Chapter 69: Peripheral Venous Cutdown

INTRODUCTION

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 this technique as an alternative to venipuncture in patients with shock.¹ There has been a noticeable lack of recent investigations regarding venous cutdowns. This is most likely due to the focus on central venous access with ultrasound guidance and intraosseous access. Recent editions of the Advanced Trauma Life Support (ATLS) text refer to the saphenous venous cutdown as an optional skill to be taught at the discretion of the instructor.² The importance of obtaining venous access in critically ill patients supports the need to know a wide variety of techniques in order to be successful in every situation.³ The steps outlined in 1940 by Keeley to expose and cannulate the saphenous vein remain mostly unchanged.¹

Peripheral venous access can be extremely difficult due to vascular collapse from shock, vascular injury, obesity, anatomically altered central venous sites, sclerotic veins, or cutaneous scars. Direct visualization of the peripheral vein in these patients can be more fruitful than indirect visualization.⁴ An additional advantage of the venous cutdown is that it does not interfere with concurrent resuscitative efforts.⁵ A cutdown may be the procedure of choice in resuscitating critically ill patients where resources are limited or nonexistent.

Familiarity with this procedure allows for large-bore access and the rapid infusions required in the critically ill patient.⁵ 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 perform optimally in the emergent setting.

ANATOMY AND PATHOPHYSIOLOGY

There are three critical areas for venous cutdowns (Figure 69-1). 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.

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 anatomic regularity and superficiality (Figure 69-2).³ The superficial and consistent position of the saphenous vein, in both adults and children, makes this the ideal vessel for a peripheral venous cutdown.⁶ 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 ...