transduction / blood gas correlation / not performed]
• Blood return and flush: [Present and flushes easily / sluggish / none]
• Securing method: [Suture type / tape type]; dressing: [type]
• Outcome if not placed: [Reason for failure and next steps]. (Include only if attempted but not successfully placed.)

Procedure Details — UVC

(Include only if UVC was attempted. If not successfully placed, document the attempt and outcome; omit Tip Position Confirmation and Utilization Plan for UVC.)

• Number of attempts: [#]
• Insertion depth: [cm]; target depth estimation method: [formula / chart / other]
• Blood return and flush: [Easy / sluggish / none]. (For multi-lumen: document each lumen separately.)
• Securing method: [Suture type / tape type]; dressing: [type]
• Outcome if not placed: [Reason for failure and next steps]. (Include only if attempted but not successfully placed.)

Tip Position Confirmation

(Include for each catheter successfully placed. Never infer tip position—must be explicitly documented from imaging. If imaging is pending, state whether line is approved for use.)

UAC Tip Position

• Imaging: [Radiograph / ultrasound / echocardiography]; date/time: [specify]; interpreter: [Radiology final read / clinician point-of-care interpretation]
• Field of view: [Includes full catheter course (chest and abdomen) / inadequate — repeat ordered]
• Position: [High position — vertebral level range / low position — vertebral level range / malposition — describe]
• Use pending confirmation: [Approved for use now / not to be used until confirmed / flush only / emergency use only]. (Include only if confirmation imaging is pending.)

UVC Tip Position

• Imaging: [Radiograph / ultrasound / echocardiography]; date/time: [specify]; interpreter: [Radiology final read / clinician point-of-care interpretation]
• Field of view: [Includes full catheter course (chest and abdomen) / inadequate — repeat ordered]
• Position: [At IVC–RA junction / above cavoatrial junction / below cavoatrial junction / malposition — portal / hepatic / intracardiac]; vertebral level: [specify]
• Use pending confirmation: [Approved for use now / not to be used until confirmed / flush only / emergency use only]. (Include only if confirmation imaging is pending.)

Adjustments

(Include only if catheter position was adjusted after initial imaging.)

• Line adjusted: [UAC / UVC]
• Initial position and reason for adjustment: [Describe]
• Adjustment: [Withdrawn / advanced] [cm]; new secured depth: [cm]
• Repeat imaging: [Modality, date/time]
• Final confirmed position: [Describe]

Post-Procedure Assessment

Patient tolerance: [Vitals and oxygenation status]

Insertion site: [Hemostasis achieved / oozing / hematoma]

• UAC lower extremity perfusion: [Color, capillary refill, pulses — normal / abnormal]. (Include only if UAC was attempted.)
• UVC rhythm monitoring: [No arrhythmia / arrhythmia noted — describe]. (Include only if UVC was attempted.)

Complications

Complications: [None / See below]

(If complications occurred, document each below. If none, state "Complications: None" and omit the list.)

• Event: [Malposition requiring adjustment or removal / bleeding / break in sterility / vascular insufficiency / thrombosis signs / arrhythmia / suspected hepatic injury or extravasation / catheter malfunction / other]
• Timing: [During insertion / after imaging / after adjustment / during use]
• Management and response: [Actions taken and patient response]
• Escalation: [Attending notified / additional imaging / line removal / other]

Utilization Plan

(Include for each catheter successfully placed and approved for use.)

UAC

• Approved uses: [Continuous arterial BP monitoring / blood sampling / other]
• Maintenance: [Flush solution and rate per protocol]; labeled as arterial
• Ongoing necessity: Daily assessment; remove when no longer clinically needed
• Triggers for removal: [Suspected infection / thrombosis / limb ischemia / malfunction]

UVC

• Approved uses: [Fluids / medications / vasoactive agents / TPN / blood sampling]
• Maintenance: [Flush solution and rate per protocol]; labeled as venous
• Ongoing necessity: Daily assessment; remove when no longer clinically needed
• Triggers for removal: [Suspected infection / thrombosis / malfunction / malposition]