A1.2.4 Venous cut-down and insertion of naso-gastric tube

This is less appropriate if speed is essential.

  • Immoblize the child’s lower leg, and clean the skin, as described above. Identify the long saphenous vein, which lies half a fingerbreadth (in the infant) or one fingerbreadth (in the older child) superior and anterior to the medial malleolus.
  • Infiltrate the skin with 1% lignocaine, and make an incision through the skin perpendicular to the course of the vein. Bluntly dissect the subcutaneous tissue with haemostat forceps.
  • Identify and free a 1–2-cm strip of vein. Pass a proximal and a distal ligature.
  • Tie off the distal end of the vein, keeping the ties as long as possible.
  • Make a small hole in the upper part of the exposed vein and insert the cannula into this, while holding the distal tie to stabilize the position of the vein.
  • Secure the cannula in place with the upper ligature.
  • Attach a syringe filled with normal saline, and ensure that the fluid flows freely up the vein. If it does not, check that the cannula is in the vein, or try withdrawing it slightly to improve the flow.
  • Tie the distal ligature around the catheter, and then close the skin incision with interrupted sutures. Fix the cannula to the skin and cover with a sterile dressing.