GENERAL INFORMATION

In the ICU, many machines, devices, and procedures are used which are relatively uncommon in other parts of the hospital. Each device has a particular job or purpose. There are reasons (indications) to use each device or procedure for assessment or treatment. Most have some risk (possible complications) as well as potential benefit about which you should be informed (see section on General Information and Expectations). We have developed information sheets that describe the indications (reasons for), risks and benefits of a number of commonly used devices and procedures. These information sheets are not a substitute for discussions with the doctor. They serve as an educational aid. As you read, you 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 risks. Nonetheless, it is important that patients and/or their families be informed of both benefits and risks. There are some devices that are commonly used in the ICU that your doctor does not need to get permission to 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) and measurement of oxygen in the bloodstream using a light probe on the fingertip (called pulse oximetry). These and other relatively low-risk parts of your treatment, including placement of catheters into the small veins of the body, blood draws and administration of medicines, are included under the consent form you sign when you come into the hospital. (For hospitals that download these information sheets for institutional use in the informed consent process, we suggest including this page with each information sheet to assure that patients and/or families understand the general purpose of these documents.)

Pulse Oximeter - The clip on the finger measures the oxygen in the blood and shows the level of oxygen on the display (in this case the oxygen level is 98%). A clip similar to this is used and is attached to the Critcal Care monitors to measure the level of oxygen.

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.

STOMACH TUBES
Many critically ill patients are not able to swallow properly. Also, patients on mechanical ventilators cannot eat by mouth. When the stomach and intestines continue to work, a tube can be placed through the nose or mouth and pushed down into the stomach. This tube allows nurses to make sure that the stomach does not get over filled, and also to feed the patient. Nasogastric (or "N.G.") tubes are thicker tubes (about the thickness of a pencil). These tubes are used when it is important both to suck out stomach fluid for testing, to prevent over filling, and for feeding. Feeding tubes are thinner tubes that are used mainly for feeding.

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 result when the tube is inserted. Doctors try to lessen the pain by putting a jelly on the tube that helps it to slide in more smoothly. Placement into the lung - While the tube is being passed, it can go down the windpipe instead of into the stomach. This can cause coughing. Doctors often get an x-ray to see where the the tube goes before they give food or water through it. Collapsed lung - While the tube is being passed, it may, very rarely, go down into the windipipe and puncture the lung. This hole may seal quickly on its own. If the hole does not seal over, air can build around the lung and cause it to collapse (this is called pneumothorax). In such cases, a chest tube is sometimes needed to drain air from around the 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.

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 check 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 to the site.

CENTRAL VENOUS CATHETERIZATION

Central venous catheterization is when a physician puts a long, thin, hollow tube into one of the large veins of the body, which are found in the neck, upper chest, legs or arms. This is similar to intravenous

(IV) tubes that are placed in the smaller veins of the arms except that a bigger blood vessel is being used. Such a catheter has special benefits but it also has a greater risk than the usual IV.

Common reasons for its use and benefits:

To deliver a large amount of fluid or blood rapidly. This is particularly important during shock. To take measurements to see how much fluid a patient needs. The catheter can have special sensors to measure pressure inside the blood vessel. To give medication through the veins for a week or longer. A large blood vessel can tolerate an intravenous tube for a longer time than a small vessel. To be able to take frequent blood samples (more than once each day) without new needle sticks. To deliver special nutrition, when food or liquids can't be given through the stomach or bowel. As part of the procedure of inserting a right heart catheter (also known as pulmonary artery or Swan Ganz catheter; see related Information Sheet on Right Heart Catheterization).

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. When the catheter is placed into the large veins of the arms or legs, any of the above complications can occur with the exception of collapsed lung.

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.

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 oxgyen 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 Statusand Withdrawal of Life-Sustaining Treatments).

WEANING FROM MECHANICAL VENTILATION

Weaning refers to the process in which intensive care staff try 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.

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.