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Common Bed Side Procedures

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VENOUS CUT DOWN
Common Bed Side Procedure No. 3
Section Editor: Prof. T.K. Partha Sarathy

Indications: To gain venous access.
Objective: Venous cut down is indicated when peripheral veins in the upper extremities are difficult to access because of obesity vascular collapse or frequent vein puncture (thrombosis).
Usual sites:

  • Saphenous vein (near medial malleolus of ankle)

  • Anti cubical vein at the elbow (Basilic vein)



Requirements:

  • Observe Universal precautions

  • Preliminary hand wash and sterile gloves (universal)

  • Povidone Iodine paint

  • Sterile drape or Fenestrated sterile towel

  • 11 blade knife

  • 2 small curved mosquito hemostats (artery forceps)

  • 4 - O Silk ties

  • 4 - O Silk or Nylon suture on a cutting needle for skin closure

  • 0.5 or 1 % xylocaine (Novocaine)

  • 5cc Syringe

  • Tourniquet

  • 23 gauge needle

  • Appropriate size placement venous catheters depending on patient (Paediatric/Adult)

  • IV fluid Dextrose in saline or Ringers Lactate. Connected to IV tubing and ready for infusion.

Saphenous vein cut down
Procedure:

  • Patient in supine position with appropriate restraints or holding in case of children.

  • Tourniquet is applied around proximal leg or mid thigh.

  • Prepare the ankle area skin with povidone Iodine solution

  • Place sterile drapes or fenestrated sterile towel exposing the medial malleolus area.

  • Identify location of saphenous vein, at the ankle. The vein is located at a point close to 2 cm anterior and superior to the medial malleolus

  • 0.5% or 1% Novocaine is infiltrated in the skin at this point for about one inch area.A transverse skin incision is made through full thickness of the skin at the selected point.

  • Using a curved mosquito hemostat the tissue planes are carefully dissected till the saphenous vein is identified.

  • Dissect the vein free of accompanying tissue and structures all around for a length of about 2 cm.

  • Now pass a 4-O silk or chromic tie around the vein and tie it at the lower end (foot end) of the exposed vein.

  • Keep the suture ties long enough to help in traction.

  • Maintaining slight traction, the vein is brought to prominence and small transverse incision is made on the anterior aspect of the vein with the point of a 11 blade knife or with a Iris scissors.

  • Release the Tourniquet

  • When the lumen of the vein is opened pass the selected venous catheter gently through it and advance the same as much as possible in to the vein.

  • Blood will seem to flow back through the catheter. Once the air in the catheter has escaped with the filling of the blood, the catheter should be connected to the IV tubing that is kept ready.

  • Another 4-O silk tie is passed below the vein using the hemostat and a tie is snugly tied around the catheter in the vein thereby stabilizing it. Free flow of fluid through the catheter is checked.

  • The long end of the ligated ties are now cut with scissors.

  • After checking for hemostasis the skin wound is closed with 4-O silk or nylon sutures.

  • Antibiotic or Povidone Iodine ointment is applied over the suture line and suitably covered with dressings. The line is stabilized with adhesive tapes.

Anti cubital vein cut down:
Location:

The basilic vein in the anti cubital area (anterior elbow) lies about 2 to 3 cms above and medial to the epicondyle. This is along the line (Parallel) of the bicipital grooves and is suitable for quick cannulation and placement of catheter.

Procedure:

  • Patient in supine position with appropriate restraints or holding in case of children.

  • Tourniquet is applied around mid arm. The skin of the anti cubital area is prepared with povidone Iodine.

  • Sterile drapes are placed to provide exposure to the anti cubital area.

  • The location of the basilic vein anatomically is marked.

  • 0.5% or 1% Novocaine is infiltrated in the skin at this point for about 3 to 4 cm area.

  • A transverse skin incision is made through full thickness of the skin at the selected point for about 3 cm.

  • Expose the underlying fatty layer with a curved mosquito hemostat.

  • The tissue planes are carefully dissected bluntly along the line of the vein.

  • The vein is identified and is freed of adjoining structures and tissues.

  • A 4 – O silk tie is passed around it and is tied distally, keeping the long ends of the tie for traction.

  • With traction maintained, using a 11 blade knife, a transverse incision is made on the vein anteriorly.When the lumen is opened the selected catheter is passed into the vein to the extent possible.

  • The tourniquet is released. Blood will be seen flowing into the catheter.

  • Another tie is passed around the vein and is snugly tied on the vein with the catheter in situ.

  • The IV fluid kept ready with the tubing is now connected.

  • Check for any bleeding in the wound.

  • The wound is closed with interrupted 4-O silk/nylon sutures. Appropriate dressings are given and the catheter is further stabilized with adhesive tapes. The free flow of fluid through the catheter is checked.

Care of cut down I.V.Sites:

Careful attention to the cut down site, by daily sterile dressing is mandatory, particularly in the lower extremities, in view of the increased susceptibility to infections. If any sign of infection at the site is identified the catheter has to be promptly withdrawn.
Complications:
Local bleeding, infection, phlebitis thrombosis and catheter occlusion or dislodgment.

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man23
I'm a 23 year old male,it was only today that I came to know about my paraphimosis. It happened because of my own mistakes,at that time I my foreskin was swollen badly,there was pain. But I didn't tell parents or consulted a doctor because I was ashamed of myself. I know it was a wrong choice. However after 15 days pain was gone,and everything was normal except that my foreskin wont come back on its usual place,and it was stuck behind the glan forming oedema. It's been 6 years, I can do all the normal thing. But my oedema is still there. I want to know if it can cause any problem in future?
man23  Friday, May 31, 2013
shadrack
what can i do as a nurse when the female urethral meatus during cathetherization is invisible.
posted by shadrack kipkorir , from kenya
shadrack  Wednesday, October 13, 2010
Rubenson
what are the problems associated with catheterization

Rubenson  Sunday, September 26, 2010
RAHUL79
I have undergone dorsal slit operation 20 days ago,now the swollen in completely cured however the cut on the foreskin has not healed till now, pls suggest how long will it take to completely heal so that i can go for regular intercourse.RAHUL.
RAHUL79  Thursday, August 26, 2010
worries
I would like ask about this. I have pain in left mandibular if I open my mouth so I just open my mouth not normal. This condition has happened for 2 weeks. what should I do?
thank you..:0
worries  Wednesday, August 04, 2010
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