Peripheral venous cutdown

Abstract

Timely establishment of vascular access is a critical component of the care of the acutely ill or injured patient. Peripheral venous cutdown, once a mainstay in the care of the severely traumatized patient, has progressively lost favor since the introduction of the Seldinger technique of central venous line placement. In fact, recent editions of the Advanced Trauma Life Support (ATLS) text refer to saphenous venous cutdown as an optional skill to be taught at the discretion of the instructor. In certain patients, percutaneous vascular access may be impossible to achieve or result in unacceptable time delays. In these situations, the ability to rapidly and proficiently perform peripheral venous cutdown techniques may prove invaluable and potentially lifesaving. This article reviews the anatomy of the most common sites used for peripheral venous cutdown, peripheral venous cutdown techniques, and the complications associated with peripheral venous cutdown.

Introduction

Vascular access is of critical importance in the resuscitation of the acute medical or trauma patient. Peripheral venous cutdown techniques were first described by Keely in 1940 as an alternative to venipuncture in patients with shock (1). Saphenous vein cutdown, which had long been the mainstay of venous access in the trauma patient, is now infrequently utilized. This is due in large part to the introduction of the Seldinger technique for percutaneous access and the declining number of residents being taught proper cutdown techniques. The sixth edition of the Advanced Trauma Life Support (ATLS) text refers to the saphenous vein cutdown as an optional skill to be taught at the discretion of the instructor (2). Although percutaneous femoral venous catheterization using the Seldinger technique has essentially replaced peripheral venous cutdown techniques, situations occur during which venous cutdown is indicated and may prove life-saving.

Percutaneous vascular access in certain situations and patient populations may be impossible or result in unacceptable time delays. Patients with profound hemorrhagic shock, asystole, or pulseless electrical activity will lack palpable femoral arterial pulses, complicating femoral venous access. The intravenous drug user or extensively injured patient without identifiable peripheral veins or scarred, anatomically altered central venous access sites may be equally challenging. It is among these patients that proficiency in peripheral venous cutdown techniques may prove invaluable and why it should remain within the emergency physician’s procedural armamentarium.