Mark J. Polak, MD

We heard from several readers about a Photo Essay we recently published in our February issue entitled "The Butterfly Technique: A New Method of Inserting an Umbilical Vessel Catheter."

 The authors, Lisa A. Wood, MD, and Mark J. Polak, MD, described modifications of standard catheter insertion techniques that facilitated successful line placement.

Most of the feedback was from readers who were already familiar with the method described in the Photo Essay. Here is a smattering of the comments:

"I've used this technique for over 20 years and have taught countless residents and fellows its benefits. Not only does it give better control of the vessels when preparing for catheter insertion, it also allows for limited use of 'umbilical tape.'

"Those who use this technique might want to cross-clamp the umbilical stump more than 0.5 to 1 cm above the skin line. This will make it easier to position the vessels and leave extra length in case of vessel wall perforation."

"The technique detailed was exactly the method that I was taught in 1983 to 1986 at Children's Medical Center and Parkland Memorial Hospital in Dallas. This was the standard technique for inserting umbilical lines in the 1980s. There are hundreds of practicing pediatricians who use this method."

"I published an article on the technique described in your Photo Essay back in 1980. . . ."

We also heard from a reader who was not familiar with the technique. He wrote:

"I have inserted several hundred umbilical catheters, yet I couldn't follow the technique the authors were trying to demonstrate. Please ask them to elaborate?

To this last comment, the authors responded, 

"It is apparent that the orientation of several of our photos may have been confusing. The drawings here depict the umbilical stump and the proper orientations. We hope these figures will resolve any confusion."

  Wood LA, Polak MJ. The butterfly technique: a new method of inserting an umbilical vessel catheter. 

Articles

We heard from several readers about a Photo Essay we recently published in our February issue entitled "The Butterfly Technique: A New Method of Inserting an Umbilical Vessel Catheter."1 The authors, Lisa A. Wood, MD, and Mark J. Polak, MD, described modifications of standard catheter insertion techniques that facilitated successful line placement.

Consultations & Comments: A "New" Twist on the Technique of Umbilical Catheterization?

The conventional method of placing an umbilical artery catheter in neonates involves cutting the cord approximately 1 cm above the skin/cord junction. The cord stump is then held steady with 2 or more hemostats while the vessels are dilated and cannulated.

 Although this method has been successfully employed by generations of pediatricians, the technique requires considerable practice to master.

Most cases of unsuccessful catheter insertion result from awkward positioning and handling of the umbilical stump, which tends to retract into the abdomen. It is nearly impossible to get a firm grasp, which makes it difficult to visualize umbilical vessels. This results in the creation of false tracts during vessel dilation and/or perforation of the vessel when attempts are made to insert the catheter.

We have experimented with several small modifications of standard catheter insertion techniques that can make it easier to insert an umbilical artery line. Our technique facilitates successful line placement.

Professional cooks use the term "butterfly" to describe the partial cutting of a fillet or other food item in a manner that increases the surface area exposed to heat.We advocate a butterfly technique in which the umbilical cord is partially sliced so that the umbilical artery is exposed. When the upper flap of the cord is folded over, the umbilical vessels are pulled upward and outward. They are easily identified and are fixed in place by the tension placed on the folded cord flap.

Mechanical advantage is maximized because:

 The directionality of catheter insertion is the inclined plane.

Practitioners at all levels of experience have had success with this technique.

 MacDonald MG. Umbilical artery catheter insertion. In: Cunningham MD, Eyal FG, Zenk KE, eds. 

Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. 

5th ed. New York: McGraw-Hill; 1999:160-164.
 

 Shilkofski N. Procedures. In: Robertson J, Shilkofski N, eds. 

17th ed. St Louis: Mosby Inc; 2005:73-104.
 

 MacDonald MG. Umbilical artery catheterization. In: MacDonald MG, Ramasethu J, eds. 

3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2002:152-170.

Photo Essay: The Butterfly Technique: A New Method of Inserting an Umbilical Vessel Catheter