Venous Cutdown

CHAPTER 209 Venous Cutdown



Wm. MacMillan Rodney, J.R. MacMillan Rodney


Obtaining vascular access is a life-saving procedure for critically ill patients in a variety of situations, but hypovolemic shock and cardiac arrest are the most common vascular access emergencies. Venous cutdowns were first described in World War II. With the advent of intensive care units in the 1960s, surgical cutdowns were frequently replaced by percutaneous approaches to the subclavian and internal jugular veins. In the 1970s, placement of these “central lines” became core curriculum in the newly established course known as Advanced Cardiac Life Support (ACLS). This course was usually taught by demonstration and did not require the traditional surgical skills of dissection and suture.


By 1980, the American College of Surgeons implemented the Advanced Trauma Life Support (ATLS) course, which required live tissue for the demonstration of vascular access techniques. These were “venous cutdowns,” but percutaneous techniques have replaced most of the cutdowns. Plastic simulators do not realistically reproduce the in vivo experience. More recently, ultrasonography has dramatically improved the ability to visualize central and peripheral veins, often directing cannulation.


In situations where ongoing chest compressions, burns, or trauma make central line placement difficult, the intraosseous route (see Chapter 198, Intraosseous Vascular Access) is quickest and most reliable for clinicians with limited surgical experience. However, intraosseous needles and central line kits are not as universally available as scalpels, hemostats, and suture. In developing countries and most locations more than 1 mile from an academic medical center, venous cutdown is the most readily available method for rapid vascular access. Ironically, clinicians in these locations are often less likely to have any experience or training with venous cutdown.


This chapter describes cutdowns of the distal great saphenous vein near the ankle and the proximal great saphenous vein beneath the inguinal crease. Brachial or basilic vein cutdowns in the antecubital fossa are rarely a first choice because of the time required for dissection, but are also discussed. In cases where the patient is undergoing chest compressions, space around the patient can be limited, and choosing a more distal location is usually better.



Indications



• Multiple failed attempts at percutaneous insertion in a critically ill or injured patient

• Hypotensive shock

• Patient requiring immediate administration of intravenous (IV) fluids or drugs

• Cardiac or respiratory arrest

• Burns, trauma, or ongoing resuscitation preventing timely insertion of percutaneous central lines

• Intraosseous access contraindicated (see Chapter 198, Intraosseous Vascular Access) or equipment not available

• Surgical consultation not available (e.g., because of time or distance limitation)

• Lack of percutaneously accessible vein (e.g., obesity, unusually small or fragile veins [as in some adults and most infants], or venous sclerosis from aging, IV drug abuse, or previous multiple venipunctures)


Contraindications



• When less invasive and adequate alternatives (e.g., intraosseous, percutaneous central or peripheral lines) are immediately available

• Long bone fracture present proximally in extremity

• Evidence of severe peripheral vascular disease such as thrombophlebitis, vascular insufficiency, history of vein stripping, history of vein sclerosis (clinician should consider different site)

• Lack of equipment

• Local infection, burns, or trauma in the area of the cutdown (relative)

• Prolonged use for administration of hypertonic fluids (relative)

• Inadequate local arterial supply (relative, arterial supply is important for postprocedural healing, so consider a different site)

• Bleeding disorder (relative)


Equipment



• Tourniquet and tape

• Sterile gloves, goggles, equipment to follow universal blood and body fluid precautions

• Sterile gauze sponges, gauze pads, and drapes

• Antiseptic skin preparation (if time permits), such as povidone–iodine or chlorhexidine soap or solution (alcohol is not preferred)

• A 3- to 5-mL syringe of local anesthetic (any kind of lidocaine; epinephrine is not necessary but is not harmful)

• Basic surgical equipment (e.g., scalpel [no. 10 or no. 15 blade for skin, no. 11 blade for minivenotomy), hemostats [large and mosquito, curved and straight], thumb forceps [pickups] with and without teeth, suture scissors, tissue dissection scissors [Metzenbaum], and a needle holder)

• Although silk ligatures (4-0) for the vein and nonabsorbable skin suture (4-0) have been recommended for the skin, this is an emergency and any suture will work. Generally, braided or monofilament absorbable sutures varying from 0 to 4-0 work fine. Concerns about infection risk with braided suture are more theoretical than real. Silk is the most reactive of all sutures in the skin and is not the first choice.

• IV fluids and setup. Cannulation is possible using a wide variety of tubes and catheters. Using the IV tubing itself (hub cut off) to cannulate permits the most rapid infusion but usually requires the proximal saphenous, and a backup IV catheter should be available. Ten- to 14-gauge plain peripheral IV catheters are almost as good for infusion of large amounts of fluid, but anything will work if cardioactive drugs are needed.

• High-frequency ultrasonography (5 to 10 MHz) and ultrasound gel to visualize or define the venous anatomy at the groin or antecubital fossa (optional; if time and the urgency of the situation allow)


Patient Preparation and General Considerations: Anatomy



1 The clinician should be familiar with the basic anatomy of the area (Fig. 209-1).

2 If the patient is alert, explain the need for IV access and the procedure. If time and the urgency of the situation allow, obtain informed consent.

3 For distal saphenous or basilic vein cutdowns, have an assistant apply a tourniquet proximal to the incision site and control it. This will enable the clinician to more easily visualize and palpate the vein. A tourniquet applied high on the thigh may help with locating the proximal saphenous vein. To minimize bleeding, tourniquets should be released at the time of venipuncture. Observe universal blood and body fluid precautions.

4 Cleanse the skin in the area around the vein and incision site thoroughly with antiseptic soap or solution.

5 To provide ample working space, if time and the urgency of the situation allow, extend a wide sterile field 8 to 10 cm proximally and distally and apply sterile drapes.

6 Regardless of which cutdown site is chosen, incisions can be made horizontally (i.e., laterally), which is also transversely. When subcutaneous fat protrudes from the incision, use blunt dissection and spread the tissue longitudinally along the axis of the vein. All of these veins are in superficial fat layers, so with a proximal saphenous or basilic vein cutdown, if the incision exposes muscle fascia, it is too deep.

7 The vein should appear pulseless and thin-walled, and it should blanch with the application of distal traction. If a vein is not readily identified, have an assistant tighten the tourniquet, which may make it more apparent or palpable.

8 With all cutdowns, the vein should be dissected free and isolated for 2 to 4 cm along its axis.


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Figure 209-1 A, Anatomy of great saphenous vein of the lower extremity. B, Superficial veins of the leg and foot (great saphenous vein at the ankle). C, Cross-sectional view; the great saphenous vein may be isolated easily and safely at the ankle. Only the minor saphenous nerve lies nearby.



Cutdown



Distal Saphenous Vein (Ankle)



Advantages



• No interference or disruption of other resuscitative procedures (e.g., obtaining blood gases in same area, cardiopulmonary resuscitation [CPR], or endotracheal intubation)

• IV access on inferior side of diaphragm

• Minimal training needed and low risk of complications compared with central access

• No valves at this level of the vein because of the minimal volume and pressure

• Most consistent vein of the lower extremity, especially in its location anterior to the medial malleolus

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Venous Cutdown

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