148 Section V ■ Vascular Access

Nonsterile

1. Materials for restraint (see Chapter 34)

2. Transilluminator (cover with sterile plastic glove to

maintain sterile field; see Chapter 13)

3. Roll of 0.5- to 1-inch porous adhesive tape

D. Precautions

1. Aspirate prior to injection of lidocaine to prevent inadvertent intravascular infusion.

2. To avoid severing underlying vein, take care not to

make initial skin incision too deep.

3. Avoid infusing extremely irritating or hypertonic solutions.

E. Technique

Anatomic considerations: The great saphenous vein is constant in its anatomic position, just anterior to the medial

malleolus. It is the only structure of importance in this area.

The cutdown procedure is facilitated by the fact that the

vein lies on tough periosteum and has sufficient elasticity to

allow withdrawal through a small incision without the danger of rupture.

1. Restrain foot in equinovalgus position.

2. Palpate medial malleolus, and locate point of incision

1 cm anterior and 1 cm superior to malleolus (Fig. 27.9).

3. Scrub, put on mask, gown, and gloves, and prepare area

of incision, as for major procedure (see Chapter 5).

4. Drape area.

5. Indicate line of incision by marking skin with sterile

surgical pen prior to infiltration with local anesthetic.

6. Infiltrate skin along line of incision with 0.5 to 1 mL of

lidocaine, and then extend infiltration into subcutaneous tissue.

7. Wait 5 minutes for anesthesia to take effect.

8. Make 1-cm transverse incision through skin, down to

superficial subcutaneous fat. A vertical, rather than a

transverse, incision is optional. The former has the

Fig. 27.9. Position of restraint for cutdown on the great saphenous vein at the ankle, indicating site of incision.

advantage that it offers the opportunity to extend the

incision cephalad, should the posterior wall of the vein

be perforated on the initial attempt at cannulation.

However, it has the disadvantage that it may be made

too lateral or medial to the vein.

9. Introduce curved hemostat into incision, with tip

down. Spread blades of hemostat parallel to vein to

dissect tissue down to periosteum. Continue this

step until adequate visualization of vein is achieved

(Fig. 27.10).

10. Reintroduce curved hemostat into incision, with tip

down, and pass down to periosteum. With a “scooping”

motion, through approximately 180 degrees, isolate

vein and draw into incision (Fig. 27.11).

11. Open hemostat carefully. Spread subcutaneous tissue,

leaving the vein surface clean.

Fig. 27.10. Blades of curved hemostat are spread parallel to

vein to dissect the subcutaneous connective tissue down to the

periosteum.

Fig. 27.11. A curved hemostat is used to “scoop” the vein into

the incision.