Pediatric venous cutdowns: utility in emergency situations

Venous access in children can be difficult and, in rare cases, impossible to achieve in a timely fashion. The three methods normally utilized to gain access, peripheral and central venipuncture and venous cutdowns, all require different skill levels for use. However, venous cutdowns, the last resort in intravenous line placement, have no performance standards by which to gauge competence. Therefore, a survey was conducted of the members of the American Pediatric Surgical Association to assess the frequency with which the pediatric cutdown is performed, the amount of time needed for the procedure, and the usual anatomic location where it is performed. Three age groups were included: neonate, one month to five years, and six to 16 years. The performance of five physician groups was also surveyed: pediatric surgeon, pediatric resident, pediatrician, surgical resident, and general surgeon. Results showed that, on the average, 56 cutdowns are done per pediatric surgeon per year. They reported that it took them an average of 11 minutes (range, one to 90 minutes) to complete the procedure in the neonate, eight minutes (range, one to 60 minutes) in the one month to five year group, and six minutes (range, one to 30 minutes) for the six to 16 year olds. The cutdown was found to be rarely used by other physician groups. The time required to complete the procedure, even by experts, makes its use as a first choice in an emergency unrealistic for most clinicians. Utilization of the pediatric venous cutdown, in emergency situations, should be done only by those clinicians familiar with the technique, and only while other methods for venous access are being simultaneously attempted.