Abstract
Background: Arterial catheters are frequently needed to optimize the intensive care in the sick newborn. Umbilical Arterial Catheters (UAC) is more popular than peripheral arterial catheterization. They are utilized to provide continuous accurate arterial blood pressure monitoring, frequent assessment of gas exchange efficiency, frequent blood sampling and rarely for exchange blood transfusion. Umbilical Arterial Catheters may be used in emergencies to infuse fluids or medications in the absence of venous access. Malposition of the Umbilical Arterial Catheter requires immediate attention. The main complication of UAC malposition is obstruction of the arterial lumen of a small caliber branching artery. This may lead to impedance of arterial flow and predisposes to arterial thrombosis and embolism. Case Presentation: We present a rare case of bilateral UAC catheterization where the second umbilical artery was erroneously catheterized instead of the intended umbilical vein. Conclusion: This case reinforces the need for thorough assessment of the position and course of any recently inserted umbilical vascular catheter.