Procedures And Therapies
A doctor performs a bronchoscopy by passing a flexible telescope into the patient’s windpipe (trachea). This may be needed when a patient has pneumonia, when there is a blockage in the airways or to aid the placement of other tubes (e.g. a tracheostomy) into the trachea. The doctor may take samples from the airways for analysis. Occasionally a small piece of lung tissue (biopsy) is taken.
In ICU bronchoscopy is usually performed through a breathing tube (ET tube or tracheostomy). Sedation is given during the procedure.
Risks involved: All procedures done in the ICU carry a small risk of bleeding or infection. A bronchoscopy may cause deterioration in a patient’s oxygen level. If a biopsy is taken, there may be a risk of damage to the lung.
A central line (also called a “central venous line”, “central venous catheter” or “CVC”) is a long, thin, flexible, hollow tube that is inserted and stays in a large vein in the body. They are very commonly used in the intensive care unit.
There is an opening at one end, which is inside the vein in the patient’s body, and several ‘ports’ outside on the other end of the line. Ports are the connections through which medications are delivered. Central lines can stay in place for several days, and occasionally longer.
Central lines are inserted under sterile conditions using local anaesthetic and some specialist equipment. The patient needs to be carefully positioned for the procedure. Central lines are secured into place with stitches and protected with dressings. They can be inserted into the neck (“internal jugular”), the groin (“femoral”), or under the collar bone (“subclavian”).
Why is it used?
Central lines have many uses. Some of the uses are to:
• Take blood for routine and specialist tests
• Give medications
• Give fluids
• Give blood transfusions
A central line is removed if there is a problem with it (for example the patient has an infection, or it has stopped working), if it has been in place for some time and needs to be changed, or if it is no longer needed. After its removal and the skin has healed there can sometimes be a small mark where the central line has been in place.
The risks of central line insertion include (but are not limited to) bleeding, infection, pain, accidental misplacement, lung puncture, procedure failure.
ECMO is only used in the sickest of intensive care patients when the heart and/or lungs are failing to respond to other treatments. Under sterile conditions a doctor inserts tubing into blood vessels in the neck, the groin or directly into the blood vessels near the heart (through the front of the chest in the operating theatre). Blood is drawn out of the body and into the ECMO machine where oxygen is added to it. The blood is then returned either into an artery or a vein. This keeps a patient alive while allowing time for the heart and/or lungs to recover.
Risks involved: All procedures done in the ICU carry a risk of bleeding or infection. Where ECMO tubing is inserted, there is also a risk of damage to the blood vessels. Impaired blood and nerve supply to the legs, damage to blood cells and the development of blood clots are also rare but recognised complications. ECMO is only used when absolutely necessary and when there are no other alternatives. It is constantly monitored for complications.
Intercostal Catheter (ICC)
Patients who have had chest or heart surgery, or trauma may need a tube (an ICC) inserted through the chest wall to drain fluid or air from around the lung (or heart). An ICC may also be required to drain collections of fluid from the chest in other circumstances (such as pneumonia).
Risks involved: All procedures done in the ICU carry a small risk of bleeding or infection. An ICC may also rarely cause damage to the lung or other parts of the body. Chest X-rays are routinely done to check for any complications.
Endotracheal Tube (ETT)
If a patient is unconscious or has severe breathing difficulty, then an ETT is placed into the windpipe (trachea). This is then connected to a ventilator. The ventilator provides assistance with breathing and additional oxygen.
When a patient is attached to a ventilator for a prolonged period, a tracheostomy is usually performed. This is a plastic tube which is placed directly into the windpipe (trachea) through the front of the neck. It is more comfortable than a breathing tube through the mouth and often allows better weaning from the ventilator.
Risks Involved: All procedures done in the ICU carry a small risk of bleeding or infection. There is also a risk of reduced oxygen to the body during intubation. Intubation may occasionally damage the trachea or vocal cords. An ET tube placed during intubation may stay in place for1 to 2 weeks and occasionally longer.
Blood Transfusion, Packed Red Blood Cells, Platelets, Fresh Frozen Plasma or FFP, Cryoprecipitate or Cryo, Immunoglobulins
Blood transfusions are required to correct low blood counts (low haemoglobin, anaemia) or replace blood loss due to bleeding. Other blood products listed above are used to correct abnormal or low levels of clotting factors (if a patient is bleeding or is at risk of bleeding during a procedure) and antibodies.
Risks involved: Serious reactions against transfusions are fortunately rare. However all transfusions carry a small risk of infection which may be passed on to the recipient. A recipient’s body may also react against a transfusion. These reactions may range from a mild increase in temperature to severe organ failure. The risk of a reaction is minimised by the extensive checking procedures to ensure that a patient receives the safest blood product possible. Estimates of the risk are shown below:
Total Parenteral Nutrition (T.P.N), Intravenous Feeding
TPN involves introducing nutrition directly into a patient’s vein. It is usually given via a CVC (see CVC). It is used when it is not possible to feed a patient via the stomach and gut. It is often possible to switch back to normal feeding via the gut as the patient’s condition improves.
Risks involved: T.P.N. may put a patient at increased risk of infection. It may also affect liver and immune function. T.P.N. is regularly assessed by nursing, medical and nutrition staff.
In-Dwelling Catheter (IDC) Catheter
A urinary catheter (IDC) is a soft tube inserted into the bladder through the urethra. It drains urine from the bladder continuously, removing the need for a patient to empty their bladder as usual. A small balloon at the tip of the catheter holds it in place within the bladder. It is essential for patients who are heavily sedated, have an epidural catheter in place, or who have limited mobility and are therefore unable to walk to the toilet. It is also used to closely record urine output. The catheter is connected to a drainage bag which holds and records the amount of urine passed.
The bedside monitor is connected to each patient and is a sensing device which provides real time information about certain bodily functions, such as the heart rate and blood pressure. The monitor has a number of alarms that the bedside nurse can set to help the staff care for the patient. When you hear an alarm it does not necessarily mean something is wrong.
Respirator, Breathing Machine, Invasive Ventilation
When patients cannot breathe adequately, they may need to be attached to a ventilator (via an ET tube or tracheostomy – see Intubation and Tracheostomy). This is a common reason for admission to an intensive care unit. The ventilator provides additional oxygen and assistance with breathing. Patients on ventilators via an ETT often require sedation. When a patient no longer needs ventilator support it is weaned and the ETT removed. If a patient requires ventilator support for a long period of time we usually perform a tracheostomy.
Risks involved: Patients who are on a ventilator are at risk of damage to the lung and infection. The risk of chest infection and pneumonia (although small) increases with the amount of time spent on a ventilator. Patients are constantly monitored for complications.
Bilevel Positive Airway Pressure, Non-invasive ventilation (NIV)
When patients cannot breathe adequately, a BiPAP machine may provide additional oxygen and assistance with breathing. This may reduce the need to insert an ET tube (intubate). BiPAP is usually applied using a tight fitting mask to the face or nose. BiPAP is used within ICU and sometimes elsewhere within the hospital.
Risk involved: As with invasive ventilation (via an ET tube) there is a risk of infection, but this is much less with BiPAP. BiPAP may increase the risk of vomiting. Some patients do not tolerate BiPAP and find it uncomfortable. Despite using BiPAP some patients deteriorate and need different therapies. Patients on BiPAP are closely monitored for complications or any signs of deterioration.
Transoesophageal Echocardiogram (TOE)
A TOE is a specialised ultrasound examination of the heart. A doctor passes an echo probe through the mouth of a patient and into the gullet (oesophagus) and then the stomach. This allows inspection of the heart and major blood vessels from inside the chest to see if there are any abnormalities. It also provides information on how well the heart is working. Sedation is given to the patient during the procedure.
Risks involved: All procedures done in the ICU carry a small risk of bleeding or infection. A TOE may rarely damage the mouth or oesophagus. The risk is increased if there is a history of a bleeding disorder, difficulty swallowing, or liver disease. All patients are carefully monitored before, during and after a TOE
A Vascath is a tube inserted into a large vein for dialysis (when there is kidney failure – see Dialysis) or for plasmapheresis (the removal of certain proteins from the blood). It is similar to a CVC. Under sterile conditions a doctor inserts a needle and then the vascath into either the neck, beneath the collar bone or in the groin. The needle is removed and the vascath is left in place for up to several weeks. The vascath is removed when it is no longer needed.
Risks involved: All procedures done in the ICU carry a small risk of bleeding or infection. Jugular and subclavian vascaths may also occasionally damage the lung. Chest X-rays are routinely done to check for any complications.
An art line is a thin plastic tube inserted into an artery to continuously measure the blood pressure. Regular blood tests are taken from it – most commonly to measure the levels of oxygen, carbon dioxide and acid within the blood.
Risk Involved: All procedures done in the ICU carry a small risk of bleeding or infection. Art lines may occasionally damage the artery and temporarily impair blood supply. They are constantly monitored for any complications.
When a patient is attached to a ventilator for a prolonged period, a tracheostomy is usually performed. This is a plastic tube which is placed directly into the windpipe (trachea) through the front of the neck. It is more comfortable than a breathing tube through the mouth and allows a gradual weaning from the ventilator.
Haemodialysis, Filter, Renal Replacement Therapy
Patients often require a dialysis machine when there is kidney failure or abnormal levels of acid and salts within the blood. It is also occasionally used to treat some drug overdoses. A doctor inserts a vascath (see Vascath) into a large vein in the neck or groin. Blood circulates through the dialysis machine, toxins are removed and the blood then returns to the body. As patients recover, the kidney function often improves and the dialysis machine can be stopped.
Risks involved: All procedures done in the ICU carry a risk of bleeding or infection. A patient’s blood pressure may drop temporarily when dialysis is started. The dialysis machine may reduce the levels of some blood components. It also leads to a reduction in body temperature.
External Ventricular Drain, Intra-Cranial Pressure (ICP) Monitor. Similar & related devices: Codman Catheter
An EVD is placed in a patient’s head to measure the pressure within the brain and to sample & drain spinal fluid (cerebro-spinal fluid or CSF). They are used in patients with severe head injury, brain haemorrhage or after neurosurgery. The EVD is inserted under strict sterile conditions by a neurosurgeon either in the ICU, emergency department or in the operating theatre. A Codman catheter also measures intra-cranial pressures (ICPs) but is not able to drain CSF. When it is no longer needed the EVD (or Codman catheter) is removed.
Risks involved: All procedures done in the ICU carry a risk of bleeding or infection. There is also a small risk of damage to the brain from the EVD. An EVD is only used when absolutely necessary and is constantly monitored for complications.
Vasopressors, Vasoconstrictors, Vaso-active Drugs, Inoconstrictors and Inodilators
Inotropes are drugs given to increase the blood pressure and support the function of the heart. They are given via a CVC (see CVC) into a large vein. Different types of inotrope (eg adrenaline, noradrenaline, milrinone) are used in various situations. Inotropes are commonly used in the ICU.
Risks involved: Different inotropes have different side effects. In high doses noradrenaline may impair blood supply to fingers or toes. Other inotropes may cause irregular heart rhythms or increase the level of acid in the blood.