ICU Topics > Lines, Leads, & Drains
Lines, Leads, & Drains
Lines, tubes, and drains are a constant presence in the ICU — and learning to work around them safely is one of the most important skills a therapy practitioner can develop. Knowing what each device is matters, but line awareness during treatment matters more. Accidental dislodgement is one of the most common nursing concerns during therapy sessions, and preventing it starts with preparation before you ever enter the room.
Lines, Tubes & Drains: Mobility Implications
| Device | Mobility Considerations | OT Considerations |
|---|---|---|
| Arterial Line | Avoid excessive movement at insertion site | Monitor line integrity and positioning |
| Biliary Drain | Drainage bag and tubing management needed | Secure collection system during mobility |
| Chest Tube | Keep drainage system upright and below chest | Monitor tubing and patient response; do not clamp without order |
| CRRT / CVVH | Often limited by equipment and hemodynamic stability | Coordinate closely with ICU team before mobility |
| Epidural | Decreased sensation/motor function possible | High fall risk; assess LE function before weight-bearing |
| Femoral Line | May limit hip flexion on involved side | Clarify restrictions with medical team |
| Foley Catheter | Keep drainage bag below bladder level | Monitor tubing during transfers and dressing |
| JP / Hemovac Drain | Secure drain during movement | Avoid pulling or compression on tubing |
| NG Tube | May be connected to wall suction | Clarify if suction can be disconnected for mobility; pause tube feed if HOB lowered |
| PEG / G-Tube | Avoid traction on tubing | Monitor tolerance to movement and positioning |
| Peripheral IV | Usually minimal restrictions | Be mindful during ADLs and transfers |
| PICC / Central Line | Avoid pulling or dislodging line | Increased line awareness during mobility |
| Rectal Tube | Use caution with transfers | Monitor tubing security and patient comfort |
| Subdural Drain (SDD) | Keep drainage system below head level; confirm orders before OOB | Follow craniotomy precautions; monitor drain security during transfers |
| Wound VAC | Portable; tubing management required | Ensure device travels safely; avoid disrupting dressing seal |
Venous Access
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Purpose: Short-term IV access for medication administration, fluid delivery, and blood draws.
Location: Peripheral veins of the extremities, most commonly the forearm or hand.
Indication: Short-term medication needs, IV fluids, blood draws.
Therapy Precautions: Usually minimal restrictions. Be mindful of tubing during ADLs and transfers. Avoid tension on the line. -
Purpose: Long-term central venous access for medication delivery and blood draws.
Location: Inserted at the antecubital fossa; tip ends in the superior vena cava, subclavian, or axillary vein. Sutured in place.
Indication: TPN, prolonged antibiotic therapy, continuous pain medication infusion, venous lab draws. Can measure central venous pressure if advanced to the superior vena cava.
Therapy Precautions: Keep dry. Do not take blood pressure over the PICC arm. Avoid axillary pressure (e.g., crutches). Increase line awareness during mobility and ADL. -
Purpose: Provides central venous access with multiple ports for simultaneous infusions.
Location: Inserted at the subclavian or internal jugular (IJ); tip ends in the superior vena cava or right atrium.
Indication: Same as PICC; can also administer chemotherapy and can be placed quickly at the bedside.
Therapy Precautions: Highest infection risk of central lines. Keep dry. No ROM contraindications for therapy. Monitor line integrity during movement. -
Purpose: Long-term central venous access; used for caustic medications such as chemotherapy.
Location: Tunneled subcutaneously from the insertion site (subclavian or IJ); exits below the nipple line.
Indication: Same capabilities as triple lumen but with lower infection risk; suitable for longer-term use.
Therapy Precautions: Keep dry. Secure tubing during mobility and ADL. -
Purpose: Implanted central venous access device requiring minimal daily care; less visible than external catheters.
Location: Port sits beneath the skin; catheter enters at the subclavian or IJ.
Indication: Same as tunneled catheter; commonly used for intermittent chemotherapy.
Therapy Precautions: Can get wet without infection risk. Standard line awareness applies during mobility and ADL.
PIV Image: Michaelberry at English Wikipedia, CC BY 3.0, via Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Intravenous_therapy_2007-SEP-13-Singapore.JPG)
Port-a-Cath
PICC Line
Hickman Catheter
Arterial Access
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Purpose: Continuous blood pressure monitoring and arterial blood draws, including arterial blood gases (ABGs).
Location: Inserted in the radial, femoral, brachial, or dorsalis pedis artery.
Indication: Hemodynamically unstable patients; patients receiving IV vasopressors.
Therapy Precautions: Do not flex the involved limb at the insertion site. Femoral placement: generally on bed rest; no hip flexion on the involved side. Values will not be accurate until recalibrated by the RN after position change. -
Purpose: Provides vascular access and measures blood pressure in the large central veins.
Location: Inserted at the subclavian region; tip ends just above the right atrium.
Indication: Critical illness affecting heart function; post-cardiac surgery monitoring.
Therapy Precautions: No ROM restrictions. Must be recalibrated by RN after position change. -
Purpose: Measures pressures in the right heart and pulmonary artery; monitors cardiac output and mixed venous O₂ saturation.
Location: Inserted at the subclavian or IJ; tip ends in the proximal left or right branch of the pulmonary artery.
Indication: Shock, acute pulmonary edema, or post-cardiac surgery hemodynamic monitoring.
Therapy Precautions: Patient is usually on bed rest. Specific orders required if therapy is appropriate. Limit overhead and repetitive shoulder movement on the ipsilateral side. Avoid excessive ROM to ipsilateral shoulder to maintain line stability.
CVP Catheter Image: Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014” - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=29452218
PAC Image: Note. From Pulmonary artery catheter, by Wikipedia, 2021 (https://en.wikipedia.org/wiki/Pulmonary_artery_catheter). CC-BY-SA.
Neuro ICU Lines & Drains
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Purpose: Drains CSF from the lumbar spine to treat CSF leaks, evaluate normal pressure hydrocephalus, and reduce ICP during surgery.
Location: Small flexible tube placed in the lumbar spine; leveled with the bed and umbilicus.
Indication: CSF leaks, normal pressure hydrocephalus evaluation, craniotomy, and transsphenoidal surgery.
Therapy Precautions: Specific activity and clamping orders required. Drain must be clamped for position change or mobility. Do not clamp for more than 30 minutes. Drain must be realigned by RN once patient returns to bed or chair. -
Purpose: Temporary system to drain CSF from the ventricles to an external closed system to monitor and manage ICP.
Location: Leveled at the external auditory meatus or tragus; adjusting HOB changes alignment.
Indication: Hydrocephalus, post-craniotomy CSF management, infected CSF, elevated ICP.
Therapy Precautions: Activity orders required for all out-of-bed activity. Drain must be clamped prior to mobility. Do not clamp for more than 30 minutes. HOB typically elevated at 30°. Closely monitor volume with position changes when drain is NOT clamped.Additional Information:
Open = actively draining; Clamped = drain in place but not actively draining
Setting: 0, 10, 15, 20 (lower number = more CSF drainage)
Drain is leveled at the tragus; gravity-dependent system
Raising the drain and eventual clamping is a sign of patient improvement
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Purpose: Drains blood or fluid from the subdural space following evacuation of a subdural hematoma, to prevent reaccumulation.
Location: Placed in the subdural space, typically exiting through a burr hole or craniotomy site; connected to a closed drainage system kept below the level of the head.
Indication: Post-craniotomy or burr-hole evacuation of a subdural hematoma; prevention of hematoma reaccumulation.
Therapy Precautions: Confirm activity orders before mobility. Keep the drainage system below the level of the insertion site. Avoid tension or kinking of tubing. Monitor drain output and security during transfers. Follow craniotomy precautions as ordered.
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Purpose: Surgical management of excess CSF; redirects CSF from the ventricles to the abdominal cavity to relieve elevated ICP.
Location: Catheter passed from the ventricles to the abdominal cavity; drip chamber located inside the abdomen.
Indication: Chronic hydrocephalus; patients who are unable to tolerate repeated EVD clamping trials.
Therapy Precautions: Does not require leveling or clamping. Follow craniotomy precautions. Gradually elevate HOB; activity orders are typically placed on post-op day 1. Do not push on the shunt visible on the head. -
Purpose: Monitors brain electrical activity to detect abnormal patterns.
Location: Electrodes applied to the scalp; connected to monitoring equipment via cables.
Indication: Seizures, traumatic brain injury, stroke, encephalopathy, brain tumors, sleep disorders.
Therapy Precautions: Seizure precautions apply. If the patient is actively seizing or burst suppressed, they are likely intubated and sedated — not appropriate for therapy. When cleared, account for available room space and cable length when planning mobility.
Lumbar Drain
EVD Image: By Rmosler2100 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11909861
VPS Image: By Cancer Research UK, (2014), CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=34332972
Oxygen Sources
Oxygen Devices: Mobility Implications
| Device | Typical Acuity | Mobility Considerations | OT Considerations |
|---|---|---|---|
| Nasal Cannula | Lower | Usually easiest to mobilize | Monitor tubing and SpO₂ |
| Oxymizer | Mild–Moderate | Similar to NC | Higher O₂ needs may reduce endurance |
| Simple Face Mask | Moderate | Portable but less comfortable | Communication and eating impacted |
| Venturi Mask | Moderate | Maintain prescribed FiO₂ | Do not change adapter settings |
| Non-Rebreather | Higher | Limited activity tolerance | Monitor closely for respiratory distress |
| HFNC | Moderate–High | Portable on some units | Monitor flow settings and tubing |
| CPAP | Moderate | May tolerate short mobility sessions | Monitor mask tolerance and fatigue |
| BiPAP | Higher | Often limited mobility tolerance | Monitor work of breathing closely |
| Trach Collar | Variable | Requires secretion and tubing management | Airway clearance and communication needs |
| Mechanical Ventilation | Highest | Requires full team coordination | Monitor airway, vent settings, and activity response |
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Purpose: Common low-flow supplemental oxygen delivery.
Location: Prongs placed in the nares.
Indication: Patients requiring mild supplemental oxygen support.Flow rate: 1–6 L/min
Therapy Precautions: Minimal restrictions. Monitor SpO₂ and tubing during mobility and ADL. -
Purpose: High-flow nasal oxygen delivery with a reservoir that reduces oxygen consumption.
Location: Nasal prongs with an attached reservoir worn at the chest.
Indication: Patients with higher or long-term oxygen needs who require portability.Flow rate: 6–15 L/min
Therapy Precautions: Heavier tubing than standard NC; monitor patient comfort. Portable — can travel with patient for out-of-bed activity. -
Purpose: Delivers moderate-concentration oxygen via a mask covering the nose and mouth.
Location: Mask secured over nose and mouth with elastic band.
Indication: Patients requiring moderate oxygen support.Flow rate: 5–10 L/min; ~35–60% FiO₂
Therapy Precautions: Impairs verbal communication and eating during use. Portable but less comfortable than NC for extended activity. -
Purpose: Delivers a precise, controlled concentration of oxygen using color-coded adapters.
Location: Mask secured over nose and mouth; adapter controls exact FiO₂.
Indication: Patients (particularly COPD) requiring accurate, controlled FiO₂.Flow rate: 2–15 L/min
Therapy Precautions: Do not change the adapter setting — this alters the prescribed FiO₂. Confirm with nursing before any position changes that could affect mask fit. -
Purpose: Delivers high-concentration oxygen via a mask with a one-way valve reservoir bag.
Location: Mask with reservoir bag secured over nose and mouth.
Indication: Acute respiratory distress or short-term high oxygen need.Flow rate: 10–15 L/min; up to 90–100% FiO₂
Therapy Precautions: Indicates higher acuity — monitor closely for respiratory distress. Activity tolerance is likely limited. Impairs communication and eating. -
Purpose: Delivers heated, humidified high-flow oxygen with mild positive pressure support.
Location: Large nasal prongs connected to heated humidifier and flow meter.
Indication: Patients requiring high FiO₂ with positive pressure support as an alternative to non-invasive ventilation.Flow rate: 10–60 L/min; up to 100% FiO₂
Therapy Precautions: Portable on some units — confirm before mobility. Monitor flow settings and tubing. No equivalent portable mode; coordinate with team for out-of-bed activity. -
Purpose: Delivers continuous positive airway pressure to keep airways open and improve oxygenation.
Location: Tight-fitting face or nasal mask.
Indication: Obstructive sleep apnea, pulmonary edema, mild respiratory failure.
Therapy Precautions: Patient may tolerate short mobility sessions. Monitor mask tolerance and fatigue. Coordinate with team regarding timing of therapy relative to CPAP use. -
Purpose: Non-invasive ventilatory support using two pressure levels — higher on inhale, lower on exhale — to reduce work of breathing.
Location: Face mask or nasal mask.
Indication: COPD exacerbation, respiratory failure, patients unable to maintain adequate ventilation independently.
Therapy Precautions: Higher acuity — mobility tolerance is often limited. Monitor work of breathing closely. Device is portable. Coordinate with nursing before removing mask. -
Purpose: Delivers humidified oxygen over a tracheostomy site.
Location: Mist collar placed over the trach opening.
Indication: Non-ventilated tracheostomy patients requiring supplemental oxygen and humidification.Flow Rate: FiO₂: 25–100%.
Therapy Precautions: Monitor whether the Passy Muir Valve (PMV) is in place. With PMV on, patient inhales through the one-way valve and exhales through native passages — this increases work of breathing. Patient may need to remove PMV to prioritize breathing over speech during higher-exertion activity.
Non-Rebreather Mask
Image: James Heilman, MD, CC BY-SA 4.0
BiPAP
Image: James Heilman, MD, CC BY-SA 4.0
Enteral Nutrition
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Purpose: Temporary nasogastric access for tube feedings, medication delivery, or GI decompression.
Location: Inserted through the nose into the stomach. Dobhoff is a small-bore, flexible variant.
Indication: Short-term enteral nutrition or medication delivery when the patient cannot take anything by mouth.
Therapy Precautions: Pause tube feed if HOB is lowered; resume once HOB is raised. Avoid tension on the tube. Secure tube to gown to prevent accidental dislodgement during activity. -
Purpose: Long-term enteral access for nutrition, fluids, and medication delivery directly into the stomach.
Location: Flexible tube placed through the abdominal wall directly into the stomach.
Indication: Patients unable to swallow or maintain adequate oral intake long-term; commonly placed after stroke or prolonged critical illness.
Therapy Precautions: Avoid traction on the tube during mobility and ADL. Monitor tolerance to movement and positioning. No specific ROM restrictions. -
Purpose: Intravenous nutrition delivered directly into the bloodstream when the GI tract cannot be used.
Location: Administered through a PICC line, central line, or port-a-cath.
Indication: GI disorders, bowel obstruction, malabsorption, or inability to tolerate enteral feeding.
Therapy Precautions: No direct activity restrictions from TPN. Apply standard precautions for the IV access line through which it is administered.
PEG
Image: Pflegewiki-User HoRaMi, CC BY-SA 3.0
Other Drains & Lines
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Purpose: Removes air, fluid (pleural effusion), or blood (hemothorax) from the pleural space to allow lung re-expansion.
Location: Inserted between the ribs into the pleural space; connected to a drainage system (e.g., Pleur-evac) kept below chest level.
Indication: Pneumothorax, hemothorax, pleural effusion, post-thoracic surgery.
Therapy Precautions: Keep drainage system upright and below the insertion site at all times. Do not clamp without an MD order. Monitor for air leaks (bubbling in the water seal chamber). Avoid tension or kinking of tubing during mobility. Confirm activity clearance with the team. -
Purpose: Negative pressure wound therapy that promotes healing, reduces edema, and removes exudate from complex or non-healing wounds.
Location: Applied directly over the wound; connected to a portable or wall-mounted suction device.
Indication: Complex wounds, surgical wounds, pressure injuries, diabetic ulcers, flaps, and grafts.
Therapy Precautions: Device is portable and can travel with the patient during mobility. Ensure adequate tubing slack during transfers and positioning. Avoid disrupting the wound dressing seal. Coordinate with nursing if the device needs to be temporarily paused.
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Purpose: Closed-suction drainage system used to remove fluid (blood, serous fluid) that accumulates at a surgical site.
Location: Inserted near the surgical site; reservoir/bulb kept below the insertion site.
Indication: Post-surgical drainage; common following orthopedic, abdominal, or neurosurgical procedures.
Therapy Precautions: Secure the drain to the patient's gown during mobility. Avoid pulling or compression on tubing. Monitor output for amount and color. Do not empty the drain — notify nursing.
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Purpose: Delivers continuous pain medication (local anesthetic and/or opioid) directly into the epidural space for regional pain control.
Location: Catheter inserted in the thoracic or lumbar spine; connected to an infusion pump.
Indication: Post-surgical pain management, thoracic and abdominal surgery, rib fractures.
Therapy Precautions: Patient may have decreased sensation and/or motor function in the lower extremities — assess carefully before any weight-bearing activity. Fall risk is high. Avoid tension on the catheter during transfers or mobility. -
Purpose: Provides mechanical suction for secretion management, typically used with tracheostomy patients or those with impaired airway clearance.
Location: Bedside or portable unit connected to a suction catheter.
Indication: Tracheostomy patients, impaired cough or swallowing, post-surgical airway clearance needs.
Therapy Precautions: Confirm with nursing whether the patient needs suctioning before therapy. Patient may require suctioning during or after activity. Device is portable and can travel for out-of-bed mobility.
ICU Lines, Tubes, and Room Equipment
General Safety Rules for Lines & Tubes
Knowing what a line or device is matters — but line awareness and safety during therapy are what protect the patient. Accidental dislodgement is one of the most common nurse concerns during therapy sessions. Keep the following principles in mind regardless of the device.
Know the equipment. Before entering the room, review the chart to identify what lines, tubes, and drains are present. Trace each line to its insertion site so you understand what it is and where it goes. Know the purpose of each device and what accidental removal or disconnection would mean for the patient.
Check the orders. Confirm the patient is cleared for therapy. For EVDs and lumbar drains, confirm whether the drain needs to be clamped for position change or mobility — and who is responsible for clamping and recalibrating.
Move safely. Ensure adequate slack in all tubing before initiating movement. Avoid tension, pulling, or kinking. Plan your mobility sequence before you move the patient so you aren't managing lines reactively.
Protect drainage systems. Keep chest tubes and urinary drainage bags below the level of insertion at all times during mobility. Keep EVD and lumbar drains clamped during movement unless otherwise ordered.
Communicate. Confirm with nursing before disconnecting any oxygen or monitoring equipment. Ask for assistance when managing complex or unfamiliar setups. If you are unsure about a line, device, or order — stop and clarify before proceeding.
References
Johns Hopkins Cerebral Fluid Center. (n.d.). Extended CSF drainage trial via lumbar drain. Retrieved September 19, 2021, from https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/cerebral-fluid/procedures/csf_drainage_trial.html
Mayo Clinic. (2020, April 15). EEG (electroencephalogram). https://www.mayoclinic.org/tests-procedures/eeg/about/pac-20393875
MedlinePlus. (2021, September 1). Ventriculoperitoneal shunting. https://medlineplus.gov/ency/article/003019.htm
Muralidharan, R. (2015). External ventricular drains: Management and complications. Surgical Neurology International, 6(7), 271. https://doi.org/10.4103/2152-7806.157620
Popovich, K. (2011). The Intensive Care Unit. In H. Smith-Gabai (Ed.), Occupational Therapy in Acute Care(1st ed., pp. 41–73). AOTA Press.
Sheffield Teaching Hospitals. (2021). Lumbar drain: Information for patients. https://publicdocuments.sth.nhs.uk/pil4116.pdf
Wikipedia. (2021). “Pulmonary artery catheter”. In Wikipedia. https://en.wikipedia.org/w/index.php?title=Pulmonary_artery_catheter&oldid=1034068291