Letters to the Editor The patient’s wife consented to publication of this letter. 3. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Wolfram Schummer1,2 1 Roentgenol 1995;164:1259‑64. Omar HR, Sprenker C, Karlnoski R, Mangar D, Miller J, Camporesi EM. The incidence of retained guidewires after central venous catheterization in a tertiary care center. Am J Emerg Med 2013;31:1528‑30. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Friedrich Schiller University Jena, Jena, 2HELIOS Spital Überlingen, Überlingen, Germany Access this article online Quick Response Code: Address for correspondence: Dr. Wolfram Schummer, HELIOS Spital Überlingen, Härlenweg 2, 88662 Überlingen, Germany. Friedrich Schiller University Jena, Jena, Germany. E‑mail: wolfram.schummer@web.de DOI: 10.4103/ijccm.IJCCM_93_18 References 1. 2. Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002;88:144‑6. Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: Experience in 32 cases. AJR Am J Website: www.ijccm.org How to cite this article: Schummer W. Loss of guidewire. Indian J Crit Care Med 2018;22:561-2. © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow Bloodless Arterial Cannulation Technique Sir, Radial artery cannulation is often used for invasive arterial blood pressure monitoring and arterial blood gas analysis. It is a routine procedure in cardiac surgical theaters and Intensive Care Units. Common complications include radial artery spasm (20%), hematoma (14%), and hemorrhage (0.5%).[1] However, many a times, this procedure involves blood spillage and soiling of drapes after successful cannulation. Further, in a haste to minimize this and establish the transducer connection quickly, there is always a potential risk of cannula dislodgement and needlestick injury to the health‑care provider. According to the WHO, needlestick injuries nearly contribute to 95% of the HIV occupational seroconversions.[2] To prevent this, the authors propose a simple modification of the radial arterial cannulation technique using Smiths medical Jelco® vascular access device. This technique is suitable for both direct and ultrasound‑guided arterial cannulation. Under all aseptic precautions, the desired site is prepped, cleaned, and infiltrated with local anesthesia. Prior to cannulation, the cap of the Jelco® is attached to the hub of cannula‑stylet assembly [Figure 1a]. After puncturing the radial artery, free flow of arterial blood is seen inside the hub. This backflow of the blood is collected within the cap attached to the hub which prevents blood spillage. The cannula is then slowly advanced over the stylet by rotating movements [Figure 1b]. After this, radial artery with the cannula in situ is compressed proximally, while the stylet‑cap assembly is withdrawn gently [Figure 1c]. Transducer assembly is then connected to the hub by the assistant. The authors are of the opinion that such a modification will help to minimize the risk of blood spillage, soiling of drapes and operation theater floor, potential direct contact with the blood, 562 a b c Figure 1: Arterial cannulation technique with (a) cap attached to the hub of Jelco®; (b) blood being collected inside the cap and (c) clean site during fixation with proximal radial artery being compressed and thereby blood‑borne infections to the health‑care personnel. In addition, the collected blood inside the cap can be used for biochemical analysis and investigations. This modification retains its cost‑effectiveness in low‑resource settings when compared to specialized intravenous safety catheters, namely BD arterial cannula with Floswitch™, BD Insyte™ Autoguard™, BD Insyte™ Autoguard™ Shielded IV Cannula, and Smiths medical Jelco® ViaValve® safety IV catheters, which prevents backflow of blood using a one‑way valve within its system. However, certain amount of skill and practice is required in this technical modification to maneuver the cannula into the arterial lumen without any manipulation of the stylet‑cap assembly of Jelco®. Indian Journal of Critical Care Medicine ¦ Volume 22 ¦ Issue 7 ¦ July 2018 Page no. 98 Letters to the Editor Financial support and sponsorship This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Nil. Conflicts of interest There are no conflicts of interest. Amruta Shringarpure, Pushkar Desai Access this article online Department of Cardiac Anesthesiology, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India Quick Response Code: Address for correspondence: Dr. Pushkar Desai, Department of Cardiac Anesthesiology, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India. E‑mail: pushkarmdesai@gmail.com Website: www.ijccm.org DOI: 10.4103/ijccm.IJCCM_17_18 References 1. 2. Tiru B, Bloomstone JA, McGee WT. Radial artery cannulation: A review article. J Anesth Clin Res 2012;3:209. WHO.int [Internet]. ©2018 WHO. Available from: http://www.who.int/ occupational_health/topic/hcworkers/en/. [Last accessed 2018 Jul 6]. How to cite this article: Shringarpure A, Desai P. Bloodless arterial cannulation technique. Indian J Crit Care Med 2018;22:562-3. © 2018 Indian Journal of Critical Care Medicine | Published by Wolters Kluwer ‑ Medknow Thromboelastographic Analysis of Hemostatic Abnormalities in Dengue Patients Admitted in a Multidisciplinary Intensive Care Unit: A Cross‑Sectional Study Sir, We read with immense interest the study entitled “Thromboelastographic analysis of hemostatic abnormalities in dengue patients admitted in a multidisciplinary intensive care unit: a cross‑sectional study” by Sureshkumar et al. published in April 2018 issue of your journal.[1] The authors have recorded and provided vital information on a relatively unexplored area and rightly pointed out that thromboelastography (TEG) may be helpful in understanding the pathophysiology of hemostatic abnormalities in patients with dengue. We would like to comment on the following points which may need further elaboration: 1. TEG was done only at admission in this study. Serial analysis of TEG parameters would have better elucidated the dynamics of hemostatic abnormalities in these patients 2. Factors such as blood sample collection technique, transportation time of sample from the Intensive Care Unit (ICU) to laboratory and the TEG assay used (e.g., kaolin or heparinase TEG) are also crucial for an accurate interpretation of the coagulation pattern by TEG.[2,3] This information needs to be clearly mentioned in the methodology 3. TEG per se is not a good method for assessment of platelet function, for which better modalities are available.[4,5] It is difficult to correlate platelet count with platelet function using TEG 4. Some patients with dengue might have been in sepsis as well, which can further influence the coagulation profile 5. The references cutoff values for TEG have been provided by manufacturer (from studies on western population), which may not be applicable to our setup. Studies on healthy Indian cohorts can generate the normal reference range values for TEG parameters in our population. A similar study was performed and published by us recently on the evaluation of coagulopathy in nonbleeding patients with sepsis at ICU admission. We found that TEG (unlike conventional coagulation assays) could delineate three types of coagulation patterns in patients with sepsis: normocoagulant, hyper‑ and hypocoagulant patterns. Besides, patients with septic shock had a trend toward hypocoagulation while those without shock had trend toward hypercoagulation.[6] It has been aptly pointed out by the authors that the correlation of TEG with usage of blood component therapy or guiding the usage of drug therapies would definitely be more relevant to the clinicians. To conclude, TEG is emerging as a pivotal tool for assessment of hemostatic dysfunction in different areas (like sepsis) besides its classical role in trauma and cardiac surgeries. Larger studies are further needed for evaluating the role of TEG in guiding transfusion practices, monitoring, or instituting drug therapy and for prognostication of outcome.[7] Financial support and sponsorship Nil. Indian Journal of Critical Care Medicine ¦ Volume 22 ¦ Issue 7 ¦ July 2018 Page no. 99 563