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Transfusions in newborn infants through abdominalwall segment of umbilical vein
TRANSFUSIONS IN NEWBORN I N FA N T S THROUGH ABDOMINAL WALL SEGMENT OF UMBILICAL V E IN Lo~JIS ]~. I~INKUS, M.D. B~oNx, N. Y. E C E N T medical literature contains several articles dealing with transfusion of the newborn infant via the umbilical vein J, 2 The various techniques described have in common the employment of the umbilical vein within the umbilical cord. Their applicability is severely limited by the brief period during which the umbilical vein remains patent within the rapidly atrophying cord. Estimates of this period vary between twelve and forty-eight hours. Following is a preliminary report on a method which utilizes that portion of the umbilical vein which lies within the abdominal wall. Here the vein is readily available even after atrophy of the umbilical cord has occurred. Technique.--A transverse cutaneous incision 2 cm. in ength is made 1 era. cephalad to the upper margin of abdominal insertion of the umbilical cord. Upon separatio~ of the subcutaneous tissue, the umbilical vein is visualized as a whitish, longitudinal, tubular structure elevating the thin midline aponeurosis. A 0.5 cm. longitudinal incision through the aponeurosis is made on either side of the vein, and the latter is easily freed from the underlying transversalis fascia and peritoneum by bhlnt dissection with tissue forceps and grooved director. After loose application of a fine silk or catg%lt ligature around the upper exposed portion of the vein, a sharp-pointed scissors is employed to make a transverse nick through its anterior wall. A blunt-tipped nylon ea~nula, size 18 (or larger, if desirable), is then introduced eephalad until blood can be aspirated through it with ease. The ligature is then tied with a single hitch to effect snug approximation of the vei?l wall around the indwelling eannu]a, and transfusion is carried out. Upon termination of transfusion, the cannula is withdrawn, and the ]igature is tightened and eomp]eted with a second hitch. Skin edges are approximated with two silk sutures. Anatomical Cons~derations.--According to Arey, 3 the empty umbilical vessels contract and gradually lose their ]nmlna by fibroblastie proliferation. This process extends through the first two or three months of postnatal life. Seam-
R
TABLE I .
PATH.
NO.
32303 32842 32970 34333 35497 35498
T H E UMBILICAL 3~E1N AND ]]])UCTUS VENOSUS IN TI~E NEWBORN INFANT ( 6 CASES)
AGE 9 hr. ]5 hr. 5 days 5 hr. 6 hr. 3 days
LENGTH OF U.V. EXTRAPERITONEALLY
3.5 2.5 4.0 2.5 3.0 3.0
PATENT U.V.
cm. cm. cm. cm. cm. cm.
yes yes yes yes yes yes
DIAMETER U.V.
0.4 0.3 0.3 0.5 0.4 0.3
cm. cm. cm. cm. cm. cm.
PATENT DUCTUS VENOSUS yes yes yes yes yes yes
T h i s w o r k w a s c a r r i e d o u t in t h e D e p a r t m e n t of P a t h o l o g y , t h e B r o n x H o s p i t a l . N e w Y o r k , N. Y. S i n c e r e t h a n k s is g i v e n to D r . J o s e p h F e l s e n , D i r e c t o r of L a b o r a t o r i e s a n d Research, for his kind guidance and help. 418
PINKUS:
TRANSFUSIONS
IN
NEWBORN
INFANTS
419
mon and Norris, * in their review of 762 cases, report obliteration of the.ductus venosus as follows: in 2.3 per cent the vessel is obliterated within the first week of life; in 18 per cent w i t h i n the second week; in 37.5 per cent within the third week, and in 100 per cent, it is obliterated after the second month. Table I is based on findings obtained from postmortem examination of six newborn full-term infants.
1 Fig. l.--Transabdominal wall approach to umbilical vein. 7, Site of inc[s~on; ~, close-up of cut-down site after separation of skin and ~ubcutaneous tissue; :~, umbilical vein isolated and cannula being introduced.
]t is to be noted from Table I that the umbilical vein was found to be an extr:aperitonea] structure for a distance of 2.5 to 4.0 era. cephalad to the upper margin of the umbilicus. Both the umbilical vein and the ductus venosus were patent in each case. The distance from the site of cut-down to the point of junction between the ductus venosus and the inferior vena cava varied between 6 and 8 cm.
App,li~ation.--To date, the above-described technique has been employed in transfusing one living newborn infant (Hospital Record No. 201217). This male, erythroblastotic iiffant, a spontaneous delivery at term, had replacemerit transfusion therapy ~nstituted twenty-six hours after birth. All attempts at passing a cannula into the umbilical vein via the cord were unsuccessful. Thereupon, the transabdominaI wall approach was made. Replacement transfusion, totalling 500 c.e. o f blood withdrawn and 540 e.G. infused, was completed with ease. CONCLUSIONS
A new approach to the umbilical vein is described. The length of time a f t e r birth during which this technique is applicable is as yet undetermined, but its usefulness far outlasts the approach via the cord. Moreover, the simplicity of technique, the large caliber of the umbilical vein, the toughness of
420
THE JOURNAL 0F PEDIATRICS
its wall, a n d its r e l a t i v e i s o l a t i o n f r o m u structures, render d e s i r a b l e f o r t r a n s f u s i d n t e c h n i q u e s in t h e n e w b o r n i n f a n t .
t h i s site mos,
L'EFERE.NCES 1. 2. 3. 4.
Mayes, I-[. W.: Am. J. Obst. & Oy~ec. 48: 36, 1944. l"viayes, tI. W.: J. PEDIAT. 28: 69, 1946. Arey~ L. 13.: Developmental Anatomy, Philadelphia, 1942, W. 13. Saunders Co. Scammon~ R. E.~ and Norris, ~E. I~.: Anat. l~ee. 15: 165-180~ 1918.
R
TABLE I .
PATH.
NO.
32303 32842 32970 34333 35497 35498
T H E UMBILICAL 3~E1N AND ]]])UCTUS VENOSUS IN TI~E NEWBORN INFANT ( 6 CASES)
AGE 9 hr. ]5 hr. 5 days 5 hr. 6 hr. 3 days
LENGTH OF U.V. EXTRAPERITONEALLY
3.5 2.5 4.0 2.5 3.0 3.0
PATENT U.V.
cm. cm. cm. cm. cm. cm.
yes yes yes yes yes yes
DIAMETER U.V.
0.4 0.3 0.3 0.5 0.4 0.3
cm. cm. cm. cm. cm. cm.
PATENT DUCTUS VENOSUS yes yes yes yes yes yes
T h i s w o r k w a s c a r r i e d o u t in t h e D e p a r t m e n t of P a t h o l o g y , t h e B r o n x H o s p i t a l . N e w Y o r k , N. Y. S i n c e r e t h a n k s is g i v e n to D r . J o s e p h F e l s e n , D i r e c t o r of L a b o r a t o r i e s a n d Research, for his kind guidance and help. 418
PINKUS:
TRANSFUSIONS
IN
NEWBORN
INFANTS
419
mon and Norris, * in their review of 762 cases, report obliteration of the.ductus venosus as follows: in 2.3 per cent the vessel is obliterated within the first week of life; in 18 per cent w i t h i n the second week; in 37.5 per cent within the third week, and in 100 per cent, it is obliterated after the second month. Table I is based on findings obtained from postmortem examination of six newborn full-term infants.
1 Fig. l.--Transabdominal wall approach to umbilical vein. 7, Site of inc[s~on; ~, close-up of cut-down site after separation of skin and ~ubcutaneous tissue; :~, umbilical vein isolated and cannula being introduced.
]t is to be noted from Table I that the umbilical vein was found to be an extr:aperitonea] structure for a distance of 2.5 to 4.0 era. cephalad to the upper margin of the umbilicus. Both the umbilical vein and the ductus venosus were patent in each case. The distance from the site of cut-down to the point of junction between the ductus venosus and the inferior vena cava varied between 6 and 8 cm.
App,li~ation.--To date, the above-described technique has been employed in transfusing one living newborn infant (Hospital Record No. 201217). This male, erythroblastotic iiffant, a spontaneous delivery at term, had replacemerit transfusion therapy ~nstituted twenty-six hours after birth. All attempts at passing a cannula into the umbilical vein via the cord were unsuccessful. Thereupon, the transabdominaI wall approach was made. Replacement transfusion, totalling 500 c.e. o f blood withdrawn and 540 e.G. infused, was completed with ease. CONCLUSIONS
A new approach to the umbilical vein is described. The length of time a f t e r birth during which this technique is applicable is as yet undetermined, but its usefulness far outlasts the approach via the cord. Moreover, the simplicity of technique, the large caliber of the umbilical vein, the toughness of
420
THE JOURNAL 0F PEDIATRICS
its wall, a n d its r e l a t i v e i s o l a t i o n f r o m u structures, render d e s i r a b l e f o r t r a n s f u s i d n t e c h n i q u e s in t h e n e w b o r n i n f a n t .
t h i s site mos,
L'EFERE.NCES 1. 2. 3. 4.
Mayes, I-[. W.: Am. J. Obst. & Oy~ec. 48: 36, 1944. l"viayes, tI. W.: J. PEDIAT. 28: 69, 1946. Arey~ L. 13.: Developmental Anatomy, Philadelphia, 1942, W. 13. Saunders Co. Scammon~ R. E.~ and Norris, ~E. I~.: Anat. l~ee. 15: 165-180~ 1918.