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  • • In general, the cutdown procedure is used for the operative placement of an intermediate or long-term central catheter or in an emergency setting when percutaneous access is unachievable.

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• In the emergent setting, a venous cutdown procedure is potentially lifesaving; however, it is considered a last resort procedure and should only be performed by a clinician familiar with the technique.

• With the development of modern vascular devices, a traditional vascular cutdown is less commonly used.

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Absolute

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  • • Infection on the skin over the area of the intended cutdown.

    • Percutaneous access that can be safely achieved.

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Relative

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  • • Bleeding disorder.

    • Coagulopathy.

    • Irritation of skin over area of the intended cutdown.

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  • • Antiseptic solution.

    • Sedative or analgesic.

    • Surgical protective wear (sterile gloves, mask, hat, sterile gown).

    • Tourniquet.

    • 4–6 sterile towels.

    • 10-mL syringe, 20–25-gauge needle, 0.5% lidocaine.

    • 2 scalpels (#10 and #11 blades).

    • 4 × 4 gauze sponges.

    • 1 curved hemostat.

    • 1 forceps.

    • Single-toothed spring retractors (optional).

    • Sutures, 4-0 silk ties (1 package), 4-0 nylon suture with cutting needle (1 package).

    • Needle holder.

    • 2 cutdown catheters (depends on size of child and vein; can use between a #14 and #22 gauge).

    • Sterile dressing.

    • Topical antibiotic ointment.

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  • • Bleeding.

    • Infection.

    • Thrombosis.

    • Arterial or nerve injury.

    • Air embolus, catheter migration or erosion, and arrhythmias (more often seen with central venous access cutdowns).

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  • • Apply eutectic mixture of local anesthetic (EMLA) over intended incision site 30 minutes prior to procedure, and administer morphine or diazepam for sedation.

    • Prepare a large area of skin over the intended dissection site with antiseptic solution and drape the area with sterile towels.

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• The most common sites for possible venous cutdown include greater saphenous, cephalic, basilic, and jugular (in neonates) veins.
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Greater Saphenous Vein

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  • • This vein is the preferred site in emergency situations due to its anatomic reliability and ease of access.

    • Runs slightly anterior to the anterior malleolus (Figure 58–1).

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  • • The knee should be abducted and the ankle turned laterally to achieve adequate exposure of the medial ankle and calf for the procedure.

    • A small transverse skin incision should be made slightly anterior and cephalad to the medial malleolus perpendicular to the vein.

    • With fine dissection, the greater saphenous vein is found in the subcutaneous tissue.

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Cephalic and Basilic Veins

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  • • Both veins can be used for both central and peripheral access.

    • The median basilic ...

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