Venous access in the critically ill patient is of the utmost
importance. The literature regarding peripheral venous cutdowns
extends back to 1940 when Keeley introduced the venous cutdown as an
alternative to venipuncture in patients with shock.1 Interestingly,
there has been a noticeable lack of recent investigations regarding
this procedure, most likely because Dr Keeley’s
indications for peripheral venous cutdowns have not changed. The
steps outlined in 1940 for exposing the peripheral vein and its
cannulation are remarkably unchanged. The peripheral cutdown indications
and technique have withstood the test of time.
Peripheral venous access can be extremely difficult due to vascular
collapse from shock, previous injury to the vessel, obesity, or
scars. Direct visualization of the vein to be cannulated will frequently
be quicker and more fruitful than indirect visualization with central
venous lines. Although this procedure has become less utilized with
the increasing popularity of central venous access, familiarity
with this procedure allows for large-bore access and the rapid infusions required
in the critically ill trauma patient or medical code with difficult
access. It is not uncommon to be managing a critically ill patient
who cannot be cannulated peripherally or centrally and the venous
cutdown becomes the procedure of choice for resuscitation. All Emergency
Physicians should be familiar with the peripheral venous cutdown
in order to effectively manage resuscitations in the trauma or medical
setting. This technique can only be successfully performed if one understands
the anatomy and details of venous cannulation. Practicing the cutdown
technique before its critical need will help one to perform optimally
in the emergent setting.
There are three critical areas for venous cutdowns (Figure 43-1).
All Emergency Physicians should be knowledgeable of the anatomy
of the saphenous vein at the ankle, the saphenous vein at the groin,
and the basilic vein at the elbow. The
potential injury to the patient can be significant if one approaches
this procedure without regard to the clinical anatomy.
Common sites for peripheral venous cutdowns include
the inner arm above the elbow (1), the inner thigh (2), and the
inner ankle (3).
The greater saphenous vein is the longest vein in the body. It
is the ideal vein for a peripheral venous cutdown due to its anatomical
regularity and superficiality (Figure 43-2). The saphenous vein
begins at the medial dorsal venous arch of the foot. It passes upward
and 1.5 to 2.5 cm directly anterior to the medial malleolus (Figure
43-2A). At the level of the medial
malleolus, the saphenous vein lies just above the periosteum of
the tibia.2 It continues to ascend in the leg, along with
the saphenous nerve, in the superficial fascia over the medial aspect
of the leg. The vein passes posteromedially to the knee. Above the
knee, it ...