Cutdown Placement of IV Catheter in

the Great Saphenous Vein

Modern vascular access catheters and techniques have

made the traditional cutdown largely obsolete. However,

this means of IV access is occasionally required in emergency situations, particularly shock, when time is of the

essence. The saphenous vein at the ankle is the safest,

quickest site for the physician with limited surgical experience. Intraosseous vascular access is an alternative method

of obtaining IV access in an emergency and is described

in Chapter 50. The method described has the advantage

of avoiding incision of the vessel prior to introduction of

the catheter. This is an important advantage in the very

small infant, in whom it is difficult to avoid excessive

venotomy and transection of the vein. Even in the most

experienced hands, the cutdown procedure may take

10 minutes and last no longer than percutaneous IV access.

When other methods cannot be performed, venous cutdowns may provide the only alternative means of emergency venous access.

Fig. 27.5. Result of infusion of lidocaine into subcutaneous tissues of lower limb.

Fig. 27.6. Extensive deep skin slough that required grafting,

caused by IV infiltration.

Chapter 27 ■ Peripheral Intravenous Line Placement 147

A. Indications

1. To provide a route for peripheral IV therapy when the

percutaneous method is not possible

2. To provide a more stable and reliable IV line in situations where even brief cessation of therapy might compromise the infant

3. To provide emergency IV therapy

B. Contraindications

1. Risks and benefits should be weighed carefully in the

presence of bleeding diathesis.

2. Should not be used as routine procedure for starting IV

when percutaneous method is technically difficult but

not impossible.

C. Equipment

Sterile

1. Gown and gloves

2. Cup with antiseptic solution (e.g., an iodophor)

3. Sterile aperture drape

4. 0.5% lidocaine HCl in 2-mL syringe

5. Two 25-gauge venipuncture needles

6. Two curved mosquito hemostats

7. 22-gauge cannula with needle stylet or a short length of

small-diameter (0.6- to 1.2-mm outer diameter) silicone

rubber catheter. The small silicone catheters reduce

irritation but can slow the process of placing the line.

8. T connector for cannula

9. Heparinized saline (for heparin lock).

10. Half-strength normal saline in a 5-mL syringe

11. Absorbable suture or 5-0 nylon suture on small, curved

needle. It is preferable to close the wound with subcuticular absorbable sutures, whenever possible, to avoid

inflammation and formation of suture tracts (7).

12. Needle holder

13. No. 11 scalpel blade and handle

14. Semipermeable, sterile transparent dressing

Fig. 27.7. A: Skin slough on scalp caused by inadvertent infusion into the frontal branch of the temporary artery. B: This is indicated by arrows.

Fig. 27.8. Burn from transilluminator used to locate vein in

antecubital fossa.

A B