Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Management of critically ill or injured patients requires immediate and adequate vascular access, especially during trauma resuscitation, when rapid infusion of crystalloid or blood products may be necessary. Venous cutdown, a time-honored surgical technique, has largely been replaced by alternative methods of obtaining venous access, including intraosseous lines, the Seldinger technique, and ultrasound-guided central and peripheral venous cannulation. Nonetheless, venous cutdown still has a role as an emergency method of achieving vascular access when other techniques and equipment are unavailable, particularly in settings outside the United States.
First described by Keeley in 1940 and Kirkham in 1945, venous cutdown offered an alternative to venipuncture in patients with shock. Though no longer taught as a mandatory procedure in the Advanced Trauma Life Support course, venous cutdown is considered optional and continues to be taught at the discretion of the instructor. Realistically, percutaneous vascular access may be infeasible in a pulseless, hypovolemic, or anatomically scarred patient. With a thorough understanding of the anatomy, the procedure, and its potential complications, this mechanically simple procedure can be performed quickly and effectively.
Indications
Venous cutdown may be used as an alternative to venipuncture for critical patients in need of vascular access when less invasive options have been exhausted or are not available. Patients with severe shock, asystole, or pulseless electrical activity will lack palpable femoral pulses, thus making percutaneous femoral vein catheterization more difficult. Surface landmarks may be obscured and veins may be unusable in intravenous (IV) drug users, the extensively injured, or severely burned patients. Attempts at percutaneous venous cannulation may be complicated or even impossible in such patients. Venous cutdown ( ) and intraosseous routes (see Chapter 25 ) are both viable options in such scenarios.
Children
Venipuncture in small children poses a challenge in even the healthiest of patients, let alone those in extremis whose veins may be poorly visualized. Central vein catheterization, intraosseous line placement, or venous cutdown should be considered as an alternative means of emergency vascular access when other peripheral sites have been exhausted. The distal saphenous vein at the ankle is often recommended for venous cutdown in children given its large diameter and anatomic predictability at this location.
Hypovolemic Shock
Initially popularized during the Vietnam War for rapid transfusion, venous cutdown has since been used for resuscitation of patients with profound hypovolemia. The flow rate of saline through a standard IV extension set cut to a length of 28 cm (12 inches) and inserted directly into the vein is 15% to 30% greater than through a 5-cm, 14-gauge catheter. This difference is larger if pressure is applied to the system. Moreover, the improvement in flow rate through large-bore lines is greater for blood than for crystalloid solutions because the viscous characteristics of blood impede its passage through small-bore tubing. A unit of blood can be transfused in as little as 3 minutes through IV extension tubing inserted directly into the vein. Consequently, large-bore lines placed by venous cutdown are an excellent mechanism for the treatment of severe hypovolemia.
Contraindications
Venous cutdown is contraindicated when less invasive alternatives exist and when performing the procedure would cause excessive delay. Highly skilled clinicians may perform a cutdown in less than 60 seconds. However, multiple studies by Westfall, Rhee, Iserson, and their colleagues have indicated that on average, the procedure takes at least 5 to 6 minutes to complete. Use of the modified Seldinger technique described both by Shockley and Butzier, and by Klofas, has been shown to decrease that time by 22%. In general, the use of percutaneously inserted central venous catheters in either the subclavian, internal jugular, or femoral vein is preferable to a cutdown.
Absolute contraindications include major blunt or penetrating trauma involving the extremity on which the procedure is to be performed. Relative contraindications include vascular injury proximal to the cutdown site, overlying soft tissue infection, coagulopathies, compromised host defense mechanisms, and impaired wound healing. Other considerations include any previous saphenous vein harvest for coronary artery bypass or other vascular surgery proximal to the anticipated cutdown site. The indications for venous cutdown should be weighed against the potential complications.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here