risks.

Nonetheless, it is important that patients and/or

ICU Devices and their families be informed of both benefits and risks.

Procedures There are some devices that are commonly used in the
ICU that your doctor does not need to get permission to
General Information use because they carry minimal or no risk. These include
continuous measurement of the heartbeat by small pads
placed on the chest (called an ECG or electrocardiogram)
In the ICU, many machines, devices, and procedures are
and measurement of oxygen in the bloodstream using a
used which are relatively uncommon in other parts of the
light probe on the fingertip (called pulse oximetry). These
hospital. Each device has a particular job or purpose.
and other relatively low-risk parts of your treatment,
There are reasons (indications) to use each device or
including placement of catheters into the small veins of
procedure for assessment or treatment. Most have some
the body, blood draws and administration of medicines,
risk (possible complications) as well as potential benefit
are included under the consent form you sign when you
about which you should be informed (see section on
come into the hospital.
General Information and Expectations). We have
developed information sheets that describe the
(For hospitals that download these information sheets for
indications (reasons for), risks and benefits of a number
institutional use in the informed consent process, we
of commonly used devices and procedures. These
suggest including this page with each information sheet
information sheets are not a substitute for discussions
to assure that patients and/or families
with the doctor.
understand the general purpose of these
They serve as
Pulse Oximeter - The clip on the finger measures documents.)
an educational
the oxygen in the blood and shows the level of
aid.
oxygen on the display (in this case the oxygen
level is 98%). A clip similar to this is used and is
As you read, you attached to the Critical C
may get worried
about the number of complications that can occur.
Moreover, not all complications may be included in this
list. For each procedure, we've chosen the more frequent
complications. We must emphasize that most of the risks
are low. Your doctor can inform you about these risks
and any reasons the risks may be expected to be higher
in your situation. Many complications can be treated if
they occur and your doctor can describe this as well.
Your doctors would not suggest a procedure or device if
they did not believe that the benefits outweighed the
I- Catheterization of the Urinary
Bladder (Foley
Catheterization)
A "Foley" catheter (or thin hollow tube) is placed in
the bladder to let urine drain from the bladder. The
Foley catheter can help patients who are too ill to
pass water on their own. It also helps make sure
that all urine is measured in patients who need very
careful fluid balance.
Common reasons for its use and benefits:
• Measurement of urine - In many critical
illnesses, the amount of urine that patients
make every hour provides an important
measure of how they are doing. Even in a
patient who is able to pass water, sometimes
a Foley catheter is used when it is important
to know exactly how much urine that a patient
is making every hour.
• To drain the bladder - In patients who are too
weak to get up and pass water on their own or in
patients who are unconscious, the Foley
catheter drains the urine from the body.
Sometimes the bladder becomes weakened by
disease or medication and doesn't empty
properly. In these situations, the Foley
catheter can prevent the excessive build up of
urine in the bladder, which can be
uncomfortable.
Risks:
Some of the risks of Foley catheterization include:
• Infection - The most common risk of Foley
catheter placement is infection. Bacteria can
move up the catheter, pass into the bladder,
and cause infections. The longer the Foley
catheter remains in place, the higher is the
likelihood of an infection. Care is taken with
the tube and drainage system to prevent
infection but it can occur even when
everything is done correctly. Infections can
usually be treated with antibiotics.
• Injury to Urethra - During the insertion of
the catheter, the urethra (the tube that leads
to the bladder) can be injured or punctured.
This complication is rare and usually it heals
on its own without treatment.
Because of the low risk and common need for this
procedure, the consent that patients sign for
general treatments at the time of coming into the
hospital usually includes permission for placement
of the Foley catheter if it is needed.
 Common reasons for its use and benefits:

• Monitoring the stomach - This is very important

to prevent the stomach from being overfilled with
food or stomach

• Juice, and to make sure the stomach juice does not

become too acid.

• Feeding - Some patients who cannot swallow and

some patients who are on mechanical ventilators
can be fed through nasogastric or feeding tubes.

Risks:

Some of the risks of putting in a nasogastric or feeding

tube include:

• Discomfort during placement - Discomfort can

Foley Catheter The tip of the catheter (shown by the result when the tube is inserted. Doctors try to
arrow) is coated with jelly to make it easier to pass lessen the pain by putting a jelly on the tube that
through the passage that helps it to slide in more smoothly.
II- Stomach Tubes
• Placement into the lung - While the tube is
being passed, it can go down the windpipe instead
Many critically ill patients are not able to swallow
of into the stomach. This can cause coughing.
properly. Also, patients on mechanical ventilators cannot
Doctors often get an x-ray to see where the tube
eat by mouth. When the stomach and intestines continue
goes before they give food or water through it.
to work, a tube can be placed through the nose or mouth
and pushed down into the stomach. This tube allows
• Collapsed lung - While the tube is being passed,
nurses to make sure that the stomach does not get over
it may, very rarely, go down into the windpipe and
filled, and also to feed the patient. Nasogastric (or
puncture the lung. This hole may seal quickly on
"N.G.") tubes are thicker tubes (about the thickness of a
its own. If the hole does not seal over, air can build
pencil). These tubes are used when it is important both
around the lung and cause it to collapse (this is
to suck out stomach fluid for testing, to prevent over
called pneumothorax). In such cases, a chest tube
filling, and for feeding. Feeding tubes are thinner tubes
is sometimes needed to drain air from around the
that are used mainly for feeding.
lung (see related Information Sheet on Chest Tube
Thoracostomy).
Because of the low risk and common need for stomach
tubes, the consent that patients sign for general
treatments at the time of coming into the hospital
usually includes permission for passing a stomach tube
through the nose or mouth if it is needed. If the tube is
needed for a long time, doctors may need to make a hole
in the abdomen and pass a tube through the skin, into
the stomach or intestines. Surgery of this nature requires
consent from patients or families.
III- Arterial Catheterization
An arterial catheter is a thin, hollow, tube which is placed
into the artery (most commonly of the wrist or groin) to
measure blood pressure more accurately than is possible
with a blood pressure cuff. The catheter can also be used
to get repeated blood samples when it is necessary to
frequently measure the levels of oxygen and/or carbon
dioxide in the bloodstream.
Common reasons for its use and benefits:
• Low blood pressure (hypotension or shock) -
When a low blood pressure cannot be corrected
rapidly with fluid given through a patient's veins.
The need to measure pressures in the large blood
vessels is greatest when the patient is receiving
powerful medications that stimulate the heart as a
way of keeping the blood pressure up. The arterial
catheter allows accurate, second-to-second
measurement of the blood pressure; repeated
measurement is called monitoring.
• High blood pressure (hypertension) - In some
situations, the blood pressure can go so high that
it is life-threatening. Such high blood pressure
must be lowered gradually in steps, and
measurements with an arterial catheter help guide
the treatment.
• Severe lung problems - When a patient has a
lung problem that is so severe that it requires
checking the levels of oxygen or carbon dioxide of
the blood more frequently than 3 to 4 times a day,
the arterial catheter can be used to draw blood
without having to repeatedly stick a needle into
the patient.
Risks:
Some of the risks of arterial catheterization include:
• Pain during placement - Discomfort can result
from the needle stick and placement of the
catheter at the time it is inserted. Doctors try to
lessen the pain with a local numbing medicine
(anesthetic like novocaine). The discomfort is
usually mild and goes away once the catheter is in
place.
• Infections - As in the case with all catheters
inserted into the body, bacteria can travel up the
catheter from the skin and into bloodstream. The
longer the catheter remains in the artery, the
more likely it is to get infected. Special care in
bandaging the skin at the catheter site and
changing tubing can help to decrease the risk of
infection.
• Blood clots - If blood clots form on the tips of
arterial catheters, the clots can block blood flow. If
another blood vessel does not carry blood to the
area beyond the clot, this can cause the loss of a
hand or leg. Such a loss is very rare. To decrease
the likelihood of these problems, the ICU staff
 checks regularly for blood flow in the hand or leg
when a catheter is in the artery.
• Bleeding - Bleeding can occur at the time of
inserting the catheter. The bleeding may stop
without doing anything. Sometimes, the ICU staff
need to remove the catheter and apply pressure
IV- Right Heart Catheterization
Right heart catheterization (also known as
pulmonary artery catheterization or Swan-Ganz
catheterization) is a common procedure in critically
ill patients. The catheter is a long thin hollow tube
that is placed through a central venous catheter
(see Information Sheet on Central Venous
Catheterization) and is then guided through the
chambers of the heart and into the large blood
vessels of the lungs. The catheter is left in place in a
pulmonary (lung) artery. This catheter measures
pressures in the heart and large blood vessels and
checks how well the heart is working.
Common reasons for its use and benefits:
In most cases this procedure is done when the
organs of the body are at risk of failure, and when it
is not possible to figure out the pressures in the
heart or how well the heart is pumping blood
without the catheter. Most experts believe that the
catheter, when used correctly in carefully selected
patients, helps the doctor decide how to better
manage some critically ill patients. Some common
situations in which doctors recommend right heart
catheterization include:
• Low blood pressure (hypotension or
shock) - When the blood pressure remains
very low despite giving fluids and medications
to the patient. The need to measure pressures
in the large blood vessels is greatest when the
patient is receiving powerful medications that
stimulate the heart as a way of keeping the
blood pressure up.
• Kidney abnormalities - When urine flow is
too low to get rid of the wastes of the body
and giving fluids and/or diuretics (medicines
intended to stimulate urine output) does not
increase urine output.
• Lung water (pulmonary edema) - In
patients with a lot of water in their lungs due
to heart failure or inflammation of the lungs,
the catheter can help monitor treatments to
prevent more water from accumulating in the
lungs.
• Specific heart abnormalities - There are
some abnormalities of the heart - such as
when fluid collects around the heart or a heart
valve doesn't close properly - in which
measurements with the catheter help to make
the diagnosis and guide treatments.
Risks:
Some of the risks of central venous catheterization
include:
• Pain during placement - Discomfort can
result from the needle stick and placement of
the catheter at the time it is inserted. Doctors
try to lessen the pain with a local numbing
medicine (anesthetic like novocaine). The
discomfort is usually mild and goes away once
the catheter is in place.
• Collapsed lung - This is called a
pneumothorax. The lung is very close to the
veins of the neck or chest. If the needle
passes through the vein, it could pierce the
lung causing it to leak and collapse on that
side. If this happens, the doctor can place a
tube between the ribs into the chest to suck
out the air that is leaking from the lungs (see
related Information Sheet on Chest Tube
Thoracostomy). This complication is
particularly dangerous when a patient is on a
breathing machine. Rarely, collapse of the
lung can cause death. This complication can
even happen when everything is done
correctly.
• Infection - Any tube (catheter) entering the
body can make it easier for bacteria to get in
and infect the patient. The longer a catheter
remains in the body, the more likely it is to
become infected. Special care in bandaging
the skin at the needle site and changing the
connecting tubes and fluids help to decrease
this risk. With great care, these catheters can
remain in the body for several weeks without
becoming infected.
• Bleeding - Bleeding around holes in the veins
is usually mild and seals on its own. Since the
major arteries run alongside the major veins,
the arteries can be punctured by accident.
Even bleeding from an artery can stop on its
own before serious problems occur. Rarely,
the chest fills with blood, which can be life-
threatening. In that situation, it may be
necessary to place a tube between the ribs to
drain out the blood (see related Information
Sheet on Chest Tube Thoracostomy).
• Clotting around the catheter - Blood clots
can commonly form in and around these
catheters inside the veins. Such clots usually
do not cause problems. Once the catheter is
removed, the body can often dissolve the clot
over time. Sometimes, clots can break off and
travel out into the lungs. This is called a
pulmonary embolism. A blood clot in the lungs
can cause breathing problems and, very
rarely, death.
• Air entering through the catheter - Rarely,
air enters the catheter as it is being inserted.
The air bubbles can travel through the heart
and cause lung injury and low blood pressure.
This problem is called an air embolism. Special
care is taken to avoid air entry.
Some risks are specific to the placement of the
catheter through the heart to the pulmonary artery.
• Heart rhythm abnormalities - The catheter
can accidentally tickle the heart and stimulate
 its electrical system, causing the heart to beat
too fast. In patients who already have heart
rhythm problems, the catheter's tickle could
cause the heart to go very slow (this is called
heart block).
• Rupture of the pulmonary artery - This is a
very rare complication in which the catheter
breaks the large blood vessel in the lung that
it is in. Such a breakage can cause life-
threatening bleeding.
Complications can occur even when everything is
done correctly. Serious complications are reported
in less than 5% of patients.
Right Heart Catheter The arrow labeled "1" shows where
the catheter would enter the patient's body, usually in
the side of the neck. The tip of the catheter labeled "2"
is pushed through the chambers of the heart into a
large blood vessel of the lung.
V- Mechanical Ventilator
A mechanical ventilator is a machine that makes it
easier for patients to breathe until they are able to
breathe completely on their own. Sometimes the
machine is called just a ventilator, respirator or
breathing machine. Usually, a patient is connected
to the ventilator through a tube (called an
endotracheal tube) that is placed in the windpipe.
Sometimes, patients can use a machine that assists
breathing through a mask or mouthpiece but this
may not work with severe respiratory problems.
Despite their life-saving benefits, mechanical
ventilators carry many risks. Therefore, the goal is
to help patients recover as quickly as possible to get
them off the ventilator at the earliest possible time.
Common reasons for its use and benefits:
• To deliver oxygen
• To eliminate carbon dioxide
• To ease the work of breathing
The main job of our lungs is to get oxygen into the
body and to get rid of carbon dioxide. When a
patient's lungs are no longer able to do this job
completely, we use a ventilator to help. Most
commonly, patients are put on a mechanical
ventilator when they are in respiratory failure.
Respiratory failure is the situation when the patient
has a low level of oxygen in the blood, even while
getting oxygen therapy and/or when the level of
carbon dioxide rises too much in the blood. Some
patients need help from a ventilator even though
they still have nearly normal levels of oxygen and
carbon dioxide in the bloodstream. This can be true
when breathing is very uncomfortable. Sometimes
patients are placed on a ventilator because of other
serious injuries that require treatment, which may
interfere with breathing temporarily.
In most cases, mechanical ventilators are used for
patients who cannot breathe by themselves. The
only other choice would be to allow the patient to
die, while using medicines to maintain comfort (see
sections on Code Status and Withdrawal of Life-
Sustaining Treatments). Mechanical ventilators do
not actually fix diseases, but rather keep the patient
alive while the hospital staff finds out why the
patient has difficulty breathing and treats the
disease that is causing the difficulty.
Risks:
Some of the risks of mechanical ventilation include:
• Infections - The endotracheal tube in the
windpipe makes it easier for bacteria to get
into the lungs. As a result, the lungs develop
an infection, which is called pneumonia. The
risk of pneumonia is about 1% for each day
spent on the ventilator. Pneumonia can often
be treated with antibiotics. Sometimes the
pneumonia can be severe or difficult to treat
because of resistant bacteria (see General
Information).
• Collapsed Lung - This is called a
pneumothorax. The mechanical ventilator
pushes air into the lungs. It is possible for a
part of the lung to get over-expanded which
can injure it. Air sacs may leak air into the
chest cavity and cause the lung to collapse. If
this air leak happens, doctors can place a tube
in the chest between the ribs to drain out the
air leaking from the lung. The tube allows the
lung to re-expand and seal the leak (see
related Information Sheet on Chest Tube
Thoracostomy). Rarely, collapse of the lung
can cause death.
• Lung damage - When the lungs are diseased
and not functioning well, they are at greater
risk of injury. The pressure to put air into the
lungs with a ventilator can be hard on the
lungs.
• Side Effects of Medications - Patients may
be given medications, called sedatives, to
make them more comfortable while the
ventilator pushes air in and out of the lungs.
These medications make patients sleepy and
help them forget unpleasant experiences. The
medications can build up in the body and the
patient may remain in a deep sleep for hours
to days, even after the medicine is stopped.
Although the doctors and nurses try hard to
get just the right amount of medication for a
patient, it is not easy to get it perfectly right.
• Maintenance of Life - In some very sick
patients, trying to keep the patient alive
means that dying actually takes longer.
Sometimes the lungs fail because the body is
dying, and using the ventilator in place of the
lungs only serves to put off what is inevitable -
death. In this way, the ventilator may increase
the length of time that patients are
uncomfortable in their final days. Sometimes,
doctors can give a good idea how likely use of
mechanical ventilation will lead to a successful
 recovery. Very often, however, doctors can
only give a rough idea of the likelihood that a
patient will survive and go home after
mechanical ventilation. A decision about
continuing mechanical ventilation or not may
come up if a patient is not showing any
recovery or is continuing to get worse (see
sections on Code Status and Withdrawal of
Life-Sustaining Treatments).
Mechanical Ventilator - A mechanical ventilator pumps
air and oxygen through the blue tubes and into the clear
tube, called an endotracheal tube (that the assistant is
pointing to), which is placed in a patient's windpipe.
VI- Weaning From Mechanical
Ventilation
Weaning refers to the process in which intensive
care staff tries to get a patient to breathe without
the help of the mechanical ventilator (also see
Information Sheet on Mechanical Ventilation). When
patients have recovered enough, they often can
breathe by themselves or with only a little help from
the ventilator. This ability is checked during a short
testing period called a weaning "trial." If the patient
remains comfortable during a trial, a small amount
of blood may be drawn at the end of the trial to
check the level of oxygen and carbon dioxide (this is
called an arterial blood gas). If these levels look
good, the breathing tube can usually be removed
from the lungs. If a patient becomes very short of
breath or anxious during the weaning trial or if the
levels of oxygen or carbon dioxide are not at an
acceptable level, we say that the patient "failed" the
trial. Further attempts at weaning may be made
later that day or on another day.
In some cases, the intensive care staff chooses to
reduce, in steps, the amount of help a patient gets
from the ventilator. This reduction can occur rapidly
(over minutes or hours) in patients who are doing
well, or it can occur gradually (over days) in patients
who are still moderately ill. At each step, the
comfort of the patient is assessed.
In a small number of patients, the breathing tube
(endotracheal tube) needs to be replaced after
being taken out and the patient is placed back on
the breathing machine. The weaning process has to
then start all over again.
VII- Tracheostomy (Putting a
Breathing Tube Through a Small
Hole in the Throat)
In patients who are doing poorly during weaning trials
(see Information Sheet on Weaning from Mechanical
Ventilation), doctors may suggest taking the breathing
tube out of the nose or mouth and, instead passing a
tube through a small hole, made in the throat, called a
tracheostomy. The opening in the throat can be done in
the operating room or in the intensive care unit. The
tracheostomy may allow the patient to come off the
ventilator more quickly and may be more comfortable. A
tracheostomy can be taken out when the patient is able
to breathe well without the help of the ventilator.
Common reasons for its use and benefits:
• Long-term mechanical ventilation - In patients
who cannot be weaned (see Information Sheet on
Weaning from Mechanical Ventilation) from the
ventilator after a few weeks, a tracheostomy is
used to continue mechanical ventilation (see
Information Sheet on Mechanical Ventilation).
• To help with weaning - Some patients cannot be
weaned from the ventilator (see Information Sheet
on Weaning from Mechanical Ventilation) with the
usual breathing tube placed in the mouth or nose.
Some of these patients can be weaned
successfully with a tracheostomy.
Risks:
Some of the common risks of a tracheostomy include:
• Bleeding - This can occur from the skin
immediately after the tracheostomy is placed or at
any time later. Bleeding from the skin is common
and is usually mild. Much less commonly, a major
blood vessel can rupture, causing life-threatening
bleeding.
• Inability to speak - In the first days after the
tracheostomy is placed, the patient will not be
able to speak. Some patients can have the
tracheostomy changed later to a special kind
called a "talking tracheostomy," which allows them
to speak.
• Inability to eat - In the first few days after the
tracheostomy is placed, the patient will not be
able to eat because the tracheostomy often
interrupts swallowing. Swallowing can be abnormal
the entire time the tracheostomy is in place. Many
patients will require feeding through a feeding
tube placed through the nose or mouth (see
Information Sheet on Stomach Tubes). If a patient
is expected to have trouble with feeding for more
than a couple weeks, the doctors may pass a
feeding tube through the skin of the abdomen into
the stomach or intestines.
• Infection - An infection of the skin can occur,
especially in the first weeks following
tracheostomy.
VIII- Lumbar Puncture (Taking a
Sample of Fluid From Around
the Spinal Cord)
Lumbar puncture, also known as a spinal tap, is done to
look for problems that involve the brain or spinal cord. It
involves the placement of a thin, hollow needle into the
lower back to get a sample of the fluid which surrounds
the spinal cord.
Common reasons for its use and benefits:
• Infections - Bacterial meningitis, an infection of
the fluid and tissues surrounding the spinal cord, is
a life-threatening disease that needs prompt
diagnosis and treatment.
• Inflammation - Some diseases can cause
inflammation in or around the spinal cord, such as
multiple sclerosis.
• Cancer - Cancers that spread to the fluid
surrounding the spinal cord can also be detected
by looking at fluid obtained with a lumbar
puncture. Because only a few cancer cells may be
present in the fluid, sometimes it can take several
lumbar puncture samples to find the cancer.
• Hemorrhage - A form of stroke, in which bleeding
occurs in the fluid around the spinal cord (called
subarachnoid hemorrhage), can be detected with
a lumbar puncture.
Risks:
Some of the risks of lumbar puncture include:
• Pain during placement - Discomfort can result
from the needle stick at the time it is inserted.
Doctors try to lessen the pain with a local numbing
medicine (anesthetic like novocaine). The
discomfort is usually mild and goes away once the
needle is removed. Occasionally, the pain will
continue for a short time, but the pain is usually
bearable and does not cause serious injury.
• Headache - Following lumbar puncture, some
patients get a headache. The headache is usually
mild and gets better on its own.
• Bleeding - Bleeding can occur around the
puncture site or, rarely, into the spinal cord.
Bleeding is usually minor and stops on its own.
• Nerve injury - In very rare circumstances, spinal
nerves or the spinal cord can be damaged while
inserting the needle.
• Brain injury - Removing fluid from the spinal
canal can change the pressure around the brain. In
very rare situations, the change in pressure can
lead to further brain damage, particularly if there
is a disease causing an abnormally high spinal
fluid pressure.
IX- Paracentesis (Taking a Sample
of Fluid From the Abdomen)
Paracentesis is performed to figure out what may be
causing fluid to build up inside the abdomen (called
ascites). Some diseases, such as liver cirrhosis (damage
of the liver), cancer and certain infections may cause a
build up of fluid inside the abdomen. The fluid can often
be seen with ultrasound or other x-ray tests.
Paracentesis involves placing a needle and/or thin,
hollow plastic tube into the abdomen to get some of the
fluid for testing.
Common reasons for its use and benefits:
When the cause of the build up of fluid is not known,
getting a sample of the fluid can help in reaching an
answer. The most common reasons for doing a
paracentesis are:
• New-onset ascites - In any patient with the
recent build up of fluid in the abdomen with no
obvious cause.
• Infection - If infection is suspected, paracentesis
may be done to help make a diagnosis.
• Cancer - Some cancers can spread and cause a
build up of fluid in the abdomen. Paracentesis may
be the simplest way to get a sample of cancer
cells to make a diagnosis instead of doing a
surgical biopsy.
• Comfort - A large build up of fluid in the abdomen
can be uncomfortable and interfere with being
able to breathe deeply. Removing some fluid may
decrease discomfort.
Risks:
Some of the risks of paracentesis include:
• Pain during placement - Discomfort can result
from the needle stick at the time it is inserted.
Doctors try to lessen the pain with a local numbing
medicine (anesthetic like novocaine). The
discomfort is usually mild and goes away once the
needle or catheter is removed.
• Bleeding - While the needle is inserted through
the skin, a blood vessel may be accidentally
nicked. The bleeding is usually minor and stops on
its own. The bleeding may cause a bruise of the
abdominal wall. Rarely can it cause internal
bleeding that might require surgery.
• Bowel injury or perforation - The needle may,
rarely, puncture the bowel. The small hole often
seals over quickly. If the hole does not seal over,
the bowel contents can ooze out and cause a
serious infection, which may require surgery to
repair.
X- Thoracentesis (Taking a Sample
of Fluid From Around the
Lungs)
Thoracentesis is done to figure out what may be
causing fluid to build up in the chest around the
lungs (called a pleural effusion). Some diseases,
such as pneumonia and cancer, can cause a large
amount of fluid to build up in the space around the
lungs. Thoracentesis involves placement of a needle
and/or thin, hollow plastic tube in between the ribs
and into the chest to get some of the fluid for
testing. Thoracentesis may also be done to make
patients more comfortable, by relieving some of the
pressure on the lungs. The needle (or tube) is
removed after a few minutes when the procedure is
completed.
Common reasons for its use and benefits:
When the cause of a build up of fluid inside the
chest is not known, getting a sample of the fluid can
help in reaching an answer. The most common • Bleeding - During insertion of the needle
reasons for doing a thoracentesis are: through the skin and chest wall, a blood vessel
may be accidentally nicked. Bleeding is
• New effusion - Thoracentesis may be done usually minor and stops on its own. Bleeding
on any patient with the new onset of fluid in can occur as a bruise of the chest wall. Rarely
the chest without obvious cause to help make bleeding can occur into or around the lung and
a diagnosis. might require drainage or surgery (see related
Information Sheet on Chest Tube
• Infection - When an infection is suspected in Thoracostomy).
the fluid in the chest, thoracentesis may be
done to help make a diagnosis. • Collapsed lung - During insertion, the needle
may, rarely, puncture the lung. This hole may
• Cancer - Some cancers spread and cause seal quickly on its own. If the hole does not
fluid to build up in the chest. In this situation, seal over, air can build around the lung and
thoracentesis may be done to help make a cause it to collapse (this is called
diagnosis. Thoracentesis may be the simplest pneumothorax). In such cases, a chest tube is
way to get a sample of cancer cells to make a sometimes used to drain air from around the
diagnosis. lung (see related Information Sheet on Chest
Tube Thoracostomy).
• Comfort - A large build up of fluid can be
painful and interfere with being able to
breathe. Removing some fluid may decrease
XI- Chest Tube Thoracostomy
discomfort.
Chest tube thoracostomy is done to drain fluid,
blood, or air from the space around the lungs. Some
Risks:
diseases, such as pneumonia and cancer, can cause
an excess amount of fluid or blood to build up in the
Some of the risks of thoracentesis include:
space around the lungs (called a pleural effusion).
Also, some severe injuries of the chest wall can
• Pain during placement - Discomfort can
cause bleeding around the lungs. Sometimes, the
result from the needle stick at the time it is
lung can be accidentally punctured allowing air to
inserted. Doctors try to lessen the pain with a
gather outside the lung, causing its collapse (called
local numbing medicine (anesthetic like
a pneumothorax). Chest tube thoracostomy
novocaine). The discomfort is usually mild and
(commonly referred to as "putting in a chest tube")
goes away once the needle or catheter is
involves placing a hollow plastic tube between the
removed.
ribs and into the chest to drain fluid or air from
around the lungs. The tube is often hooked up to a
suction machine to help with drainage. The tube
remains in the chest until all or most of the air or
fluid has drained out, usually a few days.
Occasionally special medicines are given through a
chest tube.
Common reasons for its use and benefits:
• Collapsed lung (pneumothorax) - Air has
built up in the pleural space from a leak in the
lung. This leak may be the result of lung
disease. It can also occur as a risk
(complication) of certain procedures. Chest
tubes are frequently needed to remove air
from around the lung. Failure to remove such
air can be life- threatening. Removing the air
allows the lung to re-expand and seal the leak.
• Infection - If the fluid building up around the
lung is infected, it may be necessary to insert
a chest tube to remove the fluid.
• Cancer - Some cancers spread and cause
large amounts of fluid to build up around the
lung. Doctors usually drain the fluid with a
needle (see Information Sheet on
Thoracentesis). If the fluid keeps coming back,
however, it may be necessary to insert a chest
tube to first drain the fluid, and then deliver
special medicines into the chest that reduce
the likelihood of the fluid building up again.
• Comfort - A large build up of fluid or air in the
chest can make it difficult to breathe.
Removing some of the fluid or air may
decrease discomfort.
Risks:
Some of the risks of chest tube thoracostomy
include:
• Pain during placement - Discomfort can
result as the chest tube is inserted. Doctors
try to lessen the pain with a local numbing
medicine (anesthetic like novocaine). The
discomfort can be severe at first but usually
decreases once the tube is in place.
• Bleeding - During insertion of the tube, a
blood vessel in the skin or chest wall may be
accidentally nicked. Bleeding is usually minor
and stops on its own. Bleeding can occur as a
bruise of the chest wall. Rarely bleeding can
occur into or around the lung and may require
surgery.
• Infection - Bacteria can enter around the
tube and cause an infection around the lung.
The longer the chest tube stays in the chest,
the greater the risk for infection. The risk of
infection is decreased by special care in
bandaging the skin at the point where the
tube goes into the chest.
XII- Fiberoptic Bronchoscopy
Fiberoptic bronchoscopy is done when it is important
to see the airways or to get samples of mucus or
tissue from the lungs. Bronchoscopy involves
placing a thin tube-like instrument through the nose
or mouth and down into the lungs. The tube is able
to carry pictures back to a video screen or camera.
Common reasons for its use and benefits:
• Recurrent or persistent lung collapse
(called atelectasis) - The collapse of a lung
or part of a lung over and over again is usually
caused by something blocking the airway. This
blockage could be caused by a foreign body,
such as a peanut, tumor, or thick mucus.
These types of blockages can sometimes be
seen with the bronchoscope. The
bronchoscope can be used to remove some
foreign bodies (like a peanut for example) and
mucus, and in this way help to open up the
lung.
• Bleeding - When a patient has coughed up
blood, the bronchoscope can be used to find
out the cause of the bleeding in the lung. For
example, if a tumor is causing the bleeding,
the bronchoscope can identify the tumor as
the cause, and biopsies (pieces to be analyzed
in the laboratory) can be taken through the
bronchoscope.
• Lung spot - A new spot showing up on a lung
x-ray may be caused by a cancer and the
bronchoscope can be used to identify a tumor
and take biopsies (biopsies are small pieces of
tissue that are analyzed in the laboratory).
• Infections - The cause of certain infections
(like tuberculosis, AIDS-related pneumonias,
pneumonia following organ transplantation) is
best figured out by getting mucus directly
from the airways. When a serious infection is
suspected, bronchoscopy is performed to
obtain mucus from a particular area of the
lung. These samples can be examined in a
laboratory and cultures done to try to find out
the exact cause of the infection. Bronchoscopy
can be used to find the bacteria causing
pneumonias in patients who are on
mechanical ventilators.
Risks:
Some of the risks of bronchoscopy include:
• Discomfort and Coughing - While the
bronchoscope is passed through the nose, throat
and breathing tubes, it may cause some
discomfort. It may also tickle the airways leading
to cough. Doctors try to reduce this discomfort and
coughing with local anesthetics. To decrease these
discomforts, medications are sometimes given to
relax patients or make them sleepy.
• Lung Leak or Collapse - The airway may be
damaged by the bronchoscope, particularly if the
lung is already very inflamed or diseased. If the
lung is punctured, it may cause an air leak (called
a pneumothorax). The air leaks around the lungs
and can cause the lung to collapse. This
complication is not common, but it is more likely if
a biopsy is taken during bronchoscopy. An air leak
(pneumothorax) usually requires timely diagnosis
and treatment with placement of a needle or tube
 through the chest wall between the ribs to drain
air from around the punctured lung (see
Information Sheets on Thoracentesis and Chest
Tube Thoracostomy).
• Reduced oxygen - The level of oxygen in the
blood may fall for several reasons during
bronchoscopy. The bronchoscope may block the
flow of air into the airway. Often during
bronchoscopy, small amounts of liquid are injected
into the lung to "wash" out the lung and/or to
make it easier to see through the bronchoscope.
Fluid that is left behind after bronchoscopy can
cause the level of oxygen in the blood to fall. This
usually goes away fairly quickly on its own. The
ICU staff checks continuously the level of oxygen
during bronchoscopy. If the oxygen level is
dropping, the doctor gives extra oxygen to the
patient or stops the bronchoscopy to allow for
recovery.
• Bleeding - Bleeding can occur after a biopsy is
obtained or if the bronchoscope injures a tumor in
the airways. Bleeding is more likely if the airway is
already inflammed or damaged by disease. Usually
bleeding is minor and stops on its own. Sometimes
a medication can be given through the
bronchoscope to stop bleeding. Rarely, bleeding
can lead to severe breathing problems or death.
Fiberoptic bronchoscope - The arrow shows the tip of
the bronchoscope which has a light and camera to allow
the doctor to carefully push it through the nose and
then into the lungs.
XIII- Hemodialysis
Hemodialysis is done to take over the job of the
kidneys when a patient's own kidneys are not
working properly. The most important job of the
kidneys is to get rid of wastes and unneeded fluid
from the body. The kidneys can stop working
because of a number of reasons. Even if the kidneys
still make some urine, they may not be effective in
getting the wastes out. This is called kidney (or
renal) failure. Kidney failure may be temporary. In
some diseases or with severe kidney injury, failure is
permanent. Although doctors can sometimes make
a good guess about the chances that a patient's
kidneys will recover, it is almost never possible to
say this with complete certainty. With hemodialysis,
a patient is connected to a machine that washes the
blood of waste; as such it takes the place of the
kidneys. The patient is connected to the dialysis
machine through a catheter placed in a large vein
(see Information Sheet on Central Venous
Catheterization). During hemodialysis the patient is
usually connected to the machine for 3-4 hours each
day or every other day. Some special forms of
hemodialysis take place at a slower pace, involving
most of the day.
Some patients only need hemodialysis for days or
weeks, but others may require it for the rest of life.
If the kidneys fail and hemodialysis is not done, the
wastes continue to build up and poison the body.
The patient falls into a deep sleep or coma, unless
the heart stops first.
Common reasons for its use and benefits:
The main reason for hemodialysis is for kidney
failure. Most commonly, a blood chemical or acid
has risen to a dangerous level or the brain is being
affected by increased waste. Removal of waste and
excess fluid from the body maintains life.
Sometimes hemodialysis is used to clear excessive
medication or an overdosed drug from the body.
Risks:
Some of the risks of hemodialysis include:
• A low blood pressure (called
hypotension) - Some extremely ill patients
develop brief drops in the blood pressure
during hemodialysis. Such drops can be life-
threatening and can be a reason for stopping
hemodialysis before it is completed. In a
patient whose blood pressure is very low,
hemodialysis can be very risky because it can
cause the blood pressure to go even lower.
Low blood pressure can be a reason not to
undertake hemodialysis in a patient because
the risk of death from low blood pressure may
be greater than the benefits of washing waste
products from the blood.
• Abnormalities of the heartbeat - While
washing waste products from the blood, the
heart may develop an abnormal heartbeat or
rhythm. Abnormal heart rhythms can be life-
threatening and may require emergency
medications or even the passing of an electric
shock through the chest wall to try to bring
the heart back to its normal rhythm.
• Central venous catheterization - All risks of
central venous catheterization apply to
hemodialysis, since hemodialysis is done
through a catheter placed in a large vein in
the body (see Information Sheet on Central
Venous Catheterization).
• Maintenance of life - In some very sick
patients, trying to keep the patient alive
means that dying actually takes longer.
Sometimes, the use of hemodialysis to take
the place of the kidneys may increase the
length of time that patients are uncomfortable
in their final days. Very often, doctors cannot
tell with accuracy whether or not hemodialysis
will lead to a successful recovery and whether
a patient will be able to go home after dialysis.
When a patient is not showing any recovery or
is continuing to get worse, a decision about
continuing dialysis may come up (see Sections
on Code Status and Withdrawal of Life-
Sustaining Treatments).
• Chronic dialysis - Since it is usually very
difficult to know for sure whether or not the
kidneys will recover, one risk of undertaking
hemodialysis for new-onset kidney failure is
that the kidneys will never recover and the
patient will need dialysis for the rest of his or
 her life. This usually involves going to a
dialysis center three times a week and getting
hemodialysis for 3-4 hours each time. There
are also some forms of dialysis which the
patient can learn to do at home.
XIV- Gastrointestinal Endoscopy
Gastrointestinal endoscopy is done when it is
important to see the inside of the stomach or
intestines. Gastrointestinal endoscopy involves
placing a thin tube-like instrument through the
mouth or the back passage, the rectum, and down
into the gullet, or esophagus, stomach or intestines.
The tube is able to carry pictures back to a video
screen or camera. When endoscopy is done through
the mouth, it is called upper endoscopy or
esophagogastro-duodenoscopy (EGD for short).
When endoscopy is done through the rectum, it is
called lower endoscopy or colonoscopy.
Common reasons for its use and benefits:
• Bleeding - The most common reason for
gastrointestinal endoscopy is to find the
source of bleeding from the esophagus,
stomach or intestines. Sometimes, if the
source is found, doctors can use the
endoscope to stop the bleeding.
• Tumors - Sometimes tumors can cause
discomfort or even clog the esophagus,
stomach or intestines. The endoscope can be
used to find tumors and take a small sample
for analysis in the lab, called a biopsy.
• Diarrhea - Sometimes severe diarrhea can be
caused by inflammation or infections of the
colon and endoscopy can be used to help find
the cause.
• Belly pains - Sometimes severe stomach pain
can be a sign of ulcer, a clog in the
gastrointestinal track, inflammation or
infection. Endoscopy can help find the reasons
for some belly pains.
Risks:
Some of the risks of gastrointestinal endoscopy
include:
• A low blood pressure (called hypotension) –
Frequently, medicines are given to help keep
patients comfortable during endoscopy. Some
patients develop brief drops in the blood
pressure during endoscopy. Such drops can be
life-threatening and can be a reason for
stopping endoscopy before it is finished.
• Leak of gastrointestinal contents - Rarely,
the esophagus, stomach or intestines can be
damaged by the endoscope and the contents
can leak into the surrounding area of the
body. This is a serious problem which can
cause infection and even death.
• Bleeding - The esophagus, stomach or
intestines can be damaged by the endoscope
causing some intern
Marilane M.Ferrer; BSN
BSN, RN