BRIEF REPORT catheter, wire-guided; intravenous access

A Modified Wire-Guided Technique for Venous Cutdown Access The use of a guidewire to facilitate the p l a c e m e n t of an IV cannula through a cutdovcn is described. This technique was taught to 24 novice operators (medica] students and first-year residents). In a randomized, prospective, crossover study, their performance of this technique in an animal model was compared with the use of the classic cutdown technique. The modified technique was performed 22% (two minutes, 13 seconds) more rapidly, on average, than the classic technique (P < .05). Other potential advantages of this technique are discussed. /Shockley LW, Butzier D J: A modified wire-guided technique for venous cutdown access. Ann Emerg Med April 1990;19:393-395.] INTRODUCTION Vascular access is often of major importance for the resuscitation of severely ill or injured patients. Yet, percutaneous access may not always be available in patients with peripheral vascular collapse from shock or whose veins are inaccessible due to needle tracks, obesity, or scars.~ Consequently, the venous cutdown technique is an essential skill for all emergency physicians. 1-3 To successfully accomplish a cutdown, two steps must be performed: vein localization and vein cannulation. The anatomic approaches to vein localization have been described, u4 There are several problems inherent in cannulation by the "classic" technique. First, a degree of skill and fine motor control is required. Second, the technique requires time to perform. A survey of pediatric surgeons who perform an average of 58 cutdowns per surgeon per year estimated that from six to 11 minutes were required to perform one cutdown, depending on the age of the patient, s They also estimated that it took their residents more than 20 minutes to perform the same task. 5 The third problem is that the selected vein may become damaged during the procedure (transected, perforated, or adventia dissected), rendering it unusable. Fourth, by ligating the vein, it will never be suitable for reuse should the same patient require another cutdown in the future. Finally, closing the skin over a hastily placed cutdown may increase the risk of wound infection and phlebitis. To avoid some of the problems experienced with the classic technique, a modified wire-guided technique was designed. The purpose of this study was to compare the classic technique with the modified wire-guided technique for the placement of IV cutdown catheters. Inexperienced operators were taught the two techniques and judged on their performance as measured by the time required for successful completion of each technique in a randomized, prospective, crossover study.

Lee W Shockley, MD Douglas J Butzier, MD Minneapolis, Minnesota From Emergency Physicians Professional Association, Fairview Southdale Hospital, Minneapolis, Minnesota. Received for publication June 6, 1989. Accepted for publication October 5, 1989. Address for reprints: Lee W Shockley, MD, Emergency Physicians Professional Association, 7550 France Avenue South, Minneapolis, Minnesota 55435.

MATERIALS A N D METHODS The Department of Emergency Medicine at the Hennepin County Medical Center in Minneapolis, Minnesota, uses an animal laboratory to teach medical students and residents the techniques of surgical airway establishment, thoracostomy tube placement, diagnostic peritoneal lavage, venous cutdown placement, pericardiocentesis, and resuscitative thoracotomy. This study was conducted during those sessions. All of the procedures performed in the skills laboratory have the approval of the Hennepin County

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Annals of Emergency Medicine


VENOUS ACCESS Shockley & Butzier

Medical Center's Animal Use and Care Committee. Mongrel dogs weighing between 16 and 20 kg were anesthetized with an IV injection of sodium pentothal solution (5 g in 200 mL normal saline) at a dose of 1 mL/kg body weight. Then, they were orotracheally intubated and placed on a constant infusion of the a n e s t h e t i c s o l u t i o n , titrated to maintain adequate anesthesia. They remained anesthetized throughout the experiment. Seven groups of medical students and first-year residents, containing three or four persons per group, were taught the classic and modified wireguided techniques to cutdowns as preparation for a regularly scheduled emergency medicine skills laboratory. For the cutdown portion, the femoral veins at the groin were used. Either the classic or the wire-guided technique was used to place a catheter into the right femoral vein. Then, the remaining technique was used to place the other catheter into the left femoral vein. The technique that was used first was determined at random by coin toss immediately before the procedure.

Classic Cutdown Technique Once the vein was selected, the overlying skin was incised. Although some clinicians prefer an incision that is perpendicular to the vein, a parallel incision was used to allow exposure of a longer segment of the vein. Through this incision, the vein was freed by blunt dissection. The second step, vein cannulation, began when the vein had been located in the wound. It was cleaned from its surrounding subcutaneous tissue by blunt dissection elevated on a clamp. Two suture ligatures were passed around the vein, and the distal ligature was tied. A small venotomy was made with a scalpel or small iris scissors. The cannula then was placed through this v e n o t o m y into the lumen and threaded proximally. The proximal ligature was tied, and the skin wound was closed with sutures. Although various materials have been used as cannulae, including standard IV catheters, pediatric feeding tubes, pulmonary artery introducer catheters, and sections of sterile IV tubing, standard 16-gauge IV cannulae without their needles were used. Detailed instructions in this classic technique have been pub84/394

lished.l,2,6 8

The vein was located and prepared as in the classic technique. A clamp was inserted under the vein to elevate it in the wound. The clamp was used as a stage on which the remainder of the surgery was performed. By tipping this stage, the lumen of the vein can be compressed or opened to either control bleeding or allow passage of the catheter. A small venotomy (1 to 2 mm) was made in the side of the vein with an 11 scalpel blade or an iris scissors. A large catheter with its dilator and straight introducer wire (8.517, 6.35-cm catheter with dilator and its 33.3-cm introducer wire - the Arrow Rapid Infusion Catheter Exchange Set) then was admitted into the venotomy. The wire-dilator-catheter unit had been assembled before making the skin incision for greatest time efficiency. As the wire-dilator-catheter assembly was passed into the lumen of the vein, the v e n o t o m y was dilated to fit the catheter. The wire and dilator then were removed from the catheter. The infusion tubing was connected to the catheter hub, and the infusion was initiated. After the infusion had begun, suture ligatures could be passed if necessary to control bleeding around the venotomy. If the vein was damaged or transected during the initial incision or dissection, this technique could still be used to salvage the cutdown. The proximal stump of the transected vein was lifted with a fine pick-up. The wire-dilator-catheter assembly was advanced into its lumen. Ligatures were required around the catheter in the vein and the distal stump to control bleeding. The times required to successfully accomplish the tasks were measured. No hands-on assistance by the instructor was allowed. At the end of the skills laboratory, the animals were euthanized with an IV injection of potassium chloride while still under anesthesia. The mean times required to complete the procedures by each technique were compared for statistical significance by the Wilcoxon signedrank test. 9

ical students and residents participated in the experiment and were taught these techniques. The classic technique was chosen randomly first in four sessions; the modified wireguided technique was chosen first in the other three. However, during the initial incision in a planned classic cutdown in one session, the vein was transected; therefore, placement of the catheter into the vein by the classic technique was not possible. This was judged as a failure for that technique, but by using the modified wire-guided technique, the vein was cannulated successfully in nine minutes, 36 seconds. The remaining femoral vein of this animal was cannulated by the classic technique. In another animal, after placement of the catheter by the classic technique, an additional ligature was required for hemostasis. In one of the cutdowns performed by the modified technique, a ligature was required for hemostasis. In this study, the students and residents were able to successfully cannulate the femoral vein of the dog using the classic technique seven times, with one failure, as described. This required times of from five minutes, 50 seconds to 15 minutes, 43 seconds; the mean time (± SD) was ten minutes, 11 seconds ± three minutes, 20 seconds. The same students and residents were successful using the modified wire-guided technique in all seven attempts, including the one judged to be a failure for the classic technique. The time required for successful completion of the cutdown by the modified t e c h n i q u e was b e t w e e n three minutes, 55 seconds and 11 minutes, 26 seconds in six of the seven animals with a mean (± SD) time of seven minutes, 58 seconds ± two minutes, 31 seconds. The seventh cutdown required 16 minutes, 12 seconds to perform using the modified technique due to an anatomic anomaly in that particular animal that made localization of the vein difficult; after the vein was located, cannulation required less than two minutes. If this seventh time is included, the mean time required to perform the modified cutdown (± SD) was nine minutes, eight seconds ± three minutes, 53 seconds.



Modified Wire-Guided Technique

During the seven sessions, 24 reedAnnals of Emergency Medicine

The placement of an IV cannula by 19:4 April 1990

a c u t d o w n m a y be a difficult task at times. 2 A n y t h i n g that can make this procedure easier to learn and easier to perform is valuable to the emergency physician. In this study, novice operators were taught the modified wire-guided technique in a single laboratory session. T h e y were able to perform the procedure w i t h o u t fail in all of their seven attempts and found that it was easier to insert a small wire into a v e n o t o m y than it was to insert a modest-sized catheter. T h e m o d i f i e d w i r e - g u i d e d techn i q u e was an average of two m i n u t e s , 13 seconds faster (22%) than the classic technique (not including the one prolonged t i m e that was due to difficulty i n vein localization). The difference i n t h e t i m e s r e q u i r e d to successfully complete the task by these two methods was statistically significant (P < .05). Experienced operators may have different results when c o m p a r i n g t h e t i m e s r e q u i r e d for t h e m to perform the two techniques. The potential problem of the wire being inserted into the vein wall and dissecting the a d v e n t i a rather t h a n being i n s e r t e d i n t o the l u m e n was not encountered in this study, This c o m p l i c a t i o n should be avoidable if care is t a k e n to ensure that the venot o m y does, i n fact, extend i n t o the l u m e n . Further, the potential for perforation of the posterior wall of the v e i n is c o n s i d e r a b l y less w i t h the wire than w i t h a large beveled needle as described i n the 10-gauge, catheter-over-the-needle technique, lo T h e m o d i f i e d w i r e - g u i d e d techn i q u e proved to be v a l u a b l e i n salvaging a c u t d o w n that was complicated by a l a c e r a t i o n to the vein. This near-transection made completion of the procedure impossible by the classic t e c h n i q u e . However, by abandoning this technique in favor of the modified wire-guided technique, the c u t d o w n could be completed in

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less t i m e t h a n the average t i m e required for the classic technique. By using a wire-dilator-catheter assembly, the v e n o t o m y and l u m e n of t h e v e i n c a n be d i l a t e d to a l l o w p l a c e m e n t of a large-bore catheter. This has advantages for the rapid adm i n i s t r a t i o n of large q u a n t i t i e s of fluids. T h e 8F catheter has roughly the same flow rate as c o n v e n t i o n a l IV tubing, ll Simply by gravity feed, flow rates of more than 245 m L / m i n can be achieved w i t h this catheter.12 T h e m o d i f i e d w i r e - g u i d e d techn i q u e uses only vein ligatures to control bleeding if necessary; this has two p o t e n t i a l advantages. First, one step i n the procedure is e l i m i n a t e d or at least avoided u n t i l after the catheter is in place and connected to the resuscitation line. Second, by not ligating the vein, it has a good chance of r e c a n n u l a t i o n after the catheter is removed. Sparing this valuable vein m a y m a k e it available in the future for another c u t d o w n if necessary. Also, by not closing the skin after p l a c e m e n t of the c a n n u l a i n t o the vein, another t i m e - c o n s u m i n g step is avoided. It is faster to place a sterile, m o i s t saline dressing over the w o u n d and to treat by delaying primary closure and s u t u r i n g the w o u n d in four or five days if there are no signs of infection. 13 A l t h o u g h n o t addressed i n this study, this practice also m a y reduce the i n c i d e n c e of local cellulitis and phlebitis. CONCLUSION The v e n o u s c u t d o w n r e m a i n s an essential skill for the emergency physician. The modified wire-guided t e c h n i q u e has several p o t e n t i a l advantages over the classic technique. In a randomized, crossover study inv o l v i n g i n e x p e r i e n c e d operators, it proved to be as easy to l e a r n a n d faster to perform. Although a clinical trial to investigate the clinical signif-

Annals of Emergency Medicine

icance of the technique was not cond u c t e d , its p o t e n t i a l for ease a n d t i m e saving m a y make it a valuable a d d i t i o n to t h e e m e r g e n c y p h y s i cians' a r m a m e n t a r i u m . The Arrow Rapid Infusion Catheters used in this study were kindly donated by the Kolfing Company, Burnsville, Minnesota.


1. KnoppR: Venouscutdownsin the emergency department. JACEP 1978;7:439-443. 2. Wax PM, Talan DA: Advances in cutdown techniques. Emerg Med Clin North Am 1989; 7:65-82. 3. Talan DA, Simon RR, Hofhnan JR: Cephalic vein cutdown at the wrist: Comparisonto the standard saphenous vein ankle cutdown. Ann Emerg Med 1988;17:79-83. 4. Simon RR, Hoffman JR, Smith M: Modified new approaches for rapid intravenous access. Ann Emerg Med 1987;16:67-72. 5. lserson KV, Criss EA: Pediatric venous cutdowns Utility in emergencysituations. Pediatr Emerg Care 1986;2:231-234. 6. Dundrick SJ, Daly JM: Performinga safe successful venous cutdown. Hosp Phys 1974;11: 34-37.

7. Kirkham JH: Infusion into the internal saphenous vein at the ankle. Lancet 1945;2: 815-817. 8. Posner MC, Moore EE: Distal greater saphenous vein cutdown - Technique of choice for rapid volume resuscitation. J Emerg Med 1985;3:385-399. 9. Hill AB: A Short Textbook of Medical Statistics, ed 10. Philadelphia, Lippincott Co, 1977, p 134, 315 10. HansbroughIF, Cain TL, Millikan JS: Placement of 10-guagecatheter by cutdown for rapid fluid replacement. J Trauma 1983;23:231-234. 11. Millikan JS, Cain TL, Hansbrough J: Rapid volume replacement for hypovolemicshock A comparison of techniques and equipment. J Trauma 1984;24:428-431. 12. Dailey RH: Use of wire-guided (Seldinger type) catheters in the emergency department. Ann Emerg Med 1983;12:489-492. 13. Zukin DD, Simon RR: Emergency Wound Care Principles and Practice. Rockville, Maryland, Aspen Publishers, Inc, 1987, p 75.


A modified wire-guided technique for venous cutdown access.

The use of a guidewire to facilitate the placement of an IV cannula through a cutdown is described. This technique was taught to 24 novice operators (...
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