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Good evening everyone. Am I audible to everybody here? Ok, so I will be starting the session soon, but today's session is gonna be held by two of us. That's myself and my colleague who I will be introducing at the end of my session. Uh for those of you who are new here. Welcome to another session organized by you medics. Uh We are a group of junior doctors who organize these teaching sessions every Thursday from 7 to 8 p.m. Uh based on cases and procedures we come across very often in our job. So and we just try to help out any new doctors who are joining the NHS or anywhere or even medical students. So today's session is a very basic session. It's about procedures which we are expected to do almost every other day. Uh I'm pretty sure half of you already know how to do it, but it's just gonna be a revision and it's pretty basic. But if there are any questions, please do drop it in the chat box or if something is not clear, you could always ask us questions in the chat box. So is it ok for me to start the teaching session. OK. Just give me a second. I'm just gonna OK. So the procedures I'm gonna be talking about are IV cannulation and male and female catheterization. So the first one is gonna be male and female catheterization. So before I begin, can somebody tell me the indications? Like when would you actually catheterize patient? Yes, retention, definitely. And any more indications any indication like if someone's coming to the hospital, at what point would you decide? Ok. This patient needs a catheter in them or they don't? Ok. So broadly, I think you can divide it into therapeutic and Oh yes, yes, all the answers are accurate. So you could divide it into therapeutic and diagnostic. Ok. And most often under therapeutic would be acute and chronic retention, intractable urinary incontinence or just bladder irrigation, postoperative, post, spinal injury, post anesthesia. Basically, you just need to measure the rest of your urine or investigations if you want to insert any drugs, but it's not very common, but ok, and obtain an uncontaminated urine sample, no contraindications. So, contraindications would be if there's fibrosis, a stricture rupture, any fractures or if there's blood at the end of the meat, is it is an absolute contraindication or if there's any restriction to the passage or if there's any pain and discomfort, evidence of infection lack of and patient is not consenting. But sometimes obviously, if they are acutely unwell in sepsis and you know, and they're not able to give you consent. It is ok to proceed with catheterization. But if they are able to consent for it, always make sure that you consent. So the first thing we need to do is keep the equipment ready, right? So the equipment we would collect before we go and speak to the patient gain consent, it's always better to keep the equipment ready. So get a dressing pack, a catheter, a catheter drainage bag, normal saline gauze lidocaine gel, sterile water, a syringe, some sterile gloves and then a kidney b. So this is just more theory I would say. So, obviously, the catheter is measured in gorges. So the most often that uses a 1012 or a 14 gorge cat. So I'm just gonna run through the parts of a foley catheter. So this region here would be what we call the fork. And this is the part that you connect to the urinary bag. And this is the section where you would instill the water to inflate the balloon. And then this is obviously the tip of the catheter that you insert into the um the penis or the urethra and the females. So this is what a foley catheter would look like in any procedure. The most important part is always gain consent. It explain the procedure to the patient gain consent. And once you gain consent, I would advise especially if it's things like catheterization, make sure you have a chaperone with you as well and maintain the dignity of the patient as well. So once you've gained consent, you've explained the procedure and everything. You, the next thing you will have to do is position the patient, right? You've already kept your kit and things ready. So you bring the kit next to the bedside, keep everything ready, then you'll have to position the patient. So I will show you pictures on how exactly to position the patient. But I'm just gonna run through what I've written here. So in a female, if you put them in a supine position with the legs bent and then make sure that the area is well lit so that you're able to visualize what exactly you're doing. Or if not, you can always get a bedside lamp and make sure that the a you're working on is violet. Your vision is pretty clear as to what exactly you're doing next. Open the equipment onto a trolley and show the catheter is inside the internal packaging. Don't take the catheter out of it because it needs to be sterile because you're inserting it into the body, right? So you don't want to infect it at any form. So you take it out of the outer covering, but keep it intact with the internal packaging. Now, once you've done that, wash your hands, wear ster eye gloves, well, two pairs of sterile gloves. I explained why later and then keep everything else ready. Fill the syringe with water put drapes over the region, you will be working on to create this entire sterile environment. And once you've done that, so basically, this is what I meant when you're positioning the patients. So in women, do you see she's a spine and legs apart, legs bend and getting her clean. Oh What do I say? View of the area and the same thing with the male patients. Now, the other thing that you do is you always maintain. So we call it the clean hand and the dirty hand. So your dominant hand would be the clean hand. So all the sterile things would be used with your dominant hand. And a non uh the non-dominant hand would be the one that you'll be using to hold the shaft of the penis or to open the open up the perineum and things like that. But make sure that you don't use a non dominant time to u to touch the catheter at any point because that's gonna make it non sterile. So now moving on to the procedure. Oh I'm sorry, I'm not shy to mention the penis. I'm just trying to use a very appropriate word. That's it. So the procedure would be so first hold the penis with a steroid gauze swab. So just like, do you see this picture? How so always use your non dominant hand to hold the shaft of the penis or to split the perineum? So you use a steroid gauze hold the penis and then use your dominant hand, right? And you use that to clean the shaft. So now what you do is you're holding the penis with a sterile gauze around the shaf with a non dominant hand. Retract the for skin and gently cleanse the urethral nector with gauze soaked in normal line, die in the wiping motion away from the urethra. So basically what it means is it has to be in a circular motion. So you start at the urethra and go circular away. So you do this three times with three different uh causes dip in normal roughly about three times and with the women the same thing. So use your non dominant hand to split the labia and then use a dominant hand to clean the pain. Again, here you will go from anterior to posterior. So basically towards the anus. So if you go in the opposite direction, you will actually be introducing microbes into the region. So to avoid that you go towards the anus and again that I would appreciate, I mean, it is appreciated if you do about three times of minimum. So now you have a complete sterile area, you've cleaned everything. Now insert the lignocaine jelly into the meat of the pen as well. It's the same thing with the women as well. You have to put in the lignocaine jelly. Um Anyone know why they get the lino and jelly. OK? I mean, basically, it's a local anesthetic. Right. So we give that to numb the area because you don't wanna hurt the patient when you're introducing the catheter in. Yes, exactly. It's a lubricant anesthetic. So, next thing what you do is, uh, so when we are putting the lidocaine jelly in, most of the patients tell you that they do feel something cold going in or a bit of stinging sensation. So, always warn them about it prior. So they are taken by surprise, right? And then do keep asking them if they can feel something. And then if there's any numbing after you've inserted it in, once you're done that dispose of the outer gloves. So that's why I said wear two pairs of sterile gloves. So now we dispose of the outer gloves. So again, you have like a very sterile environment. Now expose the catheter tip. So now for this, so the tip of the catheter, there will be like a section of the plastic which is kind of perforated. So you just have to tear that apart. So if you have a chapter, you could ask someone to just tear it free for you while you hold the catheter. If not, you can use your non dominant hand to do that, but make sure throughout they're not touching the tip of the catheter. Ok. So you remove the top perforated region and then you're exposing the tip of the catheter and now you will slowly insert it in. So in females like I mentioned earlier, non-dominant hand, split the labia and insert the catheter with a slightly rotator movement and with the ma males, it's the same thing. So it's just like how it's pictured in these pictures. So now as you advance the catheter, use a twisting and rotating motion, right, and also simultaneously have to withdraw the outer packaging. So you insert it, push it in and with the same dominant hand, you have to simultaneously take out the outer packaging as you're inserting in. So this ensures that throughout you maintained a non touch technique and the entire catheter is quite sterile. Now, once, so you have to insert the catheter till the bifurcation. Like I showed you initially in the picture of the foley catheter where the bifurcation was. So up until that point, you have to insert it and then make sure you keep a kidney board between the patient's legs because the minute you've entered the bladder, there will be urine coming out. So you don't want it to spill all over, right? And then connect the catheter bag and now you will have to fix the catheter in. So once you know the urine is draining inflate the balloon, the balloon that I showed earlier in the picture, but tell me of sterile water and gently pull back the catheter until resistance is felt. So this is something that needs to be done pretty gently and don't suddenly pull back because it could cause trauma. So it, when you gently pull back, you will feel this resistance and then you'll know that. Ok. It's in a fixed position. The cat, it has reached the neck of the bladder. Now, after you've done this, do not forget to pull back the penile for skin because otherwise it could lead to parathymosin. It would be quite painful because you've retracted it earlier to insert the catheter. So you will need to pull it forward again. Once you're done with the procedure and wipe off any excess lidocaine gel or if there's any spill anywhere, make sure you've cleaned the area, completely, attach the catheter back to the side of the bed and make sure it's below the level of the pelvis to avoid any back flow or any catheter bone infections. So, you've done all this, you've fixed the catheter, cleaned the entire area. Now it's time to document it. It's very important to document what you've done. So, documentation, make sure you mention the type of the catheter, the size, how much of, uh, ML of, uh, uh, sterile water that you use to inflate the balloon. Because when you want to remove the catheter, if you know, you put in 10 mL, you know, you need to re retract 10 mL. So that's what you would have to do and then proceed with any post procedure investigations and also always keep an eye for complications. Uh, can someone tell me what are the common complications of catheterization. Yes, bleeding, definitely anything else. Ok. But before I move on to the complications, another tip is so if there is no urine, once I've inserted the catheter to the full length up to the bifurcation, could either mean the bladder is empty. I mean, if there's no urine coming out or you insert it into a false passage, right? So you could maybe do a bed cide ultrasound to see if the bladder is empty and if there's no urine there. So that will just mean the bladder is empty. But if not, you may need to remove the catheter and put it back in or then sometimes just flush the catheter as well to see if it's blocked anywhere. So when I said that the balloon is at the neck of the bladder, this is what I meant. So this is the bladder here. And do you see this region? So that would be the neck of the bladder? So when you retract, the balloon is gonna come and stay there and that's why you feel the resistance and it's the same thing with the females. Yeah. Uh Another thing is if someone's coming, having a long term catheter and they've come in with infection and you're suspecting it's because of the catheter, you need to give antibiotic cover and change the catheter as well. So this antibiotic cover varies from prostate. So check the local protocols, check the, speak to the microbiologist and make sure you've given the appropriate antibiotics, the most often post procedure, we just need to take the sample and you also have to try to monitor the urine output. So make sure that that's done. Uh Some complications that would occur is a local discomfort, some pain, some hematuria, some catheter associated infection could happen, stricture formations. If you see this picture here, I'll show you what you mean by a stricture formation. And then sometimes it could be slowing of urine or no urine, post catheter insertion. It could be due to blockage of the catheter. Or if you know you cause some trauma, maybe there's like a small blood clot that's there. So most often when you flush the catheter, it would start working again. All right. So the next procedure would be IV cannulation. But before I proceed, do you, do you have any questions regarding catheterization? OK. So, is it OK for me to proceed to the next procedure? All right. Moving on. Yes. I mean, if it's not draining, but the first thing you should think of is if it's not draining is probably that it's blocked, right? So you do the flush and if it's draining then fine. But if not, so when you flush, if it goes easily at the same time, it can also remove the flush with the same catheter. So that should be OK. And then of course, if it's not going in as easily, then you can always take it off. But it's always, I think first thing would be to check if there's a blockage because most often it's just a blockage and it's not in the wrong place. Should I proceed to IV cannulation? All right. So when I say IV cannulation, obviously, every procedure has indications contraindications. So, what do you think would the indication be for intravenous cannulation? One or two indications would be? Ok. Yes. So most often it's fluids and medications. So, fluid and electrolyte replacement, administration of medicines, sometimes blood and blood products or some total nutrition, hemodynamic monitoring. Blood sampling can also be done from a cannula. The advantages of this is basically has immediate effect that goes through the vein. So there's immediate effect, there's control over the rate of administration or if the patient is unable to tolerate anything orally, this is the best way to give it to them and some dogs are better absorbed with IV than oral. So again, in those conditions and the pain and irritation when like you give subcutaneous or I am compared to that IV is again better. Some contraindications would be infection, some phlebitis and a V fistula. The picture here is of a fistula and any previous mastectomy or lymph node removals or any veins or fractured limbs, et cetera. So the equipment you need to keep ready again, just like how we had equipment for the catheter. We have equipment for almost every procedure. So the equipment would be a dressing tree, gloves apron, if you want one cleaning wipes, gauze the cannula tourniquet dressing to secure the cannula alcohol wipes, uh, a sharps bin. And then if you're putting the a saline flush and a syringe or if you're gonna give IV fluids, make sure that's also ready. So once you've done everything, you can fix that as well. So now, first thing, consult with the patient, explain what you're gonna do and why you're doing it and then gain consent. And once you've gained consent position, the patient, right, always choose a non dominant hand because with the dominant hand, what happens is a lot of movement and there is a chance the cannula can come out and you don't wanna keep trying and cannul a patient. So it's better to choose the non-dominant hand. But obviously, if you don't have, but instead you can always go to the other arm unless there are contraindications, then support the arm on pillow or other suitable, like just make sure the arm is supported. Well, before you're doing it, then check for any contraindications. Like I mentioned earlier, infection, any damaged veins, fistula, phlebitis, et cetera. So now first thing apply auto, you make sure that it's applied to the upper arm and it should be applied at a pressure so that you know that you've impeded the venous distension, but you're not restricting the arterial flow. So tie the tourniquet, ask the patient if it's too tight. If it's too tight, release the pressure of it, but make sure it's tight where you can see the venous distension, ask them to open and close the fist because that makes the veins more prominent. Sometimes if that doesn't help, you can also like fill your gloves with like warm water and place that on the region where you think the veins will become permanent, that helps the veins to be more prominent for you to visualize them and lowering the limb below the heart because that also leads to venous pooling and then you can see the veins clearly. So this is just the anatomy of the veins. So we have the cephalic vein, mainly the basilic vein and the median cubital. These are the major veins we normally use you. Sorry, you could use the smaller brains. But then for Candida, I think the bigger ones would be better because they're the lumen is larger. So it's easy for you to scent administer fluids and things. Now, what do you think are the characteristics of a good vein? Like when you say this vein is good, what do you think the characteristics could be? What would make you choose a particular vein to cannulate? Ok. So we would choose a bouncy soft above any previous cannulation sites. Uh a vein that would refill and depressed, which is very visible, which are able to palpate. You know, it has a large lumen when you look at it, it's well supported and it's so you can see the course of the vein sometimes like you can see a small section and then it's like detox. So you know that the canal is not gonna go in easily. So you can see the uh the course of the vein to an extent, at least where you know the entire length of the cannula is gonna go in. Right. So these are some of the characteristics of a good win veins that you would avoid are thrombo sclerose, fibrosed veins. If there's any inflammation and bruising, some veins are quite thin and fragile when you have a look at them or they have a very narrow lumen, uh some veins, what happens is when you palpate them, you realize that it's quite mobile, so it moves. So when you try to actually insert a camera, it's gonna move and then you're not actually gonna be going into the vein that you are you were thinking of and it's very close to the bony prominences or if there's any signs of any infection around there or multiple previous functions to the same particular vein, maybe for blood sampling, et cetera. So don't avoid using these veins to cannulate procedure, wash hands, prepare your equipment, make sure you've taken the can and everything out of the packaging and you have your tree completely ready right, loosen the white cap and gently replace it, apply a tourniquet. So apply to identify the vein, clean the site of the vein with alcohol wipe, you can palpate the vein with out gloves first just so that, you know, get a good feel and you know which vein you want, you clean the site, allow it to dry. Now, put on your gloves, if you are not, can immediately advise you take off the turning here if it's gonna take time for you to put on the gloves. So to remove the tourniquet, put on the gloves, reapply the tourniquet. Now remove the protective sleeve from the cannula. Do not touch the needle of the cannula, right? Hold the cannula in your dominant hand, do not repalpate the vein that is very important because the minute you touch the vein again, you're gonna make that region non sterile. So make sure you don't do that. Hold the cannula with a dominant hand, you can use a non-dominant hand to stretch the skin over the area where you want to insert the cannula that anchor the vein to stretch your skin, anchor the vein with a non dominant hand and use the dominant hand to insert the candela in go at an angle of 10 to 30 degrees like in this picture. And most often the minute you go in, you get a flashback. So when there's a flashback, you know that you are in the vein and now it's safe for you to proceed no lower the cannula slightly. So you puncture at a 10 to 30 degree and then like when you get flashback, lower the cannula slightly so that you can insert it easily. And so make sure that it enters into the lumen, do not puncture exterior wall of the vessels. So don't take the needle out and re introduce the needle because that would lead to puncturing of the vessel. So gently advance the cannula or the needle while with drawing the guide. So that would be something like this. So you're slowly inserting the candle. At the same time, you withdrawing the needle. Once you've done that, you'll get a secondary flashback. So you know, you're in, you need to secure it. So release the tourniquet first, apply the pressure over the vein where you've inserted because otherwise it's gonna be bleeding. So make sure you stop that this and put the white cap on to secure the cannula. Once you've done that, make sure you've removed the needle completely. And it's called the sharp spin. We attach the white log, secure the can an appropriate dressing and then flush the cannula with the cell line. And when you're flushing, make sure that as the patient can, they most often say they can feel something cool, go into their veins. So that means that you know that you are in the vein and also check for if there is a swelling. So like when you flush, if there's swelling around the side of the cannula, it means that you are not in the vein and you have damaged the vein. So when that happens, you have to remove the cannula immediately because it will just lead to complications. Otherwise, and you'll have to find a different vein and recannulate. But if not, if there's no swelling or anything, you know that you are in the vein and everything is fine and you can use the particular cannula for your medications, your fluids, sampling blood, giving blood blood products, et cetera. Post procedure and every procedure. Make sure you document exactly what you've done. Make sure you write the date and time that you took consent from the patient, the size and site of the cannula, make sure you've recorded everything and then also make sure that you've disposed of the needles in the appropriate bins and also the used gauzes and everything. Make sure everything is disposed of in appropriately. That's very important. So when the minute you finish any procedure, you have to make sure you've also disposed. It, don't let it lie around. This is some of the common complications of any procedure. Last thing is infection. So that's what's gonna happen. So you have to keep an eye for all these things, infection, cellulitis, infiltration or pushing or extravasation. The minute you find any of these complications, do remember to take the cannula out and then find a different site. Sometimes you can keep it in a monitor. But if you feel like it's worsening, do make sure that you take the candle out immediately, thromboembolism, thrombophlebitis, bruising or hematoma. This is something you will see very, very often. So most patients I be like a lot of bruising everywhere. So it's quite difficult to find uh vein to c Yes. So that's it guys. These are my docs procedures. Uh I will be handing over the session to punit who will be talking about blood cultures and E PG and E BG. So, but before I hand it over to him any questions? OK. So that is a good question. Um I'm actually not very sure. How do you know which exact size to use? Like if is aware, maybe he could explain. Yeah, but I'll get to it at the end of the session because uh it comes into play when I talk about venous sampling as well. So I'll touch up on that in a week. OK? All right. I'm sorry about that, Alison, but Punit would be answering your question for you. So, hello guys. A very good afternoon, good evening and good morning to everyone joining us from all parts of the world I UK. Um I think I covered the most um difficult and technically more extensive. Uh do s procedures. I'll be talking about the more simpler ones. Uh Let me just get this up first. Um So I'll be talking about two procedures. Uh Why we do them, the indications regarding them and I mean, all the procedural steps, the difficulties that we usually face when we do those. So firstly, the, the main things that we need to know is blood gasses, blood cultures, blood samples, these are very commonly uh things that need to be done during you. You know, when you're a junior doctor, you, you will come across all of these procedures that you have to do routinely in the ward. Most of the times you might be asked to do bloods, you know, very rapidly for multiple people might become stressed about how it, how it works. And it's basically, it has a learning curve. It also has a decay factor. What does these two mean? Basically learning curve is as much as you practice these, you, you get better at these and the decay factor, what the decay factor is as long as you don't, if you stop doing this, you will start becoming more and more, you know, distant from the procedure and it might not be as successful as previously. So definitely practice uh these whenever you, you can find the time in the wards and it should help you guys, you know, be more efficient and faster at doing this. So, firstly, venous blood sample, are we talking about it? And you do it for any kind of blood? So anyone coming in with anything, literally chest pain, abdominal pain, any symptoms, any infective symptoms, you have to do a venous blood sample and it's very important, you know, what investigation and why you're doing the the blood test for the patient. So preparation wise like aura has already talked about every procedure has its own set of things that you have to prepare. So in venous blood procedure, venous uh blood sampling, you have a tray, alcohol swab, Tonique back cutaneous. So back cutaneous again, uh you have different types of them based on what you're trying to look out for. So, coagulation, u or urine electrolytes, different different blood tests. Uh you'll need different uh caps that you need. That. Usually most of the trust you have a guideline regarding which blood you need to uh which blood back retainer you need to select based on the blood test. So you don't actually have to remember most of them, but you have to make sure that uh you got the right one. So you can see here an alcohol swab to this is the butterfly needle for those of you guys who might be new to this. This was my uh first time seeing such a butterfly needle here as well. So butterfly needles, the advantage with them is that they are very flexible, they are very thin, they are practically almost painless when compared to the syringes. And essentially when selecting between us or a butterfly needles, basically boils down to the trust guidelines. So do review them before you go about uh selecting one of it. And uh you need a connector, some gauze and bandage, selection of veins is very, very important. Often you find pediatric people, you find geriatric people or people with IV drug abuse in those people. Selection of veins becomes a main issue because uh finding the normal vessels that we usually use, such as the cephalic and the median coital becomes very problematic. Um In those we usually, what we try to do is uh we try to try a cephalic and to vital palpate it first try to see if it is bouncy or springy. Most of the times. Uh there might be uh things like tendons, some areas where they have been thickened due to previous uh cannulation attempts, some hematoma, some bruises, like what was discussed by my colleague. In those cases, you have to make sure that um you avoid those areas and try to find a nice vessel that is springy when you touch a good way. How uh you you can do this is basically just tap on the vessel and observe that when you lift off your finger, it pulls with your finger. So it just basically pushes against your finger and you go up. So that is one way you can actually set up a a vessel to, to do a venous blood sampling steps wise again, take consent, explain the procedure to the patient that is first and foremost, and um get the tree ready, apply a tourniquet, try to find the vessel first uh establish where the vessel is establish the entire course of the vessel. Once you have established uh the course of the vessel, what you do is then you take the alcohol swab and clean the area thoroughly. So when cleaning or clearing the area, make sure that you do it in circles from inside out and not from outside in, you do that for 30 seconds and let it air dry. After that, you take the appropriate needle and you go in at a 10 to 30 degree angle to the skin. Again with this, you have to observe a flashback. And if needed, you can advance further. If you feel that it's enough for you to take samples, you can just stop there and observe as the va fills up. And once you have sufficient blood supply or sorry, once you have a sufficient blood sample, you stop, uh you just remove the tourniquet, remove the syringe, apply gauze and bandaged the area. So when applying pressure, make sure that once you have removed the needle and the tourniquet, you apply a decent amount of pressure on the area. If it's venous blood sampling, you have to apply pressure for at least one minute. Uh This is so that the person doesn't bleed out in that area or blood doesn't extravasate. And this is the main, you know, steps behind IV cannulation, uh uh blood sampling. But both IV cannulation and blood samplings share similar uh you know, complications. They have the same hematoma, they have bleeding, they have nerve and artery injuries. Usually what happens is sometimes when you don't get the vein, you tend to p go in deep. Usually, um nerves are located much more deeper. And when you s when you uh inad prick into that, that might cause some amount of nerve injury coming to cultures, that culture is another important thing uh in, in, in, in any practice. And you should, that you should know mainly because you see so many patients with septic features coming in that you have to make sure that you know how to do a blood culture uh on a patient. The different be the difference between blood cultures and uh normal venous blood samples is firstly, the equipment. As you can see, you have a aerobic and an ana anaerobic bottle. This is not there in, in these blood sampling. The next step is in cultures, we have to make sure that uh making sure the f is sterile is the most important step um of the entire procedure. Why? Mainly because we're trying to find what organism has caused all of these, you know, uh problems for the patient. So in case of sepsis, in case of infective endocarditis, in case of spondylodiscitis, in case the person spikes temperature and you need to know what organism might be in his blood. You need to do culture and making sure you're completely, you're completely sterile yourself is one of the main main important things that we look for because most of the times you do get samples which have been heavily contaminated during procedure. So one tip, which is um probably the most important drug I was taught during when I first started was to remove these metallic tips on these bottles and then wipe them down with canal. Uh you know, any alcohol swabs and make sure they're ready to go. Uh just putting your finger on them, can introduce a lot of bacteria that will bring up the wrong report. And ultimately, the person will be given uh a different entire different set of antibiotics that might not even help in the resolution of symptoms. So you have to make sure that you are careful when you're doing a blood culture. The procedure behind uh blood culture is the same as a venous blood sampling where sometimes in different trust, you have their own culture sets. Uh These culture sets come with gloves, so they come with these two bottles, they come with a complete needle holder with a needle. And basically, these are usually what are most needed during the culture. Why we do uh this so importantly is mainly because of sepsis. And as we all know, sepsis is one of the potentially fatal and one of the more serious uh medical conditions that we usually face on day in day out basis doing uh our work. So just to recap about things if it's not been told earlier, is that few things that you have to do immediately is obviously provide oxygen, start them on IV, fluid, start them on antibiotics. Make sure you send blood cultures, make sure you send blood for sampling, make sure you send urine. Um All of these are very important coming to but gas, um but gas is a bit more difficult, mainly because of the nature of how it's done. Uh You have to go at a deeper angle. It usually takes up, it's quite painful for the patient. It is not simple and usually in more difficult people with difficult habits, it's even more difficult to actually perform this A DG on them. But ABG is very important, especially to assess for ventilation, especially to understand how the person is in terms of uh respiration wise and whether he's been having any problems with acid base balances to tweak oxygenation and treatment options. So most mostly I've seen in respiratory wards where people come in with COPD, where they come in with respiratory depression, respiratory failure. Uh you basically go ahead and do the arterial blood tests mainly to make sure that, you know, you can treat them effectively and efficiently if they are put on equipment like high flow oxygen, uh NIS and things like that. So arterial blood gas is very important. Usually some places uh usually give a local anesthetic even before we do an ABG. So any idea what this is, if anyone can drop you in the comment uh comment section. OK. So, so essentially this is the modified Allen test. So why we, why do we do the modified Allen test? So even before we do arterial blood gas, the most common site that we do an arterial blood gas on is on the radial artery, the radial artery and the ulnar artery both supply the palm of the hand and we don't want to compromise on the blood supply to the palm of the hand. So we do the modified elements whereby we occlude both the ulnar artery and the radial artery, ask the person to make a fist and occlude them and then ask them to open up their hand and then release the ulnar artery. So what do we expect? We expect the farm to be turning pink and red with establishment of patent blood supply to the farm. So, if that is not bad, that essentially means that the ulnar artery is not competent enough to supply the palm of the hand. And what happens in these cases are if you do an ABG on the radial artery and it fails and the radial artery has a puncture in it and the ulnar artery is not competent. The patient might go into things like limb ischemia. Uh He might have complications where the blood supply is completely cut off to his hands and fingers. So a simple modify all test on the bedside just before you plan on doing an ABG, would, would be the best way forward, contraindications wise, uh cellulitis, fistulas, peripheral vascular disease and bleedings and coagulopathies in these conditions. You will obviously look out for um places where you might benefit from doing like femoral brachial rather than radial. If, if, especially if the area is affected by, you know, things like cellulitis, localized infections, any anatomical uh problems that might arise in the region, like, you know, ganglions, any cysts, things like that, Equipment wise, equipment wise, as you can see, the ABG needle is right here. It's quite small and compare as compared to other syringes. Uh when you look at the ABG needle, it has a needle safety device at the back. And um these are the equipments we usually collect for an ABG, we have the gloves, the gauze alcohol wipes, tape ABG needles. So there is no merit pretty much uh in, in, in most of the, the, the NHS uh trust. Uh so far that I've seen where you actually use an alcohol wipe, but it is obviously a good practice to keep the area clean uh before you do an ABG. And so um just review the local trust guidelines for your, for your hospital before you choose to use an alcohol wipe. So when it comes to doing an ABG, as you can see, there's a machine there, a huge machine here uh mainly used to study ABG SDB GS. Give you an idea regarding what kind of uh respiratory feature the person might be coming in and give you an idea regarding the ph of the blood, the PC two of the blood, the po two of the blood, all of this is just the, the content of gasses which are present in the blood so that it can help you with the treatment coming to the steps. So arrange the equipment, flush the heparin through the syringe first, extend the patient's wrist to a 20 to 30 degree angle. So um as you can see here, try to extend the patient's hand to a 20 to 30 degree angle. Uh you can put a towel. Uh I basically use a IV fluid bag sometimes and this is another tip or trick that you can take away uh most of the times with blood, you know, with blood sampling, abgs catheterizations, you usually try to observe as many as you can and pick up these kind of uh small uh tips along the way. So, in, in, in, in my practice, I've seen a lot of people using IV bags at the uh just below the hand and then it, it makes the hand kind of uh you know, extend to a 20 to 30 degree angle, palpate the radial artery, just like how you palpate for the heart rate. You can palpate the radial artery and then try to feel it in its length. Again, here, there's a concept of a non dominant and dominant hand, the non dominant hand to put, it simply is basically just to know the the the path of the radial artery. Uh it's just gonna palpate along the ra artery length to make sure that with the dominant finger, you can prick it exactly where it needs to be. So using a dominant hand, hold the ABG needle like a duck. As you can see uh the person on the left, the photo to the left, it shows the guy holding with his dominant hand and the left hand held proximally to the uh radial artery just for guidance. Previously, I was told to try to kind of put your non-dominant hands, ring finger and uh your index finger and then try to pick prick in between. But that is not safe and has resulted in a lot of um adverse events. So, rather than doing that, you can have the non diamant hand as just calculating the cost while you use the dormant hand to hold the tart inside at a 30 to 45 degree angle. Um You advance slowly and you'll observe a flashback and you start feeling in a pulsatile manner. So once it's once you have sufficient sample, usually we need a approximately about 1.5 to 2 mL uh just on the safer side, just engage the needle safety device, which is this part so that you don't prick yourself or anyone else and then analyze the sample here. The most important thing for ABG S is to apply pressure at the site for at least five minutes. Uh As you're puncturing an artery, there's a lot of high force in the artery and it spreads out just like how the heart kind of uh functions. So with a lot of pressure, blood usually kind of spreads out. So it does not release pressure on the hand, even to check uh whether you've got it or not, um hold the pressure for five minutes, ensure that there's no more bleeding. And then afterwards document what you have done and also explain to the person about uh you know, post E BG uh taking care of the site like to, to let us know if there's any bruising to let us know if there's any kind of pain, um any nerve nerve related, like if you feel tingling numbness, things like that to alert you guys. The next step would be just to make sure that you immediately go and get the sample to the analyzer because that is very important. You need that information there. Um These are my references and coming to the doubt about um selection of sizes of cannula. So we have a number of different colors when it comes to Cannula selection. Just like how we select uh Cannulas. We, we, we have like orange, gray, green, pink, blue, yellow, violet, we have a number of different types of can uh uh you know, Cannulas and we have a lot of different types of gear use. So essentially it is from 14 all the way to 26 gauge. So you are 1416, 1820 22 24 26. So gauges going up by two in every step of the way as it goes up by two gauges every, every every time uh the amount of fluid that you can give through the, the, the IV catheter also. So kind of decreases. So in orange, you can give up to 240 mL per minute. Whereas in the entire opposite spectrum where you have a pilot, you can only give 30 mL per minute. So when it comes to cases where you have a lot of loss of blood, like a traumatic episodes, uh things like that, you try to go for a lower gauge, which means the needle is wider and you can give a lot more fluid in a single output. For example, if a person is bleeding and you know, he has lost a lot of blood, uh what we would probably do is put in two gray needles or green needles where you can give up to 180 ml per minute. Whereas if you go for thinner ones, like pink blue, which are higher gauge like 2022 what happens is a decreased amount of fluid as compared to the gray can be given. So when you want to give boluses, it becomes quite hard. So selection of IV can is very important. Usually with older frail people with very uh uh you know, difficult veins to establish IV cannulation. We try to go for the thinner ones. Uh even though they, they, they might not, you know, have any indication for the larger ones. So if you, if an older person comes with very fragile veins or he has a lot of comorbidities, you don't expect to give a lot of fluids. The first line or according to the trust would probably be a pink or a blue. But if you have a person who you feel that needs probably would need or needs a high volume within a short period of time, you can go for things like gray and orange where a lot of, a lot more fluids can be given. Um I will put up a photo because unfortunately, we don't have it here in this presentation uh in the next uh next, next week, probably there's another session. Uh We have a, we have a session next week as well. It is gonna be uh another interesting session. I'm gonna drop the link in the comments now, um They will probably show the photo of the IV Cannula during the next session. So, so that, you know, you guys can just take a look at what IV can, you can select and things like that pretty much. These are the more important dos that we usually face during day to day basis. Uh You know, in the what what if does anyone have any doubts? Please drop it in the comment so that I can answer for you guys. These are all printers. So I'm just gonna drop the link for next week. Apologies for. So next week is gonna be about abdominal pain and this is the link if you guys want to register and that's about it for today. I hope you guys have found the session useful and if there's any other doubts, please drop them. The main section. I think uh there's uh policies regarding per venous that my colleague has just drop in the comment as well. Can just take a look at it. It's quite a huge um length at the moment. So, all right. Thank you guys. We'll see you next week. I hope you had a good one today. Take care.