Venous cutdown is an emergency procedure where a physician surgically exposes the vein and inserts a cannula into the vein under direct vision. It is mostly done in cases of emergency where rapid access is required for intravenous (IV) fluid therapy. A cutdown procedure gives the physician access to the saphenous or antecubital vein. The physician recommends this procedure when other less-invasive procedures for IV insertion fail.
Venous cutdown is indicated in the following conditions:
- Difficulty in locating a vein large enough for a needle to pierce unbroken skin
- Unsuccessful peripheral IV attempts
Furthermore, a cutdown procedure is indicated in
- Infants, children, and adults in shock due to fluid loss from the body.
- Burned patients.
- People with deformities in whom anatomical landmarks cannot be located.
- Cardiac arrest without a palpable pulse.
- IV drug abusers where all the veins are scarred.
- Femoral-popliteal or femoral-distal bypass (lower leg bypass operations requiring a vein graft).
- Blood vessel operations requiring a vein patch.
A cutdown procedure should be avoided when you have
- Coagulopathy or bleeding diathesis (a condition in which the blood’s ability to clot is impaired).
- Vein thrombosis (blood clot in a vein).
- Overlying cellulitis (a bacterial infection involving the inner layer of the skin).
In infants and children, venous cutdown has largely been replaced by intraosseous access.
How does a physician perform a cutdown procedure?
Before the procedure, the physician selects two sites for venous cutdown: the primary site and the secondary site.
- Primary site: The primary site is the greater saphenous vein at the ankle.
- Secondary site: The secondary site is the antecubital vein or basilic vein, which is a prominent superficial upper arm vein located at the inner side of the elbow.
To perform a cutdown procedure, the physician
- Prepares the skin for sterilization with Betadine and drapes the area.
- Injects local anesthesia to the surgery site.
- Makes a 2.5-cm incision through the area of anesthesia.
- Identifies the saphenous vein, and with the help of an instrument called a curved hemostat, they release the vein from the adjacent nerve.
- Elevates and dissects the nerve to free the vein from its bed.
- Ties the vein using a suture.
- Cannulate the vein directly as in regular intravenous (IV) procedure.
- Attaches the IV tube to the cannula and closes the incision site.
- Applies antibiotic ointment to the incision site and covers with a dry sterile dressing.
What are the complications of a cutdown procedure?
With a cutdown procedure, there may arise complications due to venous cutdown or during the insertion of a cannula. Some of the complications include:
- Cellulitis
- Hematoma (localized mass of blood outside the blood vessel)
- Phlebitis (inflammation of a vein)
- Venous thrombosis
- Nerve transections (cut around a nerve)
- Arterial transaction (cut around an artery)
- Perforation (piercing) of the back wall of a vein
- Injury to the surrounding structures
- Sepsis (a life-threatening complication of an infection)
- Failed cannulation
- Air embolism (entry of one or more air bubbles into the vein or artery, causing it to block)
It is important to remove the catheter within 12-24 hours to reduce the incidence of complications.
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References
https://emedicine.medscape.com/article/80393-overview#a4
https://www.ncbi.nlm.nih.gov/books/NBK532880/#:~:text=The%20venous%20cutdown%20technique%20is,intraosseous%20vascular%20access%20have%20failed.
https://brooksidepress.org/surgery/lessons/lesson-3-emergency-surgical-procedures/3-2-venous-cut-down-procedure/
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