ABSTRACT
Importance
Umbilical venous catheterization (UVC) is a common procedure for critically ill newborn infants. The insertion depth was estimated before the procedure using various formulae.
Objective
To compare the accuracy of five published formulae based on birth weight (BW).
Methods
This is a secondary retrospective analysis using data collected in a previous study, in which the actual final insertion depth of UVC was recorded. Predicted insertion depths were calculated by five published formulae based on BW. Then the actual depth and predicted depth were compared. Accurate position was defined as predicted depth being within ± 10% of actual depth. The accuracy rate calculated as “(accurately positioned UVCs/ all UVCs) × 100%” and the ratio of difference calculated as “(|predicted depth − actual depth|/ actual depth)” were compared among five formulae.
Results
Totally 1298 were enrolled, with gestational age 29.8 ± 2.3 weeks and BW 1215 ± 273 g. The accuracy rates were: Tambasco formula (67.2%), Shukla formula (65.0%), JSS formula (64.4%), BW formula (48.9%), and revised Shukla formula (26.9%). Tambasco formula had the highest accuracy rate in newborns with BW ≥ 1000 g. JSS formula had the highest accuracy rate in newborns with BW<1000 g.
Interpretation
It is suggested to use the Tambasco formula for estimating the UVC insertion depth for newborns, especially for those with BW ≥ 1000 g, and to apply the JSS formula for newborns with BW < 1000 g. There is no universal formula for achieving 100% accurate positioning.
Keywords: Accuracy, Depth, Infant, Newborn, Umbilical vein catheterization
There are many formulae for estimating the depth of umbilical venous catheterization (UVC), but a definitive consensus on the superior choice has not been reached. This study compared all five published formulae based on birth weight (BW) and found that selecting an appropriate UVC depth estimation formula according to BW intervals was crucial before performing UVC procedures.
INTRODUCTION
Umbilical venous catheterization (UVC) is a common procedure in neonatal intensive care units (NICUs) for critically ill newborn infants and extremely low birth weight (BW) infants. 1 The insertion depth was estimated before the procedure using various formulae. Assessing the catheter insertion depth is crucial before the procedure. However, there is no single magic formula for achieving an accurate placement of the catheter tip. Clinically, X‐rays, ultrasound, or both are usually the methods for confirming and adjusting the catheter tip position, which is crucial to avoid complications caused by malpositioning. 2 , 3 , 4 The recent guidelines consider real‐time ultrasound‐guided (USG) UVC insertion to reduce the rate of malpositions. 5
A cohort study 6 , 7 conducted by our team on UVC indwelling time and complication incidence in NICUs across 44 hospitals in China was performed. Currently, formulae are typically classified into two categories: one relying on BW and the other utilizing body surface measurement. 8
When our team drafted the Guidelines for the Prevention and Control of Complications Related to Umbilical Vein Catheterization in Neonates, 9 all five published formulae to estimate UVC insertion depth based on BW were identified after literature review and screening (Table 1). Although various formulae exist for determining UVC insertion depth based on BW, current research comparing these methods is sparse, thus precluding definitive clinical conclusions regarding the most effective formula. Therefore, the primary objective of this study was to evaluate and contrast the accuracy of these five formulae for estimating UVC depth based on BW, aiming to establish an evidence‐based framework for the clinical selection of the UVC insertion depth estimation formula.
TABLE 1.
Five formulae for estimating umbilical venous catheterization (UVC) insertion depth based on birth weight (BW)
| Name of formula | Formula details a |
|---|---|
| Shukla formula 10 | (3 × BW + 9)/2 + 1 |
| revised Shukla formula 11 | (3 × BW + 9)/2 |
| BW formula 12 | 1.5 × BW + 5 |
| JSS formula 13 | 0.5–0.749 kg: 6 |
| 0.75–0.99 kg: 6.5 | |
| ≥ 1 kg: 6.5 + BW | |
| Tambasco formula 14 | ≤ 1.5 kg: 2.6 × BW + 4.35 |
| > 1.5 kg: 1.1× BW + 6.52 b |
All insertion depths of UVC were in “cm” and BW were in “kg”.
This was the corrected Tambasco formula by the original author.
METHODS
Ethical approval
This study was approved by the Institutional Ethical Review Board of Beijing Children's Hospital, Capital Medical University (2019‐K‐337). Informed consent was waived for this study, as all data were de‐identified and there was no requirement for additional blood or tissue samples.
Setting and participants
This study was a multi‐center retrospective analysis, building upon the previous cohort study 5 , 6 that investigated the dwelling time and complication incidence of UVC. The study was conducted from November 1, 2019, to August 31, 2021, and performed at NICUs of 44 tertiary hospitals in 24 provinces in China. Patients were included if (1) the gestational age (GA) was more than 24 weeks and (2) received UVC within 2 hours after birth which was inserted successfully with the tip position confirmed by imaging. Infants were excluded if one of the criteria was met: (1) BW was less than 400 g; (2) vital information was lacking; (3) they had diseases affecting the thorax or abdomen, including congenital diaphragmatic hernia, hydrops fetalis, and malformations.
Measurement and outcomes
UVC procedures were performed by neonatologists or trained clinicians using their preferred formula to estimate the insertion depth in all participating units. Subsequent imaging was conducted to determine and adjust the UVC's position immediately after catheterization. The correct position for the UVC tip was defined as being at the junction of the inferior vena cava and right atrium (the 9th thoracic vertebrae on anteroposterior X‐ray). Once the UVC had been successfully positioned, the actual final insertion depth was recorded. In addition, the demographic and clinical data including gender, GA, and BW were systematically collected by the case report forms. The data were meticulously entered into the database by a specially trained individual.
Predicted insertion depths were calculated by five published formulae based on BW. Then the actual final insertion depth and the predicted insertion depth were compared. Position accuracy was defined as the predicted depth being within ± 10% of the actual depth. During the pilot study, we ascertained that setting the fluctuation threshold at 10% was reasonable, as the obtained accuracy rate was consistent with the results reported in the literature. The accuracy rate is calculated as “(accurately positioned UVCs/ all UVCs) × 100%”, and the ratio of the difference calculated as “(|predicted depth − actual depth|/ actual depth)” between the predicted depth and the actual depth of UVC were compared among 5 formulae. Infants were categorized into three groups for subgroup analysis: BW < 1000 g, 1000–1499 g, and ≥ 1500 g.
Statistical analysis
When normal distributed data conformed to a normal distribution, results were expressed as mean ± standard deviation (SD), and the t‐test was used for comparison of the groups. Skewed distributed data were expressed as median (interquartile range, IQR), and non‐parametric Mann‐Whitney tests were performed for pairwise comparisons. Count data were represented by percentages and compared using the χ 2 test. A two‐sided P‐value < 0.05 was taken as statistically significant. Analyses were conducted using the Statistical Package for the Social Sciences version 26.0 (SPSS IBM) program.
RESULTS
Patient flow and characteristics
After excluding 874 cases (870 with missing vital documentation, three with hydrops fetalis, and one with congenital diaphragmatic hernia), there were 1298 newborns enrolled in this study. BW was 1216 ± 273 g, and GA was 29.8 ± 2.3 weeks. Almost 2/3 of infants enrolled had BW 1000–1499 g (Table 2).
TABLE 2.
Infant demographics and maternal characteristics (n = 1298)
| Items | Data |
|---|---|
| Infants demographics | |
| Male | 691 (53.2) |
| Birth weight (g) | 1216 ± 273 |
| <1000 | 296 (22.8) |
| 1000–1499 | 810 (62.4) |
| ≥1500 | 192 (14.8) |
| Gestational age (week) | 29.8 ± 2.3 |
| <28 | 249 (19.2) |
| 28–<37 | 1042 (80.3) |
| ≥37 | 7 (0.5) |
| Maternal characteristics | |
| Maternal age (year) | 30.8 ± 5.4 |
| Adverse pregnancy history | 259 (20.0) |
| Singleton pregnancy | 909 (70.0) |
| Cesarean section | 919 (70.8) |
| Assisted reproduction | 275 (21.2) |
| Premature rupture of membranes | 394 (30.4) |
| Use of antibiotics before delivery | 496 (38.2) |
Data are shown as mean ± standard deviation or n (%).
Comparison of the accuracy rate
The accuracy rate of the formulae ranked from the highest to lowest were: the Tambasco formula (67.2%), Shukla formula (65.0%), JSS formula (64.4%), BW formula (48.9%), and the revised Shukla formula (26.9%). The Tambasco formula exhibited a significantly higher accuracy rate than the revised Shukla formula (χ 2 = 422.95, P < 0.001) and BW formula (χ 2 = 88.85, P < 0.001). There was no significant difference when compared to the JSS formula and the Shukla formula (Table 3).
TABLE 3.
Accuracy rate and the ratio of the difference between predicted depth by five published formulae and actual depth of umbilical venous catheterization (n = 1298)
| Name of formula a | Count of accuracy | Accuracy rate, % | Ratio of difference b | P‐value |
|---|---|---|---|---|
| Tambasco formula | 872 | 67.2 | 0.070 (0.100) | Reference |
| Shukla formula | 844 | 65.0 | 0.070 (0.110) | 0.246 |
| JSS formula | 836 | 64.4 | 0.080 (0.090) | 0.136 |
| BW formula | 635 | 48.9 | 0.100 (0.100) | <0.001 |
| revised Shukla formula | 349 | 26.9 | 0.160 (0.110) | <0.001 |
All were based on BW.
Shown as median (interquartile range).
Abbreviation: BW, birth weight.
Stratifying by BW, the JSS formula demonstrated the best performance among neonates with BW <1000 g, achieving an accuracy rate of 64.2% (190/296). A statistically significant difference in accuracy rate was observed between the JSS formula and the revised Shukla formula (χ 2 = 53.54, P < 0.001). For neonates in the BW range of 1000 g to 1499 g, the Tambasco formula showed the highest accuracy rate at 70.2% (569/810), with statistically significant differences compared to the revised Shukla formula (χ 2 = 337.06, P < 0.001), BW formula (χ 2 = 93.66, P < 0.001), and JSS formula (χ 2 = 5.945, P = 0.015). For neonates weighing ≥ 1500 g, the Tambasco formula reached a higher accuracy of 68.2% (131/192), with significant accuracy discrepancies noted when compared to the Shukla formula (χ2 = 47.09, P = 0.034), the revised Shukla formula (χ 2 = 72.09, P < 0.001) and BW formula (χ2 = 21.46, P < 0.001). Across all three weight groups, the revised Shukla formula consistently showed the lowest accuracies, recording rates of 34.1% (101/296), 24.7% (200/810), and 25.0% (48/192), respectively (Table 4).
TABLE 4.
Comparison of the accuracy rate and ratio of difference among five published formulae stratifying by birth weight (BW)
| BW <1000 g (n = 296) | BW 1000–1499 g (n = 810) | BW ≥1500 g (n = 192) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name of formula | Count of accuracy | Accuracy rate, % | Ratio of difference a | P‐value | Count of accuracy | Accuracy rate, % | Ratio of difference a | P‐value | Count of accuracy | Accuracy rate, % | Ratio of difference a | P‐value |
| Tambasco formula | 172 | 58.1 | 0.080 (0.100) | 0.129 | 569 | 70.2 | 0.070 (0.090) | Reference | 131 | 68.2 | 0.070 (0.100) | Reference |
| Shukla formula | 168 | 56.8 | 0.075 (0.120) | 0.064 | 565 | 69.8 | 0.070 (0.070) | 0.828 | 111 | 57.8 ** | 0.085 (0.100) | 0.034 |
| JSS formula | 190 | 64.2 | 0.080 (0.070) | Reference | 523 | 64.6 ** | 0.080 (0.100) | 0.015 | 123 | 64.1 | 0.075 (0.110) | 0.388 |
| BW formula | 172 | 58.1 | 0.090 (0.100) | 0.129 | 377 | 46.5 ** | 0.110 (0.100) | <0.001 | 86 | 44.8 ** | 0.110 (0.110) | <0.001 |
| revised Shukla formula | 101 | 34.1 * | 0.150 (0.110) | <0.001 | 200 | 24.7 ** | 0.160 (0.110) | <0.001 | 48 | 25.0 ** | 0.160 (0.110) | <0.001 |
Expressed as median (interquartile range).
* P < 0.05, compared with the JSS formula.
P < 0.05, compared with the Tambasco formula.
Comparison of the ratio of difference between the calculated value and actual value
The formulae were ranked according to ratio of difference [median (IQR)] between the calculated value and actual value from low to high: Tambasco formula [0.070 (0.100)], Shukla formula [0.070 (0.110)], JSS formula [0.080 (0.090)], BW formula [0.100 (0.100)], and revised Shukla formula [0.160 (0.110)] (Table 3). In the BW < 1000 g group and BW ≥ 1500 g group, the Tambasco Formula exhibited the best performance, with a ratio of difference of 0.075 (0.120) and 0.070 (0.070), respectively. In the BW category of 1000–1499 g, the Shukla formula slightly outperformed the others, with a ratio of difference of 0.070 (0.100) (Table 4).
DISCUSSION
To our best knowledge, this study was probably the first multi‐center study evaluating five formulae based on BW published in the previous literature, and the sample size was not small. The BW of the study population was 1215 ± 273 g and GA was 29.8 ± 2.3 weeks, both of which were consistent with the major preterm population for UVC studies in literature. 12 , 15 , 16 In our research, infants with BW < 1500 g and with BW < 1000 g represented the primary population for UVC application, accounting for 62.4% and 22.8% of the total number.
Among five formulae for estimating UVC insertion depth using BW, we found that the Tambasco formula demonstrated the highest performance, achieving an accuracy rate of 67.2% (872/1298), with a difference ratio of 0.070 (0.100). Tambasco et al. 14 from Yale University regarded a catheter tip measuring between 0.5 cm below and 1.0 cm above the right hemidiaphragm medially on an anteroposterior radiograph radiograph as the optimal UVC position. They also developed the UmbiCalc mobile app to facilitate the use of the Tambasco formula. In a subsequent prospective study, the team observed a UVC placement success rate of 77% using the Tambasco formula, significantly higher than the Shukla formula (32%). 14
Shukla et al. 10 derived a regression equation for catheter depth (cm) = (BW × 3 + 9)/2 + 1, from a retrospective study involving 10 newborns who underwent UVC implantation in 1986. We found a marginally higher accuracy rate of the Tambasco formula compared to the Shukla formula (67.2% vs. 65.0%, P = 0.246). This discrepancy may arise from variations in baseline characteristics, including BW and GA, as well as differences in sample size and study methodology. Tambasco's study reported a median BW of 1650 g and a GA of 31 weeks, whereas our study found a mean BW of 1215 g and a GA of 30 weeks.
A randomized controlled trial 13 , 17 evaluated the JSS formula, revealing that it achieved a significantly higher success rate in UVC placement than the revised Shukla formula (28/52, 53.8% vs. 19/48, 39.5%), aligning with our findings. Our findings indicate that the two latest formulae which are stratified by BW, exhibit higher accuracy. Theoretically, as GA increases, the growth of weight and length in neonates may not be strictly proportional, potentially leading to a non‐linear relationship between BW and internal blood vessel length. As a result, a single linear formula based on BW might not be universally applicable to all neonates across varying BW categories. 8 , 18 Formulae stratified by BW may be a better option.
A single‐center prospective observational study was carried out in 2010 and demonstrated that only 24% (20/84) of the catheter tips were at the ideal position (catheter tip position at T9–T10 on a chest X‐ray) when the Shukla formula was used. 19 In contrast, 75% (63/84) of the catheter tips were placed higher than the ideal position. Therefore, this led to the introduction of the revised Shukla formula, defined as catheter depth (cm) = (BW × 3 + 9)/2. Subsequently, a prospective observational study involving 268 neonates was conducted, which demonstrated that the revised Shukla formula yielded a higher success rate compared to the original Shukla formula (43% vs. 26%, P < 0.05). 11 However, we found that the revised Shukla formula had the lowest accuracy among the five formulae, achieving an accuracy rate of 26.9% (349/1298), significantly below that of the Shukla formula, which achieved 65.0% (844/1298) (P < 0.001). Furthermore, the accuracy rates of the revised Shukla formula consistently ranked as the lowest across all subgroups, with accuracy rates ranging from 24.7% to 34.1%. Mutlu et al. 20 conducted a prospective observational study to compare three UVC formulae and found that the Shukla formula demonstrated a higher catheter placement success rate of 53% (17/32) in comparison to the revised Shukla formula with success rate of 40% (12/30). The observed discrepancy may stem from differing definitions of optimal catheter tip location. Currently, the UVC tip at the junction of the inferior vena cava and the right atrium is widely considered to be the gold standard. 9 , 21 The optimal positions were at T9–T10 on a chest X‐ray for Verheij et al.’s study 19 and the UVC tip at 0.5–1 cm above the diaphragm or T9 for this study. Currently, there is no consensus on the optimal placement of the catheter tip on chest‐abdominal X‐ray. Greenberg et al. 22 found that 90% of catheter tips at the T8–T9 level corresponded with the junction of the inferior vena cava and the right atrium, and all catheter tips at the T9 level were located at this junction. However, some studies suggest that the T9–T10 position might be more suitable. 12 , 23
Limitations of this study were: (1) This was a secondary study based on a previous study, which did not aim at comparing the accuracy of methods for estimating UVC insertion depth. The length of the umbilical cord stump was not recorded in the previous study. Hence, a theoretical length of the umbilical cord stump from textbooks 24 was used in replacement. (2) Data of anatomical body surface measurement was not collected due to the secondary study nature. This restricted the comparative analysis of more formulae based on body surface measurement. 25 (3) Most of the participating centers in this study used X‐ray as the standard method to check the catheter tip position after UVC. However, chest‐abdominal radiography is hardly the standard method for evaluating the catheter tip. There were evidences 26 , 27 , 28 that ultrasound directly visualized the actual anatomical location of the catheter tip, providing a clear advantage in pinpointing its position. However, 24‐hour available bedside ultrasound has not yet been standard practice in NICUs in China.
In conclusion, among the five BW‐based formulae, it is suggested to use the Tambasco formula for estimating the UVC insertion depth for newborns with BW ≥ 1000 g and the JSS formula for newborns with BW < 1000 g. There is no universal formula for achieving 100% accurate positioning. It is necessary to select an appropriate UVC depth estimation formula for infants with various BW when professionals are at the preparation stage of the UVC procedure. Further randomized controlled studies on this topic should be conducted.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
Luo J, Zheng X, Yang Z, Li K, Chen L, Hei M. Comparative analysis of formulae for umbilical venous catheterization depth based on birth weight. Pediatr Investig. 2024;8:265–270. 10.1002/ped4.12451
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