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Persons with psychological nonepileptic seizures (PNES) pay a price when they are improperly diagnosed. There is an average of 7 years delay between the onset of seizures and the correct diagnosis of PNES.1 During that time, while they are being treated for epileptic seizures (ES), patients are prescribed antiepileptic drugs (AEDs) that do not treat their disorder. When their seizures do not abate, they are prescribed more AEDs, sometimes to the point of toxicity. They also undergo repeated testing, typically with multiple EEGs and neuroimaging studies. Over time, the tangible and intangible costs add up for the patient, the medical system, and society. The person with PNES has an estimated $100,000 lifetime cost for diagnostic tests, procedures, and medications.2 Of the 1% of the US population with epilepsy, 5 to 20% actually have PNES. Repeated workups and treatments for what is mistakenly thought to be epilepsy are estimated to incur $100 to $900 million per year in medical services.2 The risk to the health of the person with PNES is considerable. Aggressive treatment to stop the seizure sometimes results in oversedation requiring paralysis and intubation. Other risks are posed by toxic medication levels, pic lines, venous cutdowns, vagal nerve stimulator placement, and evaluations for temporal lobectomy.3 Vocational costs …

Pseudoseizures are often misdiagnosed. We report a patient with pseudostatus epilepticus who has had 27 venous cutdowns on different occasions when she was admitted to hospital with repeated seizures.

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.

Venous cutdown is an essential skill for emergency physicians. Trauma patients in hypovolemic shock with peripheral venous collapse should have one upper and one lower extremity cutdown with large-bore catheters to facilitate fluid replacement. The greater saphenous, basilic, cephalic, external jugular and brachial veins are compared for advantages and disadvantages as cutdown sites. Knowledge of the anatomy is critical in performing a cutdown and avoiding injury to other structures in the area. A protocol describes a method for safe, rapid venous cutdown.

Thirty-five preterm neonates that had 42 central venous lines placed via saphenofemoral cutdown in the groin are reviewed. The mean gestational age was 29 weeks; mean birth weight 1,320 g. There were no catheter-associated deaths. Minor complications occurred in 50% of patients. Leg swelling (43%), catheter occlusion (12%), and catheter fluid leakage (10%) were the most common. Infections were minor and occurred in 8% of the cases. We believe this study shows the effectiveness and safety of the saphenofemoral cutdown for central venous access in the premature neonate.

We studied the venous system at the groin, ankle, and antecubital area in relationship to easily palpable or visible surface landmarks, and developed new approaches or modifications of existing approaches to localize the saphenous vein at the groin, ankle, and the basilic vein in the antecubital area. A prospective crossover study comparing these new cutdown techniques with the most commonly described traditional techniques, was performed, using inexperienced medical personnel. They were divided into two groups, and the average time to successful venous isolation with each method at each of the three sites was studied. Both groups were similar in that all participants were medical personnel (interns, flight nurses, an equal number in each group) who had not previously performed venous cutdowns. In each group, at, all sites, the new cutdown techniques resulted in a more rapid isolation of the vein. This was true in each case regardless of which technique was learned and attempted first.

INDWELLING plastic catheters placed by venesection ("cutdown") have become commonplace in the treatment of seriously ill patients in nearly every field of clinical practice. Cutdowns are utilized primarily in two settings: in emergencies or at surgery when a dependable intravenous route of large caliber is needed; and, more commonly, when intact superficial veins are no longer available for needle puncture in the course of prolonged hospitalization. Septic complications of cutdowns are frequent, ranging from local suppuration and phlebitis to systemic infection, and have been documented to some extent in the literature.1 2 3 4 5 For example, in a study from this hospital describing . . .