VENOUS CUT DOWN: A QUICKER AND SAFER TECHNIQUE

Introduction

Venous cut down is an emergency procedure that is potentially life saving. It is taught in the ATLS (Advanced Trauma Life Support) course, and might often need to be performed by the inexperienced in severely ill trauma patients. It is one of the few modern surgical procedures in which speed is a crucial factor due to the presence of hypovolemic shock. An important drawback is the difficulty in cannulation of the vein. We describe simple modifications in the conventional technique that make the procedure safer and faster.

Technique

Step I

(Figure 1)

The great saphenous vein at the ankle is commonly used for the procedure; although other sites are also available. After isolation of the vein in the usual manner1, a loop of thread is passed under the vein as shown in the figure 1. The apex of the loop is then divided.

 

  

 

 

The distal ligature is knotted and the ends of the proximal ligature are held without knotting. A needle (21G needle or the needle of the intravenous cannula which is to be used for the cannulation) is used to transfix the vein at the proposed site of cannulation, as shown in figure 2.

Step II

(Figure 2)

   

 

 

 

Step III

(Figure 3)

 The circumference of the vein anterior to the needle is almost completely incised with a scalpel as shown in figure 3. The needle prevents injury to the posterior wall of the vein and also facilitates a clean-cut incision.

 

  

 

 

The intravenous cannula without the inner needle is then introduced into the venotomy opening, with the needle steadying the vein (Figure 4). The needle is then removed, the proximal ligature tied over the cannula and the wound closed.

Step IV

(Figure 4)

 

Discussion

Venous cut down is an effective option for venous access in multisystem trauma and hypovolemic shock, when peripheral cannulation becomes difficult or impossible. Central venous access has a greater complication rate and requires more experience and skill than a venous cut down. There is also the potential for serious complications related to attempted central venous catheter placement, i.e., pneumo- or haemo-thorax, in a patient who may already be unstable2. The advantage of measuring central venous pressure by central venous access is not important in the initial management of most shocked patients.

The complications of venous cutdown are cellulitis, haematoma, phlebitis, perforation of the posterior wall of the vein, venous thrombosis and nerve and arterial transection2. Perforation of the posterior wall of the vein can occur during venotomy or vigorous attempts at cannulation. By the use of the described technique, perforation of the posterior wall during venotomy becomes unlikely. Also, cannulation of the vein becomes easy because of the presence of a well-defined opening in the anterior wall of the vein.

References:

1.                  McIntosh BB, Dulchavsky SA. Peripheral vascular cutdown. Cr Care Clin 1992; 8: 807-18.
2.                  Shock. Chapter 3. Advanced trauma life support student course manual. 6th edition. American
                 College of Surgeons, Chicago. 1997; 87-125.

 

 

Saba Balasubramanian, Suresh Kumar, Ajay Sharma
Email: s.p.balasubramanian@sheffield.ac.uk <mailto:s.p.balasubramanian@sheffield.ac.uk>