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 Interestingly, there has been a noticeable lack of recent investigations regarding venous cutdowns, most likely due to the focus on central venous access via the Seldinger technique with ultrasound guidance and intraosseous access. Recent editions of the ATLS text refer to the saphenous venous cutdown as an optional skill to be taught at the discretion of the instructor.2 However, despite the apparent lack of popularity of the peripheral venous cutdown, 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. 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, or scars. Direct visualization of the vein to be cannulated can be more fruitful than indirect visualization with central venous lines without ultrasound guidance in the patient with shock. However, in a study in 1994 comparing venous cutdowns versus percutaneous femoral venous access, all times to completion of the procedure and infusion times were faster in the percutaneous femoral access group versus the cutdown group.3 Despite these statistics, it is not uncommon to be managing a critically ill patient who cannot be cannulated peripherally or centrally and the venous cutdown becomes a procedure of necessity for resuscitation. An additional advantage of the venous cutdown is that it does not interfere with concurrent resuscitative efforts at the head, neck, thorax, and abdomen.
Familiarity with this procedure allows for large-bore access and the rapid infusions required in the critically ill trauma or medical patient with difficult access. 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 54-1). 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).