Difficult Vascular Access- Basic to advanced devices - Dr Vibhavari Naik

Added: 2026-05-30

[00:00:00]series session 7 and today it is a great honor for us to have Dr. Dr. Vibari ma'am with us this evening. She's a senior consultant enco anesthesiologist at Baswvataram Indo-American Cancer Hospital and Research Institute Hyderabbad.

[00:00:19]She is widely reputed for work in encothesia, pediatric anesthesia and simulation training.

[00:00:26]Ma'am as we all know is an inspiring chief speaker a passionate academician.

[00:00:30]She has delivered more than 200 lectures at national and international forums and contributed extensively to numerous publications and book chapters. At present she is the clinical lead of world federation of society of anesthesiologists and today's topic selected by her difficult vascular access from basics to advanced vascular devices is highly relevant and highly useful for our daily clinical practice. and our esteemed moderators for today's evening Dr. Raanapraasad S professor Gaitri Vidya Parish Medical College Dr. TDP sublaki ma'am professor and head of the department Government Medical College Sriaklam and Dr. Vijay Khans head of the department of anesthesia omni hospital sushaka patatnam I'm sure the guidance and experience will further enrich this academic session also thankful to all the delegates for joining us this evening and request them to actively participate and make this session interactive and academically rewarding.

[00:01:35]I now hand over the proceedings to the moderators for the evening.

[00:01:43]Madam welcome madam. We are looking forward to an enlightening session from you.

[00:01:49]Uh over to you madam. Please you can start madam.

[00:01:55]>> At the outset I just want to thank uh Dr. Vid Kumar for uh inviting me. I think uh we've been in touch earlier because we were planning some airway session and which did not work out but I'm hoping that uh we are able to do that workshop soon and thank you subakshmi madame braasad sir and Dr. Vijay Khan um for moderating the session.

[00:02:25]Today I would want to cover a topic that is uh extremely close to my heart. I just want to check the slide is visible and is in full screen.

[00:02:36]>> Yes ma'am.

[00:02:38]>> Oh okay perfect. Right then uh I bring greetings from Basataram Indo-American Cancer Hospital and Research Institute. Um for those of you who don't know this is a 600 bed standalone cancer institute in Hyderabad and we do about 8,500 major cancer surgeries every year. uh our department caters to enco anesthesia, surgical critical care, pain as well as palative medicine and we run enco anesthesia fellowships as well as FNB in encothesia and we also have DNB in paliative medicine.

[00:03:16]Okay. So now let's I I think the most important question here is why are we talking about vasces?

[00:03:27]Baselaxis is definitely important for all doctors and nurses but it is the primary skill set for us as anesthesiologists and uh often we are called as the uh vein specialists when uh no one in the hospital can find a vein they start looking anesthesiologist. So we are considered masters in secular access particularly when it is difficult and hence each one of us I feel has to be has to have the knowledge and the skills of anything and everything that's available for vascular access right basic devices basic techniques to the advanced and that's what we are planning to do here today however I feel that uh there are so many seniors in here. Uh I would really like to listen from seniors uh because each one has their own uh you know so I feel that the more we share the more we learn. So please I would really want to listen to your experiences session is over.

[00:04:42]I feel that vascular access is not just about knowledge, skill, science, but it's an art. It's an art to know when to do what beyond what the science tells.

[00:04:55]And let's see, let's try few of those aspects today.

[00:05:01]Talking about difficult vascular access the difficulty can be uh can be in a wide variety can be very diverse. It can be because the skin is dark the patient is obese or there is a demma. It can be because the skin is unhealthy. It can sometimes be also the patient is hypoalmic which means the veins are perfectly fine. But because the patient is hypoalmic, you are unable to pandmate that patient. Sometimes it is unexpected and sometimes just wrong judgment. So let us try. So I'm going to videos, photos. I think most of my presentation is all about that and I hope uh that it rings some bells and uh it helps you learn at least a few things already know.

[00:05:55]Let's begin talking about the peripheral venus axis. Now just to give you an example uh say a 5-year-old girl is is posted for some simple surgical procedure and uh the child refuses IV can run. Now in my horse is the practice um when the when children are posted for procedure either uh we ask them and they agree to it. If they don't we take them in for inhalational induction. So veins look doable. It wasn't a difficult airway. So we took the child inside and this is how we went about inhalational induction. Typically the way it is done putting 8% SEO florine and uh getting the patient engaged on a video. I was recording this video on the phone while she was watching herself and then she fell off to sleep.

[00:06:46]A busy Monday morning. I jumped up quickly to put in an IV candler, my assistant helping me, but I failed.

[00:06:56]So, what could be the causes?

[00:06:59]Now, I think there are some basic rules that I want and and most of this presentation is actually directed to postgraduates. So the seniors in there please excuse me when I start talking about very uh basic things. So for the PGs I wanted to say that children when they have longer fasting intervals these children can have veins collapsed and as I mentioned earlier hypoalmia can make candidate even if there is a vein what will happen is you'll tend to counter puncture it and to canulate it properly.

[00:07:33]Also remember that when you put on seo floren directly to 8% though it provides faster induction it it has a more propensity to collapse the veins. So it's very important that you maintain that balance start with 5% first and then gradually increase.

[00:07:57]What we also need to understand that longer or gradual increase in percentage can uh increase the time that uh you need to take for canulation because if you the child can go into spasm right and you do not have an IV access yet so what is an optimal time for canulation if you're doing an IV induction so this is just uh what is available and also So what I have experienced in my practice that if you have a gas monitoring you can look at SE concentration person if the entital SIBO has reached 2% most of the times the child will not move when you pick the child now if you do not have entitle SIBO then could go time based and if you're using only SIBO florine oxygen as a mixture it could take more than 3 minutes to achieve that depth after the loss of eyelash reflex in a child. If you are adding nitrous oxide to it, maybe you've given some oral premedication to the child, then this time gets reduced to minutes.

[00:09:13]If you've given dex and the reason I mentioned is that I know many started using dex as a premedication in children, then this further reduces to around 1 and 1/2 minute. But remember to give sufficient time so that when you puncture the child doesn't go into spasm right but um important point also here I wanted to say is that this time could actually be lesser if the child is sicker but a sicker child definitely has an IV access so not very relevant here.

[00:09:50]Now another important point which is very simple is the way you hold the hand. The way you are doing it. Are you standing? Are you sitting?

[00:10:01]If the blood flow through gravity if the hand is falling downwards. If you're sitting temperament really matters. The chance of success increases.

[00:10:16]Also, there are many veins that require the love and attention. For example, when I lifted this hand, the vein wasn't really visible. But look at the way I'm holding it. I'm I'm giving it like squeeze, release, squeeze. I'm I'm not holding it continuously. Because in children what happens is if you hold it continuously and give more than probably the uh arterial uh flow that allows into the limb your vein is not going to get prominent. I like to perform the squeeze stop squeeze stop action and then of course uh rubbing alcohol swab is useful and if the child is very cold particularly in the the hand will also be useful now I was mentioning about the tunic be very careful if you're using tunic in children because if the tunic is you may never get the vein dilated because the arterial blood flows is going to be occluded to the vessel. So one way to do it is if someone is holding or you've applied a ton feel the pulse nice and bounding it is appropriate. If you're feeling it feeble you have to loosen it also instead of tunic for younger children infants and sometimes even neonates your your index finger itself can become the tunic. So this is how you need to wrap the index finger around the hand and the thumb offers the second support.

[00:11:51]The thumb also allows the skin to be stretched and this is the way you're going to hold the hand before you canulate.

[00:12:01]Now we often use 24 gauge or 26 gauge uh canulas for younger children, infants as well as neonates. But we need to remember that there's amount of needle that protrude outside the catheter and that actually we have to ensure that the needle as well as catheter enters the vein before we start uh pushing the catheter inside.

[00:12:30]Sometimes the skin if it is thick it will shear the canula before it enters.

[00:12:36]So what I prefer doing is to give a nick. So as you can see in this video I'm using the canla I give a nick so that the skin is open and then I am using it again to enter because if you do it just one time then the skin might get held the catheter might get held levels give the nick and then enter and as you saw the index finger can be used to occlude the vein while you remove these still and push uh saline in there. Now I think the best thing that has happened with the mobiles coming in and particularly children getting addicted is that a lot of times we are able to put candlas without the child realizing at all. So, it's an extremely useful technique and I'm sure uh even you have used it with uh the child's most favorite videos being played while you're securing an IV camera. There's also another device that's available on Amazon and that's called the Buzzy. It creates vibration so that the pain sensation with canalation is significantly reduced.

[00:13:57]Traditionally, we've used uh local anesthetic creams uh to apply to reduce the pain. But remember the duration that you need to wait and this could be as long as 45 minutes or I have noticed that sometimes if you're using the pryilox which is the pyloane combination of local anesthetic cream, it induces vazo constriction. So a vein that looked probably uh doable can actually become vazoc constricted. So we've actually uh stopped using local anesthetic creams in our practice because of this side effect.

[00:14:38]Um it's very very important that we know the anatomy of the veins the way they run the venus flexes dorsal venus flexes both on the hand as well as the legs. So that some of these veins can become lifesavers. So as you can see on the leg or probably even this the one that runs over the thumb. However, let me tell you that they can just be something that you begin fill up the patient and then transition onto something more stable.

[00:15:13]Putting IV lines on joints and at such peripheral locations particularly on the leg is not recommended because if you put a peripheral venus scan law on a leg for a longer duration it is going to increase the risk of DVT. So that should be avoided.

[00:15:31]Now talking about devices, infrared devices are ex extensively available in the market and you can see uh these uh red light emmitting devices uh that are um there but uh in literature as well as in my practice I feel they are not very useful and the reason I feel is that one um they can identify really only very superficial veins. So if you really uh make a good tap and you know you u try and uh make them more prominent you might be able to pick them up and you may not really need the um the red light device. Also the accuracy can sometimes just be 0.25 mm which means it can be slightly this side or that side through what you can see. Though it's found to be helpful for dark skin, I feel there are a lot of artifacts like here there is some depression and that has got picked up like a vein. So there is no vein here. Okay, there is no vein but there is a depression and it can falsely be seen as a vein. So I think these devices are not very useful.

[00:16:50]Something that I have found more useful than these devices is this app. So this is a vein scanner pro app that is available on a phone. It's available both on iPhone as well as Android version. Let me say that I have no financial interest in this uh app. But when you put the flashlight with this app on it looks something like this. So this is my phone. This is the way I'm holding the hand and look at the difference between here and here. So uh it helps identify veins by the same principle probably that the red light filter is used and uh so I feel these are slightly better than the um the red light devices that are available but my personal favorite is trans elillumination and we have this device it is called as the otica it's available on Amazon probably for 1,500 or 1,800 rupees but it's significantly ly helps highlight the vein. So you can see this hand and the way it has got trans illuminated. You can also identify that probably there was some vein punctured or earlier for this child. So this part of the vein is not welldeveloped. It not just allows you to look at the vein, it also helps you assess pilling. Which means if you use the harvest technique, you know, two-finger test, you spread it across from release, you will know whether this vein is thrombos or whether this vein is allowing filling patency. Okay. So I think that also is allowed uh by transillumination.

[00:18:34]Now the only disadvantage with trans elimination I feel is that assessing the depth is a challenge. You can see where the vein runs with pretty precision but the vein could be deeper or maybe superficial and it may be difficult to identify that. So I have a video here to show and as you can see I can see a vein I'm entering there but I did require to change the depth a bit before I could enter the vein. So assessing the depth can be a little difficult. You may have to try it gradually in different planes to get your depth correct.

[00:19:16]This is one trick that I use whenever someone is hypolaying. What happens when uh when when there isn't enough blood filled in the vein is that even when you're correctly positioned in the vein there may not be adequate backflow. So one way to avoid that is to fill in some saline in the hub.

[00:19:42]Pine drop into the hub it actually reduces the surface tension. The moment you enter the vein, you will start getting back flow through the up. And this is I feel a useful technique especially when uh the patient is hypoaming.

[00:20:01]But I'm sure all of you will agree ultrasound has been a gamecher and with more and more ultrasounds being available at more and more hospitals every time I meet someone whether it is a or a third uh even in hospitals I know government hospitals in Hyderabad also have uh ultrasounds. So I think uh it's a very very useful uh uh device. However, it requires some good practice if you're going to use it for a peripheral venus scanation. So let me just take you through what are the important aspects. We are often more used to using an ultrasound machine for doing a block. But whenever we use ultrasound machine for a block most of the time we'll use an in plane approach which means that the needle runs parallel to the surface such that we are able to see the entire length of needle but most of the time when we are doing the using the ultrasound for vascular axis it is out of plane. So what happens is at a point of time you're able to see only one point and this is actually what needs precision requires the coordination of your right hand that is moving the needle of your left hand that moves the probe to and fro to catch that point and uh that's what I'll try and explain in the next uh couple of slides. So as you can see fanning of the ultrasound you know moving front and behind is important as this needle is advanced so that we are able to capture uh the needle tip exactly the way it moves into the vessel. It is also called as the vanishing target sign which means at one point you are able to see the tip as a bright white spot and then you move the ultrasound away and it disappears. So it has vanished. Then you move the needle ahead so that you again look at you get to see this bright spot. So it is the target sign again. So it's it's shuttling between these two that will help you keep the track of the needle tip in the vein. And I'll show you a few examples. Now I'm going to show you a video of ultrasound guided canulation.

[00:22:34]Please remember that hand hygiene is extremely important. Also it is important that you not just clean the skin with chlorhexidine but you also clean the probe with chlorhexidine because the candla tip and the probe can be very close to each other and you can use sterile saline as an interface instead of using jelly when you're canulating the vessels. I also like to measure the dimension of the vein. So any vein you select you measure the dimension and based on the dimension you're going to select the gauge of the canula and these are some of the uh canula gauges and their outer dimensions that I have mentioned and uh you should try and avoid having a canula that is more than third in the vein because if your canula occupies more than 2/3 third of the vein it will not last longer also the blood flow gets completely occluded so there is more chance of stasis so remember 2/3 it should occupy in the vein and not more than that now just to give you an example uh we had a very chubby child and uh there was lot of difficulty in finding veins so I decided to use ultrasound and there was a vein but look at the depth it's like almost close to a cm deep and we kept giving giving some glue on D for this child so that we could get the child to cooperate while we are doing the procedure and here you can see the canula coming in and now it is just entering the vein as you can see the bright spot inside this vein and then as I'm moving it the I'm actually doing the vanishing target sign uh very closely and then once I feel that at least half a cm or more is entered. See this child is so hypoalmic. There was hardly any backflow. I had to fill up the hub again with saline so that I could flush it. So uh this was just a video to show you how in a very difficult uh peripheral venus axis in a child uh you can do an ultrasound guided canulation.

[00:24:55]One more favorite vein that I have is the external jugular vein.

[00:25:00]You know, most of the veins over the hands or the legs uh may not be good, but external jugular vein often uh stays by your side. Particularly if you've forgotten to take a little wider bore axis and it starts bleeding, then external jugular vein is right there close to you so that you can quickly secure it. Uh there are some rules though. Always bend your canula. Always bend your canula before you do this axis because it runs very close flush to the skin. And if you do not bend the canula, you are likely to counter puncture. So bend the candla. The moment you enter the vein, lift the skin and the vein as you advance it and then uh it'll help you successfully canulate the external jubila vein. Also if the patient is awake you can ask for a waver. It helps further distend the external jugular vein.

[00:25:58]Again elderly patients another group where the vein may be very nicely seen but every time you puncture it >> it'll blow out you know because the veins in elderly patients are extremely fragile. So one when you're making it prominent do not rub the skin very hard.

[00:26:19]Do not make it too prominent. Do not tie the tunic very tight because if the pressure venus pressure in the vein increases or if the vein becomes too engorged the moment you hit your needle hits even before you've entered the catheter inside the vein it's going to start blowing out. Okay. So these are some of the tips. Remember to stretch the skin well. Sometimes these veins can roll and your canula can move on the either side. So fix the vein. Stretch the skin. Fix by just touching the vein and then push it quickly inside. Okay.

[00:27:01]So that's how you do it. Some more tips from my kitty. I feel applying this reverse tunic. You see that I'm actually trying to pull blood that is pulled in the entire arm and this can be particularly helpful for ICU patients who are lying for some time and who may have some. So I'm applying a reverse tiki so that there is some blood collected in the distal part so that I'm able to find some vein.

[00:27:29]One more thing, if yourself or someone else has already tried a canla but they haven't got it because the veins slip, do not remove that canla at that point of time. Leave that canva in place and try the vein again from provided the vein is not punctured by at another site uh with another canula. And the reason is one if you pull out the canula it will start bleeding from there and you may have to you know keep holding it for a much longer time before you can try and access that vein. Second thing is uh a canula that is close to the vein actually helps stabilize the vein. So the puncture with the second canula if you leave this first canula in place will be much more um successful is is what in my practice.

[00:28:26]Okay. Now I have a question. Is it okay to take a peripheral venus at a paralyzed arm?

[00:28:36]that I'm not really going to wait might get missed but the current consensus says that it can be used but it should be monitored closely until a suitable access is secured. So this is what the recent literature says.

[00:29:01]Now another important question particular Patients do undergo breast surgeries, axillary dissections. Is it okay to take a peripheral venus axis on the side of breast surgery after the surgery has been done for that patient? Well, typically while learning I was taught that we should not take uh can we should not do canulation on the side that auxiliary dissection has been performed. However, recent evidence shows that its lateral arm can be used for short duration canulation. Another thing there are many patients who have been told that do not get blood do not use NIDP on that side you know because there can there is a risk of lympadema.

[00:29:55]Uh but recent literature says that NIDP measurement can be done and even IV canation can be done for short duration if required provided provided there is no lympidma on that hand. one. Second, more and more surgeries these days are sentininal node biopsies. So the incidence of complete axillary dissection has come down. So with more and more sentininal node biopsies, the concern of developing lympidma has significantly come down. So if a patient does not have a lympidma one year after sentininal node biopsy on the same side or 3 years after axillary uh lymph node resection then it is safe to put an peripheral axis on that side. Okay.

[00:30:53]Remember that whenever you are canulating the epsilateral site maintain all as septic precautions and use the shortest duration that uh is recommended which means within 24 hours uh beyond that you should not uh pain.

[00:31:12]Okay. Now we've talked a lot about peripheral venus access.

[00:31:18]However, there are other accesses and devices that we as anesthesiologists need to be aware of. And now I'm going to take you through something that's called the midline catheters or midline devices which are also peripheral venus axis. And then move on to central venus axis. Talk about the pick lines, the standard central lines which are nonpled ones. We'll also talk about the tunnel central lines which is the hickman catheter and implantable port which is typically seen in patients who require very long duration of vascular access like for cancer patients and then quickly touch upon intracious axis before we close on for today.

[00:32:06]Now let's talk about midlines and there's also something that is called as the mini midline. So let us see what they are. Now if the Venus axis is difficult and you think that a little longer duration access may be required say maybe 1 week 10 days but you may not get veins again and again for a patient you may have to opt for mix.

[00:32:46]So mid lines are typically put in the deeper veins of the arm.

[00:32:53]And when it comes to forearm, we call them mini midlines. So if we talk about the deeper veins of the arm, there is a basilic vein on the medial side and there are brachial veins along the bra and there's also vein on the lateral side. So whenever you put a line in these deep any one of these deep arm vein and the tip of the catheter is in the central position you call it a P catheter that is periphally inserted central catheter. But if you put a longer line in this vein something that does not reach the central location it is called as the midline. So needless to say the pick lines are longer than midlines. pick lines also last longer as compared to midlines.

[00:33:48]So here is a midline that I will show a video. Uh we typically like this child was a child who's undergone neurosurgery and was structurized required antibiotics for a little longer duration. So midlines are typically used whenever you need to give antibiotics, antifungals which are typically required for uh two to three weeks or sometimes even four weeks. If some patient has osteomiitis you would want to give antibiotic for 4 to 6 weeks. So these are typically the indications of midlines. So as you can see I'm using an ultrasound to screen for the deep veins and here is the brachial artery that I have highlighted through the Doppler and just next to it is the brachial vein. So this is a midline that I'm going to use and as you can see uh I've given some local anesthetic after identifying the vein and here you can see the needle coming in as I'm tracing the tip and this is the vein where I'm targeting. So it has come and it has entered the vein.

[00:34:55]The moment it has entered we reduce the angle of the needle and push in the guide wire. I always like to confirm that the guide wire as you can see coming down here is correctly located in the vein. See this is the vein and this is the bride guide wire. So the position is correct and then the needle itself is used to make a small nick. A dilator uh is used so that the insertion of the catheter is easy. And this is how once we put it, we check the flow and we fix it. Uh for this case, we have done a Cam but that's not really required. Um this is how we would fix it. This fixation is actually a sutureless fixation. Okay. So we just a clip. We put the two wings.

[00:35:46]The holes are there in the wings. We put it in the clip and we fix it like this.

[00:35:51]It's also important to label it as midline because it can get confused with a pick line unless uh you have documented it in a chest X-ray and labeled it of course. Now talking about mini midlines. Now mini midlines as I said are something that you would put uh in the forearm veins and typical veins are the capilic and the basilic veins. Sometimes the midline vein of the forearm also can be used and these are long peripheral uh IVC's. So Helen hermir is one company uh that produces it and it is something that looks like this because it is long um they have given an extra flange here so that we can hold and grip it comfortably otherwise putting something with a very long we may not get that uh precision while we are uh inserting. So that's the reason why it is given and midlines typically would last for about one to two weeks and often uh we prefer he keic vein in the forearm to put this and you should avoid putting it on the joints. So I have a video here to show you how we are putting the mini midline.

[00:37:10]So this is the long PIVC. As you can see there are two flanges. One flange is here and one flange is here. And I'm holding this flange and here as I'm I'm doing an IDed you need not do ultrasound guided if the vein is very nicely visible but um this is what I'm doing.

[00:37:30]So I have identified the capilic veil and as it uh moves look at the way I have pulled the ahead and then pulled out the uh still it okay so this is how it needs to be moved the moment it enters the there is a holder which is there the pink color and we use it to pull you know like push it aside. So unlike normally where we insert the canula together, this technique is slightly different and I always like to uh countercheck the length at which it is uh placed inside and also label it as long PIVC so that uh people don't consider that it's just a regular canla because it does look like a regular cana from outside and u they should know that they have to handle it more carefully.

[00:38:27]Now I I told you about different lines uh the other uh devices as I said peripheral line uh usually it doesn't last beyond 3 to 5 days because uh the length of the cana is small it tends to develop thromboplabitis earlier whereas midline catheter because it is longer it lasts for about 1 to two weeks. mini midline also lasts for about 7 to 10 days. Uh the regular central line can last if it's antibiotic coated it can probably last for about 3 weeks but most of the time if it is not antibiotic coated it could be just probably around 2 weeks. Pick lines are meant though though I've written more than one week it depends on the indication but it usually lasts for three months six months. We've also had patients who've uh retained their pick lines for around 2 years. Hickman is something that lasts longer but it is wide bore. So there is slight difference between the indications for pickline and hikman catheter. An implanted port is a device that can stay in the body for years.

[00:39:40]Now which device to use depends on what type of medication is going to be required. So certain characteristics of the medication that we all need to know when selecting whether a peripheral axis is required or central access is required are the pH any extremes in pH you have to go select central venus axis hyperosmolar solution hypo or hypertonic solutions any solution for nutrition where the percentage of dextrose is more 10% or more or the drug is irritant or vesicle you should use a central venus axis. Now let's talk about central venus axis.

[00:40:24]Um there are three most common sites the interal subclavian and the femoral vein.

[00:40:30]This table I've put up mainly for the uh residence. Um once uh but but the choice actually depends uh based on screening and the availability of ultrasound. If ultra with ultrasound available internal jubila has become extremely popular subclavven can also be accessed using difficult it requires a little more training but in terms of comfort for the patient particularly if it's going to stay for a longer time subclavian vein is much more comfortable it is associated with the least risk of as well as thrombosis and femoral vein is something that's not commonly done unless It's done in an emergency or because of some reason the upper body ultrais is multifactor. It's not just useful to identify the vein but use as a real time puncture and at multiple of once you've pushed in the guide wire use the ultrasound to again confirm that the guide wire is in correct position. After you've pushed the catheter, again use the ultrasound to verify that the catheter is in place. It can also be useful to identify the tip of line and we'll talk about it in a minute and also identify the complications meaning whether there has been a hematoma or there has been pneumothorax can be identified ultrasound.

[00:42:06]Now this is the technique that described Rasias screening which is sevenst step approach to um do screening before you decide and where to puncture at what level if you're using IGV or this is also included in this and you're going to select the most appropriate puncture site.

[00:42:31]Now before we talk about central venus axis it is important especially for the postgraduate artery from the vein and this can be identified by completely. So if you're compressing as you can see the vein gets collapsed the artery may not however if it's a child if you apply too much of pressure you can also compress an artery. So remember that this is a ref.

[00:42:57]You can throw in some color Doppler and you will see that Doppler in an artery is more pulsatile as compared to vein.

[00:43:06]And I have this video to show you. This is actually a subclavian artery and vein where not able to identify much. Then we put in some color Doppler. So both looked pretty similar. So we used a pulse drop look at the waveforms that are generated and you can make out the difference.

[00:43:27]This is a veil because the waves are of lesser amplitude as compared to the artery and this is something that can be more sureot as compared to the other techniques.

[00:43:41]Now how many times that you have tried to do an internal jugular vein axis have you actually looked at artery if you've not the next time you're going to do it please have a look and this is because while we do a IGV access right behind artery is there and we have to identify where it is how it is running before you decide to do the puncture. because so many times it'll be closer and it is at risk of uh counter puncture the remember to look at the vertebral artery I uh video I wanted to show you because this is a child who has an IGV thrombus.

[00:44:31]So this is how you identify can you see this bright eco structure inside the vein. So this is an IGB.

[00:44:39]So obviously we cannot canulate this veil and we'll have to select some other vein. So especially patients who undergone repeated canulations or those who are at uh venus thrombus that can be identified and should be identified before you do the puncture.

[00:45:01]Okay. I think I've told you about the inplane out of plane axis but with specific to the central venus axis IV as I mentioned earlier a short axis technique is preferred. So short axis you can see the IGV like this you can see the coroted artery on one side you can see the vertebral artery posteriorly but the needle that you are putting in will not seen as one continuous you it will just be one of hypercoic structure that you see as a needle. So this is the disadvantage with short axis. If you're using long axis wherein the probe is put vertically over the entire length of the veil, you are able to see the entire length of the needle but you able to see the artery and that is the disadvantage.

[00:45:56]There is something that described as oblique axis that you can use wherein you will be able to see the length of the needle as well as the other structures and I have a video for you to show. So this is the short axis and then we turn it obliquely so that now the IGV has become longer and the corroted is also seen and this is how we've done the puncture. The whole length of needle is also seen. So this is how you do a oblique axis puncture for the IGV.

[00:46:31]Now I told you earlier that ultrasound helps us tip location. Now what's the ideal tip?

[00:46:41]It is the cavo atrial junction between the superior venneava to the right atria is the ideal tip position.

[00:46:51]Many a times we say up to two or 3 cm below the level of corina. So level of below the level of corina as identified on chest X-ray. But chest X-ray is always done after the procedure is it not? So we'll talk about how can we make sure that the central line tip is in appropriate position. If you're doing it in an adult on the right side 13 cm. If the patient is tall then 15 cm and add two more cm if you're doing a left side vein. Okay.

[00:47:28]If not you can actually measure the length and in there is something that's called as the P's formula wherein height in cm can be divided by 10 and that is what length that needs to be put inside.

[00:47:48]Okay.

[00:47:51]That you put an IGV and it's moved into the subclavian bin.

[00:47:58]Yes, it has happened sometimes, right?

[00:48:01]Is it possible to have an ultra sound guidance to make that this never happens?

[00:48:09]Yes. And this is once you've made the puncture you have to slide the ultrasound probe till the root of the towards the foot so that you are able to get this view. Now this is a view wherein the IGV has enter it's it's the view at the pyog confluence is what they say where the subclavian from the side mer become the brachioic and here if you see the catheter or the guide wire moving towards subclavian then it is not correct placement you should be able to see it moving downwards towards the brachio and we have actually detailed uh all uh this technique in one of our in 2019. So you can probably just have a look at this and if you use this technique with an ultrasound guidance, you'll never misplace the uh central line direction.

[00:49:10]Now I spoke of knowing exactly are we able to predict if it lies at the SVC junction and one of the ways we can do it is by doing ECG guidance which is intracavitary ECG. So let's assume that tip of the central line for some reason or with some tech was able to capture ECG. How would that ECG look? As this tip moves closer to the SA node which is the which is roughly at the SVC junction, the Pwave is going to become taller and once it crosses the SA node, there is going to be initial negative deflection the wave. And this principle you can use to place the uh CVC tip correctly. And I'm going to show you a video of how we do it. So this is a device that is required for intracavitary ECG guidance which is available with u I think the teleex has uh the central lines have this disposable white uh tubing and this is that you need to have I mean we have it we had got it locked back. So this is how we do it. So if you see we have connected this guide wire and to the ECG cable adapter and as we are pushing it in Pwave is becoming taller right once it has gone to a significant distance now if we push it more inside can you see this negative deflection that has started coming so negative deflection means we have crossed the SA node so we'll have to pull it back again slightly so this is how you use intra cavity ECG guidance for the central line tip adjustment technique that you can use which is the ecog guided. So someone else is to do eco. So there's an apical view that is being done and you can see the air bubbles entering and they say uh this is called as the rapid atrial swirl sign and if you see it in 2 seconds then you are in correct.

[00:51:21]However we are not very fond of this technique. What we found more useful is something that I'm going now this is an echogguided technique wherein you have to use a subcostal by cable view. I'll show you what it is but in this view you'll actually be able to see the guide wire coming into fromc into the array. So let us see this video. So it is sternal and as I'm changing you are able to see. Okay, I'm going to pause this here a bit. You're able to see on the ultrasound screen. What you are able to see is this view. So you can see the IVC. So this is the typical IVC hip that we take to look at IVC collapsibility. But we tiltly headwards so that we are also able to capture the RA in the same um in the same uh view and somewhere here we get to see the SVC. So as I continue the video, please focus on the RA and please focus on what is coming through the SVC. You will see a guide wire that comes into the SVC first and then gradually as I pull the guide wire, you will see the guide wire coming and then I leave it up to here and that's our correct uh position. So here it is.

[00:52:43]Now we'll go back.

[00:52:46]This is the IVC. This is your RA. And can you see this guide wire coming in?

[00:52:51]Yeah. So the guide wire was coming in.

[00:52:53]Now I've started pulling the guide wire outside. See now you can see this bright hyper equal and that's the perfect location. So uh this is something that uh we foundatively more useful and precise.

[00:53:14]Now we are going to move on to subclavian vein panulation which can be done infraicular or supraclavicular approach. This is a quick video to show you the infra subclav. So this is the clavicle. This is the short. You could see the cilic vein that came in to join the subclavian vein. This is the subclav artery and the needle coming in till it enters the vein. We can see it as a hypercoic spot. And this is how it got canulated.

[00:53:46]Similarly, a supraclavicular subclavven can be accessed in long axis. So here is a long axis view. Here is uh the external jugular vein that's joining in and you can see the needle that is entering and it's almost rather than supraclavicular subclav it's entering into the brachioilic and um this is how you canulate a supraclavicular subclavian or a brachioaphilic puncture.

[00:54:15]But remember whenever you've approached a super subclavian and you fixed it typically the way you fix a subclavian catheter it can kink when the patient is turned in lateral position. So if you if the patient is requiring lateral position either for surgery or may require lateral position in an ICU then it's always better that you feel the um catheter posteriorly. There is no clinking as you can see in these images.

[00:54:48]We often in cancer hospital have to canulate central veins where the counts are low and whenever the platelet counts are low there's likelihood that it can keep oozing um from the site. So what we found very useful is this. It's called a true seal. It's a wound closure device and uh putting you know just sealing the entry spot as well as if we've taken sutures the suture spot then uh it helps reduce uh bleeding from that spot even if the platelet count is low.

[00:55:26]Want to talk a little more about opportunity to read these advanced lines and hence I'm going to be very uh crisp in what you need to know about these lines. As I mentioned earlier that pickline is a peripherally insert central catheter from the deep veins of the arm toward location.

[00:55:58]Traditional pick lines were these. When I was training, we used to use cababaixes. But this is an older generation. And there are some disadvantages with this. And the first and the most important is that the vein has to be adequate size and visible and palpable at least for you to use it. The puncture usually used to be around the elbow. So it increases the risk of um thrombosis as well as infection for uh these pick lines. Whereas and hence uh keeping these pick lines probably just for a couple of weeks was what was possible. Whereas the newer picss which are ultrasound guided placement uh can be kept for months and sometimes even a year. As I said, there's a specific screening that's called as the raptiva screening that has been described at different locations for you to look at the veins before you decide again which vein are you going to canulate and at what location for decline insertion. The vein typically selected should be occupying only one/ird. If you venus axis I said that it should not occupy more than 2/3 whereas here it should not occupy more than one/ird because this is a uh deeper vein and a little bigger vein. So uh we have to make sure that there blood flow that is allowed otherwise there is a risk of thrombosis uh in these veins. Depth of the vein should not be less than 2 cm and it should lie in the center of the arm. Now this is a picture that shows the axilla on this side and the elbow on this side.

[00:57:45]So it is um something that we call as Dawson's zone and the green zone is in the mid which is the appropriate for puncturing the uh for the pickline. Now I have a quick video for you to show the pickline insertion. So this is the middle one/3 of the arm ultrasound guided part is I'm doing for a brachial vein and once that is done we put in the guide once the guide wire is in place. Now here it's here we are just confirming that the direction and the length is correct because once we know uh the length is correct then we are going to cut the pick line. This is a dilator sheath that needs to be put in before the pickline goes in. We remove the dilator and through the sheath we are now pushing in the pick line. So this is how pickline is placed. The sheath is torn off. The guide wire is taken off and then checking the backflow and fixation.

[00:58:51]This is how uh we sometimes use chlorhexidine gel patches which help reduce the infection for these lines. And this is a post-procedural X-ray showing the corrective location of the pick line.

[00:59:06]We're now going to move to tunnneled central venus catheters and uh which is the hikman catheter. So what's peculiar about these catheters is that they have a special dacron cuff as you can see here and this dachron cuff because uh we subcutaneously tunnel these lines this dacron cuff that lies in the tunnel is going to cause fibrosis of this tunnel and this is how it reduces the risk of infection for these lines and we can keep it for a up to a year these uh devices are very uh wild gauged you know it's like a 12 French catheter that goes in in an adult uh in children a smaller French sizes are available so for in human can be used little older child can be seven French and um a teenager can take nine French whereas as I said uh in adults we use 12 French and a double minhickman catheter So this is a quick video to show hickquin catheter placement. This done and a guide wire is placed IGV. You can see uh now we are tunneling it subcutaneously from an exit point on the chest and that is the tunneler rod. So once it is tled uh the rod goes in we tie the hickman catheter and pull it up. See, did you see that cuff? Dacron cuff that went in.

[01:00:44]Yeah. So, this is the location of the Dacron cuff. Now, now we've put in the dilator sheath in the IGV. We are measuring the required uh length. And now we are going to pass this catheter through the sheath in the IGV into the IGV. And once it goes completely inside, we are going to push it in. We are going to verify the position on uh CRM. We have made sure that it is all the loops are smooth. There is no kinking anywhere. And then this is how we fix the hickman catheter. This is how the hickman catheter is going to look on an X-ray. This is however a subclavian placed hickman catheter. And this is one expplanted single lumen. A single lumin catheter that we put in ch children as I said for French is called a groiac catheter.

[01:01:39]Now the last part which is implanted ports. This is how it looks like. It has a port body, a connector and a catheter.

[01:01:49]And once it sits uh inside the body, the needle puncture is done through the skin subcutaneous tissue to enter this port body. So this picture I have uh taken to show you how the silicon septum which sits here. I've actually broken this port so that you're able to see the needle that passes beyond the silicon septum into this cavity and here is where the catheter is connected. You need special needles uh they are called as the hub needles to access these ports.

[01:02:23]Uh the implanted port placement in my hospital is done by us anesthesiologists and that's the reason why I am showing you this video. But most hospitals, most centers, it is done by the surgeons.

[01:02:41]So I think uh it is very similar to the hikman catheter except that a subcutaneous uh pocket is made. As you can see, we have made a port pocket and again the railroading is done and we are bringing the catheter into the pocket. The port pocket is where the port body is going to lie. And after checking the correct position and making sure that there are no kinks, we trim the catheter. After trimming, we connect it to the port and then we tuck in the port inside the port pocket. And then this is how it looks in CM. And then we are going to close the wound. This is how it looks on a chest X-ray. And this is how it looks after it has healed completely.

[01:03:35]I just wanted to show you how to access a port because it is likely that you get a patient who has a port and you should know how to use it. You should feel confident about using it. So this is how you're going to use the special needle which is the hub needle. I like I call it a three-point fixation. I've used three fingers to stabilize the pot while the index and the thumb finger is using is used to push the needle inside the silicon septum and then check that there is backflow. If there is no backflow, please do not use the port. Okay?

[01:04:12]Because it's likely that the port needle is not in position and then there can be problem. Look at the way I'm flushing it. It's push stop push stop. You have to flush. This is the special technique that's required to flush whenever you are using a port. And now I have a video to show you the removal of the needle.

[01:04:31]Once you have given whatever is required, stabilize the port with two uh fingers of one hand and pull out the needle like this. So just to show you how to access and deac.

[01:04:46]Now if you do not have a huber needle is it okay to use the pot? Well no. And the reason is if you use a normal needle it can actually damage the silicon septum.

[01:05:01]The puber needle like this is a traumatic. It makes a very tiny hole when it enters. Whereas when you use a normal uh needle it can actually tear away the seption. So septum. So unless it's a lifesaving indication you there's no Venus axis and you're wanting to give adrenaline do not use normal needles use only a hub needle now while I summarize all the devices that I have shown you I feel what really ma matters is knowing what is available with you and be able to use it properly it's often good to keep it simple it's good to as knowledge maybe even for exams for post-graduate students but when it comes to practice I think this vortex approach is extremely useful which means that you start with a standard peripheral IV access if you're not able to do it and you have an ultrasound go ahead and use ultrasound for placement provided you've trained yourself in using it I I ask my fellows to do ultrasound guided peripheral line access practice is after the patient is under general anesthesia you know so that they can take their own time and they build confidence so that they're able to do it uh whenever uh they required to do it awake if you still do not get a good peripheral vein then you can go ahead and choose central venus canulation so you each one of us should be very good with these three things and that will sort out literally 95 five% of the situations if not more and as a vortex approach if situation demands we should also be able to do the introious access.

[01:06:57]So I think these are the four things that I would want um each one of you to focus on and learn and be expert at. So to close I thought I'll just finish up the introious axis. It is a lifesaving technique each one of to do it. So these are various areas and the distal tibia, the distal femur and the proximal humorous. Of course punctures have also been done in uh adults for introious access. You may not have all these fatrocious needles but what we have done in our crash cards across hospital is that we've put sternal puncture needles and these are the ones that uh you know in an emergency we use as introious needles.

[01:07:50]I have a quick video for you to show how introious access can be done. I think the voice may not be uh you may not be able to hear the voice but I'm just trying to how we can do it.

[01:08:08]Okay.

[01:08:10]Okay. So this is just a mannequin that I'm going to use to demonstrate and this is the pro tibia that I'm going to choose for doing it. As I said, it can be a distal femur or a distal tibia that can be used. So here I've used an official needle and it comes in different sizes. So if you have a typical introious needle, uh you can use it or sternal puncture needles like I showed.

[01:08:43]I think uh let me just take you back to quickly on Yeah. So, so I think what is important is it needs to be about a finger's breath medial as well as inferior and you make sure that you support the needle where a sterile quickly clean the area.

[01:09:13]Local anesthetic can be used ifuation demands directed slightly inferiorly so that it stays away from the epipes.

[01:09:38]Whenever it's going to stand by itself without support, you have to remove the stilllet and you're going to aspirate and be some narrow like thickened blood that comes in and make sure that whenever you are flushing there should not be any local swelling here which means that it is in correct position.

[01:10:06]Now just one last thing I wanted to mention and that is can contrast be injected in a IU line and this is very very important because maybe there's a case that's come with trauma you haven't had access so you've put in an introious line and now this patient needs to go in for a CT and there has been literature to say that yes you can use iol line for contrast injection And this I'm going to sum it up by saying that we are the experts in vascular access and it is our responsibility to make sure that we learn various types of vascular access and uh are able to use them appropriately.

[01:10:57]also set up teams um involve the nurses, technicians at critical areas especially ICUs, ERS uh in our also in the preopholding area the nurses are trained so that you know if someone faces uh difficult Venus access these are the locations where they know uh that they need to refer the patient so that um we can place with an technique with this uh thank you so much for patient listening. I know the audience has been very diverse different uh levels probably I feel right from graduate and seniors uh faculty uh I hope that each one has had their uh respective uh take home from this talk.

[01:11:47]There are a few articles that uh I have contributed to and uh that can be used for further reading uh for those who are interested. Also recently we have compiled this how I do it uh ISA u video monographs and the vis section there is extremely helpful.

[01:12:10]I also want to uh say that in the upcoming We doing a special mask on Venus and we are going to have mannequins there hands-on experience. So those who are interested in learning midlines and pics you could join us there. Thank you so much for patient listening and this is my department my team uh without whom I would not have been able to uh achieve this. Thank you.

[01:12:58]It's pretty heartening to see so many people logged in. I think at a point of time I also saw uh some 80 members. So thank you 80 members. I remember 81 is what I saw. So thank you so much everyone for logging in. If you have any questions, I'm more than happy to answer. And I would really like seniors sharing their experiences on how they handle difficult Venus access.

[01:13:29]>> I think Vijay is saying something but he's muted. You need to unmute yourself, sir.

[01:13:38]Vijay can please unmute yourself.

[01:13:40]>> Yeah. Yeah.

[01:13:42]Good evening madam. Am I >> good? Yes.

[01:13:45]>> Yeah. It's excellent lecture madam. No doubt. So you covered from basics to all advanced. How to place a key, how to daily from all those aspects to advanced techniques. Definitely we learned a lot from you and uh my thing is uh we are definitely Venus experts and uh but I hope someday we will reach your expertise so that we can also do uh these things. So my experience is like I share so many uh areas of interest with you like pediatric anesthesia and collect anesthesia. So practicing since more than 23 years. So my experience uh I have a doubt uh the thing is uh we long back we had one pediatric case few months baby for crantomy. So it is a difficult IV access. Uh finally I got a peripheral V and seenosphere. Uh so we started the case but uh case is under the drapes total baby is covered under the drapes but after some time we observed hypotension uh due to bleeding we thought but after maybe 2 3 hours finally we observed the swelling in the lower limb. So fluids we are giving through syringe pump. So if it is normal IV fluid gravity dependent usually that stops when it is uh not in intravascular place but syringe pumps they push wherever is the can lies. So how do you monitor how do you monitor these small tiny babies under the drapes whether that vascular access is intact or not that is one question. The same baby we had that experience baby collapsed.

[01:15:23]After that we saved we saved with an intro scan put through an epid epidural needle with put through an epidural needle and after some infusion we got a line and finally we could save the baby.

[01:15:37]So after that I bought even that introious kit that that was worth around 25 to 30,000 at that time but fortunately I need not use that kit. So ultrasound came into use after that. uh maybe I got exposed to ultrasound after so many years. So my doubt is this. So how do you monitor uh a vascular access site in a small baby covered under?

[01:16:00]>> Sure. So uh if you have ultrasound I think the best way is to actually screen and make sure that the you know venus tip is inside. So I think that's the most sure short way. As you rightly said that infusion pumps can sometimes be very deceiving. they will push and sometimes extraation can be missed once you have placed just by so connecting an IV bottle is important and reversing it you know you take that bottle and put it down you sometimes will be able to see some flashback so I think these are two or three things that u in my >> yeah definitely madam that is when we inserted the candle of Ashley to confirm the place but I think during the process You should try and keep yeah you should try and keep under vision as far as possible the place where we have canulated and any doubt like you said you know patient started hypotensing the first thing that should should come to your mind is to check the um IV canula >> and all the difficult cases I'm starting the case after second IV can candle after complet so only one IV can if it is difficult case if we lose that we may lose the baby also so that's what I practice Wonderful.

[01:17:18]>> Yeah, very important points. Thank you, sir.

[01:17:22]Anyone else wanted to share? I thought someone had raised the hand. Was it Ra Prasad, sir?

[01:17:26]>> Yes, madam. Good evening, madam.

[01:17:28]>> Please. Good evening, >> madam. Can can when you are in doubt in central scanulation.

[01:17:34]>> Mhm.

[01:17:34]>> Can we connect it to a transducer and see the waveform and confirm and also can we send the sample for ABC?

[01:17:44]>> Absolutely.

[01:17:45]Very. So actually I didn't deal that point that occasionally uh after entering the vein by mistake the needle tip when we are pushing the guide wire the needle tip can counteruncture and enter the artery that's what you are mentioning right we've had such incident some time back. So what happens is it is by mistake in the artery when you put it initially in the vein you aspirated you knew it was vein because the blood looked dark you disconnected the flow was not like arterial but when you're pushing in the guide wire by mistake that the needle moves ahead and enters an artery and then the guide wire is now in the artery and you have dilated and you have put in a central venus line inside as you rightly said if you are in any doubt transducing it or sending a blood gas or even if you connect an IV you know if it's a veil it'll flow in properly if it's an artery it'll start jumping behind so that that is the way that you can identify but more importantly I want to talk about uh what to do if that happens after you have identified so literature says if it is seven French or more in an adult that you have dilated in an artery.

[01:19:07]Uh you have to be ready to explore if you are removing in fact the literature says that you should not remove it like that. You have to explore and suture off that artery but we have removed it occasionally and it should be a compressible site. If it is a non-compressible site like in subclaven artery you have entered then there is a high risk of uh bleeding that can you know keep collecting in the plural cavity and we losing the patient. So we have to be extremely careful uh if by mistake we have canulated the artery.

[01:19:51]Madam uh technically which is easier right subven or left subclavion?

[01:19:57]>> Right subclavion is always preferred because it is straight. It has a shorter course towards heart. So right is preferred. Left you can use if right has some problem.

[01:20:14]What's your experience? One of my friend in my friend in America told left is easier technically but preferred is right.

[01:20:26]>> Yeah. No, I don't think so. I think I I think both would be same in terms of difficulty but preferred is right just because it has a straighter course towards the heart. left. Once you put as I said, you need to check which direction it has gone on this side as well as this side you know also on the right side you have to verify that it has not gone into the right subclavian otherwise it might start from right IGV it went into the brach sorry left IGV it went into the left brachioic but it entered the right subclavian we've had such situations also so you have to screen both on the left root of the neck as well as right root of the neck to ensure that it has gone towards the heart.

[01:21:10]>> Madam, one hand is having a fistula and another hand is edimeatus. What trick you >> will play to get a Venus axis?

[01:21:21]>> So, uh AV fistula hand should never be used for the other hand. How much is the edma? If you have an ultrasound and you are able to see a vein then we can use the idatus hand also but make sure that your canula is longer. So use a mini midline because uh the length of the canula is longer. So even if it is idatus uh a significant amount of the catheter is going to lie in the vein. uh you can go a little more proximal because often idimma is more distally if you go proximal the edma will be relatively lesser it's something like you'll have to try a midline as I said or central venus axis of course >> thank you thank you so much thank you ma'am any more questions Everything is so clearly explained and in detail. I have no doubts. I only have one experience once when my one of my postgraduates was canulating the subclavian vein. Right.

[01:22:33]Subclavian vein. He accidentally punctured the subclavian artery twice actually. But fortunately we gave a lot of pressure for a prolonged period of time in the neck region itself and uh we could save the patient. We didn't lose the patient fortunately when we like uh learn about all the complications uh uh during the subclavian vein canulation.

[01:22:59]Arterial canulation is one of the most uh uh uh dreadful complication for in subclavian ve complication because we cannot put a pressure on the art uh while doing it but we were very fortunate that is one experience I had >> just wanted to add before we move on to the second point you want to say so uh there is you know twopoint compression whenever a subtle artery has been punctured as you said from the root of the neck you have to press here and also infraul so twopoint puncture twooint pressure if you give then I think u is the way to do it >> yeah that's the thing we have done madam and for a prolonged period of time I took a lot of time uh to see to that the hemodynamics of the patient was stable and they didn't get disturbed because one way of assessing the internal bleed will be uh to monitor the hemodynamics right >> so at the same time madam I was asking him to change the direction but he was he punctured it twice really which really was very dreadful that was and most often even in neurosurgery cases madam when sometimes we don't find proper peripheral vein access uh I found the digital veins very madam as you have shown in one of your pictures you said you start with a digital vein and you can go for a after the >> you fill up the patient or after induction there's little but madam we can even canulate the digital veins with an 18 gauge canulus >> yes madam I have done it multiple times once or twice yeah and I'm very comfortable and confident with the digital veins actually so when I saw the picture I was very happy to see that somebody else also follows the same pattern which I follow >> there are lots of occasions when digital veins were the only ones available and no other peripheral veins were available in the Apar upper li uh it was a very insightful >> thank you for sharing correct thank you >> thank you I see Dr. Rajendra Prasad also wanting to say something. Tell me sir.

[01:25:10]>> Uh madam pulling the hand will straighten the vein while canulating the supply and makes the process easy. Easy.

[01:25:21]>> Oh yes. Oh yes. Oh yes. Um so so I used to do that when I did not use ultrasound you know. Uh whenever you know the hand is like this I believe that pulling it down isn't it? That's what you're saying. you know pulling that hand down.

[01:25:36]>> Yeah, it I feel the way it helps is that it slightly opens up that space. So you have to keep something under the shoulder and pull the hand. It opens up that space so that you don't um you probably don't hit the clavicle. You can safely go under the clavicle and I think it improves the for some reason. I don't really know what the reason is but uh it does help.

[01:26:02]And keeping the sandbag under the shoulder blades also helps or >> Yes. So um so where I like to keep the um sandbag or that bolster is between the two scapula blades because if you keep it under the scapula I don't want the shoulder to turn like this because then the subclavian vein goes deeper. I want the shoulder to fall down you know.

[01:26:30]So I leave it only in the center of the two scapula. It if it comes too much lateral some people put it till here. If you put it till here this shoulder is not going to fall down. You know what I'm saying? So >> I think no I think Dr. Rajendra you want to say something Dr. Raja >> you have to unmute yourself. Yeah, >> we are putting 500 ml NS bottles madam and pulling the hand one side especially in obese patients it is helping madam then the thin patients the patient is very obese and so much of subcutaneous fat is there sometimes it is helping m >> absolutely so it helps to open up that space and the subclavian vein becomes more superficial otherwise the subclavian vein will be deeper in obese patients so that's why it is useful Yes. Yes. And >> thank you for sharing placement of the needle like whe most of times in the medial or lateral usually we will put 1 cm below and 1 cm lateral madam.

[01:27:44]>> Yes.

[01:27:44]>> But in obese patients if you're putting little medial it's becoming easy sometimes madam.

[01:27:50]>> Correct. Correct. So I think uh it depends on the so so the way subclavian vessels run more medially or laterally depends on the shoulder style you know there are two types of patients patients who have very droopy shoulders and patients who have like you know stout who are stout. So patients who are stouter I have in my experience the supplein vein is much more medial as compared to lateral but patients who are thin built and you know who are who have droopy shoulders they will have the vessel more lateral so you could probably use that. Yes, that's like in patient putting the little medial we are getting easy when compared to putting lateral madam.

[01:28:36]>> Correct. Correct. Same same. I think my experience is also the same.

[01:28:40]>> Thank you madam.

[01:28:41]>> By listening to this uh I got a small doubt. So the thing is I think few people are still using blind technique.

[01:28:48]So is it legal to do blind technique nowadays?

[01:28:53]>> I feel that. Yeah. So I feel if you don't have an ultrasound obviously you'll do blind but I would request each one of us to try and bring in ultrasounds in our because I think that's the future that's the tomorrow that's what is going to add safety for us and we have to ask for ultrasounds for our and if you have an ultrasound and still don't use it then it is not >> that's what that's what if you have ultrasound in the you should use it >> and and if you don't use it is it legally bound for us to be like >> I don't think it is yet I don't think it is yet legally bound but let me give you an example of a patient whose ICD placement caused uh clinic injury and the patient collapsed and died and this case was like more than 10 years back in one of the hospitals in Mumbai >> Mumbai >> and and they said that why did you put an ICD without checking and marking the uh sple. So what I'm trying to say here is that if it's available then it's always good that we learn how to do it and we use it for our safety because if there is any complication then it'll be difficult in the court of law.

[01:30:16]the same case I I have seen that that's why I asked the same >> I think we came a long way from looking the vein and after that a few years of experience feeling the vein and now again we are looking through ultrasound the same circle we so we started with looking the vein looking at the vein feeling the wheel now again we look at the vein and granulate that's what uh how we evolved >> sure thank you sir >> good evening madam dran from >> Good evening sir. Thank you for joining in.

[01:30:50]>> It was really was a really nice topic madam because you have covered from the very basics to the latest techniques using gadgets and one clarification madam actually added one point when you have doubt in differentiating whether it's arterial or venus especially fummeral ve >> because some people take the heper salin syringe.

[01:31:12]>> Mhm. Instead of that if they can take an empty syringe of course definitely will aspirate and it will be easy to differentiate by just by looking whether it is arterial or venus it mixes with it >> and the color you may not be able to differentiate >> correct color becomes very bright like an artery even if it is vein it will look like an artery correct I agree >> point I want >> yeah yeah thank you yes I agree thank here.

[01:31:42]>> Thank you ma'am.

[01:31:46]>> Okay, looks like we've reached >> Thank you ma'am for a wonderful presentation that with very very practical insights. I think it would be very useful to each and every postgraduate and every practicing consultant. Now I request Dr. Rajendra Prasad City branch executive member to present the vote of thanks.

[01:32:11]>> Good evening madam. It's very uh excellent presentation madam not only for the posterior students even for the practicing anesthesiologists.

[01:32:20]Uh you have enlightened very very well madam.

[01:32:25]uh and thank you Raas siri madam and vijan sir for your inputs and thanks to all the participants for attending the today's schedule and thank you pre sir for selecting such a good topic uh from a apt teacher sir thank you very much sir >> thank you good night everyone good night thank you thank you everyone