Lines, Leads, & Drains

Purpose: Long-term medication needs or if unable to establish peripheral intravenous catheter.

Location: Extremities

Precautions: If accidentally disconnected from tubing, occlusion can occur within 4 min

Purpose: Long-term medication needs or if unable to establish peripheral intravenous catheter.

Location: Enters at antecubital fossa and ends in superior vena cava, subclavian or axillary vein. Sutured in place.

Indication: Total parenteral nutrition (TPN), prolonged antibiotic needs, continuous pain medication infusion, and venous lab draws. Can be used to measure central venous pressure if advanced into superior vena cava.

Precautions: Keep dry. Avoid taking blood pressures over PICC. Caution with using crutches with pressure applied to the axilla.

Purpose: Provides central venous access and multiple access ports

Location: Enters at subclavian or IJ and ends in superior vena cava or right atrium.

Indication: Same as PICC, can also give frequent chemotherapy doses. Can be placed at the bedside quickly.

Precautions: Highest rate of infection. Keep dry. No contraindications for therapy.

Purpose: Provides central venous access. Used for caustic medications such as Chemo

Location: Tunneled subcutaneously from the insertion site (subclavian or IJ) and exits at the site below the nipple line

Indication: Same capabilities as non-tunneled version but with lower infection rate; can safely be used for a longer term.

Precautions: Keep dry

Purpose: Provides central venous access. Less noticeable; requires less daily care

Location: Same as tunneled catheter, but port is located under the skin

Indication: Same as tunneled catheter

Precautions: Can get wet without risk of infection

Purpose: blood pressure monitoring and blood draws; arterial blood gases 

Location: Inserted in the femoral, brachial, radial, or dorsalis pedis artery. 

Indication: Provides more accurate blood pressure than noninvasive techniques; used when patient is getting IV pressors 

Restrictions: Do not flex involved limb at site of insertion. Femoral line: generally, on bed rest; no hip flexion on involved side 

Precautions: Only provides accurate BP reading when it is level with the atria. Needs to be recalibrated by RN after change in position; values will not be accurate until then. 

Purpose: Provides vascular access, measures blood pressure in the large veins of the body. 

Location: Enters in subclavian region. Ends just above the right atrium. 

Indication: Critical illnesses affecting heart function. Also used after heart surgeries 

Restrictions: No ROM restriction 

Precautions: Needs to be recalibrated by RN after position change 

Purpose: to detect heart failure or sepsis, monitor therapy, & evaluate the effects of particular drugs. Allows direct simultaneous measurement of pressures in the right atrium, right ventricle, and pulmonary artery, and the filling pressure (“wedge” pressure) of the left atrium. Monitors intravascular volumes: central venous pressure, cardiac output, & mixed venous saturation of O2. 

Location: Enters in the subclavian or IJ. Winds through the right side of the heart, ending in the proximal left or right branch of pulmonary artery. 

Indication: Critical illnesses affecting heart function such as shock or acute pulmonary edema. Also used after heart surgeries 

Restrictions: Usually on bed rest. Appropriately only for splinting and positioning. If appropriate specific orders are required. Limit excessive overhead/repetitive movement and avoid ROM to ipsilateral shoulder to ensure line stability. 

Precautions: May produce bleeding, vessel rupture, dysrhythmias, and other life-threatening complications. No contraindication unless device is placed in the femoral region. 

Purpose: treat cranial or spinal CSF leaks, evaluate for normal pressure hydrocephalus, and reduce ICP during craniotomy or transsphenoidal surgery (Johns Hopkins Cerebral Fluid Center, n.d.). Drains directly from the lumbar region of the spine and are level with the bed and the umbilicus. 

Location: Small flexible tube placed in the lumbar spine 

Precautions: Specific activity and clamping orders are required. Drain must be clamped for position change/mobility. Generally, do not clamp drain for > 30 minutes. Drain must be realigned by RN once returned to bed/chair. 

Purpose: Temporary system to drain CSF from the ventricles to an external closed system (Muralidharan, 2015). 

Location: external auditory meatus or tragus is the anatomical reference for correct drain alignment. Adjusting height or head of bed alignment can change this. 

Indication: treat excessive CSF in the ventricles (hydrocephalus), following craniotomy until CSF circulation is re-established, to drain infected CSF, or to provide a way to measure ICP and allow CSF drainage to treat elevated ICP (Muralidharan, 2015). 

Precautions: Activity order required for all out of bed activity. Drain must be clamped prior to mobility. Generally, don’t clamp for >30 minutes. HOB usually elevated at 30° 

Additional Information to Know:

• Open = actively draining

• Clamped = drain is in place, but not actively draining

• Setting: 0, 10, 15, 20 (lower number means more CSF drainage)

• Drain is leveled at tragus

• Gravity dependent system 

• Higher drain = more pressure (ICP) is required to push fluid out through the drain

• Raising the drain and eventual clamping is a sign of patient improvement

Typical course:

• Drain placed due to increased ICP (blood, edema, lesion occupying volume in skull) or hydrocephalus (trauma, blood, tumor obstructing the flow of CSF)

• Drain leveled per ICP needs; most aggressive typically 0 and open (some patients may be -5 or more, but this is uncommon)

• Per patient tolerance, the drain is raised typically to 20-25

• If the raised drain is tolerated, drain stays in but is clamped

• If the raised clamped drain is tolerated, EVD is pulled

• If clamped drain causes ICP elevation, then it is re-opened; re-attempt wean later

• If unable to tolerate repeated EVD clamp trials, eventual plan for shunt

Purpose: Surgical management of excess CSF. Provides an alternate path to redirect excess CSF from one area to another using an implanted tube. With overall goal of relieving elevated ICP from excess CSF

Location: a catheter is passed from the ventricles to the abdomen to directly drain CSF (MedlinePlus, 2021). The drip chamber is located inside the abdominal cavity. 

Precautions: doesn’t require leveling or clamping. Craniotomy precautions. Gradual elevation of HOB and activity orders are generally ordered on post-op day 1. Patients may complain of headache and stomachache. Do not push on the shunt that is visible on the head.

Purpose: Test to monitor and detect abnormal brain waves. 

Indication: diagnose and treat seizures, brain tumors, evaluate trauma, extent of brain injury, inflammation of the brain, stroke, sleep disorders, or monitor blood flow in the brain during surgical procedures (Mayo Clinic, 2020).

Precautions: seizure precautions; if the patient is actively seizing or burst suppressed likely intubated and sedated, thus not appropriate to participate in therapy. When patient is ready and appropriate for therapy, an additional consideration is the amount of equipment in the room (is there enough room to complete your session) and the length of the wires/cables attached to the patient.

• Check the orders: is the patient cleared to participate? does the drain need to be clamped for position change?

• Make sure the drain and tubing are secure

• Be sure to limit tension on the drain tubing

• Limit physical contact with the drain insertion site

• Closely monitor volume with position changes when EVD or Lumbar Drain are NOT clamped

Purpose: common mode of supplemental O2 delivery

Intended for: 1-6 Lpm

What is it?: A mask that provides a high concentration of oxygen. Comprised of a mask that fits over your nose and attaches with an elastic band around your head. The mask has a plastic reservoir bag attached to it that is filled with a high concentration of oxygen. This serves as a one-way valve that prevents the exhaled oxygen from mixing with the oxygen in the reservoir bag.

Purpose: Non-rebreathers allow the patient to receive a higher concentration of oxygen than a standard mask or nasal cannula. Generally, only used for short-term increases in oxygen.

Intended for: 6-15 Lpm (95-100% FiO2)

What is it?: special oxygen cannula that can be used to supply high flow long-term oxygen therapy

Indicated for: 6-15 Lpm

Benefits: doesn’t obstruct your mouth, uses up the O2 tank slower, portable

Downside: heavy tubing, not flexible

What is it?: mask to deliver oxygen. It rests on the chin and opens upward toward the mouth and nose.

Purpose: can be used to provide a controlled concentration of oxygen and increase moisture to the mouth and nose

Indicated for: 25-100% FiO2 humidified air mixed with room air

Benefits: good for mouth breathers, very humidified

Downside: big, can’t eat and difficult to speak. Not portable.

What is it?: Mist collar which attaches over the trach to provide moisture.

Indicated for: 25-100% FiO2

*If you’re using it to mobilize with a patient, pay attention to whether their PMV is on. While they’ll be able to inhale through the one-way valve and oxygenate with the FiO2 you’ve provided, they are being forced to exhale through their native passages – which may be harder! May have to sacrifice being able to speak for being able to breathe

What is it?: oxygen delivery system that is able to deliver up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute

Able to Provide: 10-60 Lpm and up to 100% FiO2

Benefits: doesn’t obstruct the mouth, provides a little PEEP, humidifies the air

Downside: expensive

*There is no direct science to finding the equivalent travel/portable mode. Can usually default to a combination of oxymizer or NC with NRB at 25L flow (because that’s the highest the tanks will go), which provides 100% FiO2.

What is it?: a non-invasive method to decrease the work of breathing and provide ventilatory support to a spontaneously, but insufficiently, breathing patient using a facemask or nasal mask.

• 2 levels of pressure: one for positive pressure on inhale, one lower positive pressure for exhale.

• Variable pressure support & FiO2

• It is portable

What is it?: small tube that is inserted through the nose, down the throat and esophagus, and into the stomach. Dobhoff is a type of NGT that is small-bore and flexible.

Purpose: Provides temporary access to 1) decompress the GI tract or 2) administer oral agents (i.e., tube feedings, medications)

Precautions:

• If the patient is in bed and you lower the head of the bed, be sure to pause/hold the tube feed until the head of the bed can be raised again.

• Be careful to not pull or put tension on the tube to prevent accidental dislodgement while working with the patient. It can be helpful to tape or pin the tube to the patient’s johnny/clothing.

What is it?: a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach.

Purpose: Longer-term option to allow nutrition, fluids, and/or medications to be put directly into the stomach, bypassing the mouth and esophagus.

What is it?: intravenous or IV nutrition; patients can receive TPN for long-term

Purpose: typically used when all or part of a patient's digestive system does not work. The patient may require TPN because of:

• A GI disorder that severely limits the ability of their digestive tract.

• Inability to swallow food, move the food through the digestive system, or absorb nutrients from the food.

Location: Administered through a PICC, central line, or port-a-cath

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