I Nyoman Semadi

Thoracic cardiovascular devision Department of surgery

Introduction
Venous cutdown was performed in OR, ICU, ER
In shock patient When failure to insert needle for infusion Child more common then young people Difficult to do when the patient small Difficult to care when the patient not cooperative

Purpose
Venous route/line
Give infusion to the patient Fluid resuscitation Transfusion Shock management

Indication
When the patient in hypovolemic shock
When vascular difficult to find through blind needle

injection Operator not experienced in CVC

Contraindication
If less invasive alternative exist
When excessive delay would be required Previous coronary bypass surgery Where hypertonic sol need to be given iv Local inflamation process History on severe PVD Relative : abdominal and lower extremity trauma

Where
Great saphenous vein at medial malleolar and in the

groin Cephalic vein at the wrist Basilic vein proximal and medial to the cubital fossa

Venous system for venous cutdown

saphenous vein cephalic vein basilic vein

Operative procedures
(Kirkham, 1945)
Preoperative evaluation Perpare the skin of the ankle with antiseptic and drape the

area Infiltrate the skin if time permit Apply a tourniquet on the thigh Perform a full-thickness transverse skin incision 2.5 cm over the vein, 1.5 cm superior and 1,5 anterior from the medial malleolus If the vein cannot be seen, the incision should commerce at the anterior border and extend to the posterior border of tibia Identify ofthe vein (blunt dissection), dissect it from the accompanying structures

Continue.......

Take care to separate the saphenous nerve from the vein Elevate and dissect the vein for a distance of app roximately 2 cm, to free it from it bed Ligate the distal, mobilized vein, leaving the suture in place for traction. Donot ligate the proximal on saphenous vein Make a small transverse incision (venotomy) and gentle dilate the venotomy Use standar iv catheter(large lumen) The cannula is threaded into vein, and secure it in place by tying the proximal vein, prevent dislodging Attach the intravenous line to the cannula Stitch the catheter in place and close the incision(skin sutures) Secure the catheter to the skin with adhesive tape after applying topical antibiotic ointment over the incision

Alternative methodes
Shiu, (no dissect)
Seldinger technique (guide wire and dilator), Shockley

et al, Klofas et al

Materials
Needle holder Mosquito hemostat Antiseptic No 11 scalpel blade Sterile gloves and drape IV catheter (large bore) Local anesthetic solution 3 cc syringe with 25 G needle Forceps Intravenous fluid set Silk ligature up Non absorbable skin suture Seldinger guide wire if available Tissue dissection scissors
Tourniquet

Solution for infusion

Crystaloid
Isotonic solution

Complication
Infection Phlebitis Septic (>48 hour: 50-78% infection rises) Hematoma Time consuming (5 menit) Thrombotic occlusion Inability to advance the catheter Incising the vein with the initial skin incision Incorrect placement Injury to the vein (transection)

THANK YOU VERY MUCH