Chapter 43

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.

###### FIGURE 43-1

Common sites for peripheral venous cutdowns include the inner arm above the elbow (1), the inner thigh (2), and the inner ankle (3).

### Greater Saphenous Vein

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 ...

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