ICU Bedside Procedures: Central Lines, Chest Tubes, LP and More

Before any procedure

Every procedure here shares the same skeleton, and the skeleton is where the preventable disasters live. The needle is the easy part.

• Confirm the indication out loud. "This patient needs a central line because they are on two pressors through a peripheral IV." If you cannot finish that sentence cleanly, stop.
• Consent, or document why not. A capacitated patient consents themselves, a surrogate consents for the incapacitated, and a crashing patient with neither gets an emergency consent and a note that says so.
• Check the coagulation status, then think. Platelets, INR, anticoagulants and timing of the last dose. Thresholds are local and differ by procedure. For most compressible sites a moderately abnormal number is not an absolute bar, and delaying a truly indicated procedure to chase a perfect INR can be the worse decision.
• Time out, every time, even at 3 a.m. Right patient, right procedure, right side, consent on the chart. The wrong-sided chest tube has been placed by smart people who were tired.
• Set up everything before you scrub, ultrasound screen where you can see it without turning your head. Once sterile, everything you forgot costs a second pair of hands or your sterility.
• Sterile technique is binary. For central lines: cap, mask, gown, sterile gloves, full-body drape, chlorhexidine that has dried. "Mostly sterile" is a line that comes out on day three with a fever attached.
• Know your stopping rule before you start. Two or three failed passes at a site means change the site, the operator, or the plan; the complication rate climbs with every attempt.

Last thing: bed at elbow height, patient at the edge of the mattress, lighting on. Ergonomics buys more first-pass success than an hour of reading.

Central venous catheter IJ, subclavian, femoral

Indications

• Vasopressors, the most common reason. Short peripheral runs of dilute norepinephrine are increasingly accepted, but escalating pressors for septic shock, as on the sepsis bundle page, need central access.
• Caustic or hypertonic infusions: concentrated potassium, hypertonic saline, chemotherapy, parenteral nutrition.
• No peripheral access after real attempts, including ultrasound-guided peripherals.
• Hemodialysis or plasmapheresis, which take a dedicated large-bore catheter, not a triple lumen.
• Hardware: transvenous pacing wires, PA catheters, and the introducer they travel through. CVP monitoring comes along free.

Contraindications

Almost all relative. Infection over the site, thrombosis of the target vein, and distorted anatomy move you to another site. Severe coagulopathy pushes you away from the subclavian, which you cannot compress. A patient on high PEEP with one working lung should not get a needle aimed at the pleura on that side. The only absolute contraindication is no indication.

Choosing the site

The kit

The tray: chlorhexidine, full drape, lidocaine 1 percent, introducer needle on a syringe, J-tipped guidewire, scalpel, dilator, the catheter, usually a 7 French triple lumen in 15 or 20 cm lengths, flushes, suture, sterile probe cover, dressing with chlorhexidine disk. Pick 15 cm for right IJ and right subclavian, 20 cm for left-sided and femoral; a 20 cm catheter jammed to the hub in a right IJ is sitting in the right atrium.

Ultrasound windows and landmarks

IJ: short axis first. The vein is lateral or anterolateral to the carotid, oval, thin-walled, and collapses when you push with the probe. The artery is round, pulsatile, and does not. Compress before you stick, every time, because a thrombosed vein does not collapse either. The landmark backup is the apex of the triangle between the heads of the sternocleidomastoid, needle at 30 to 45 degrees toward the ipsilateral nipple.

Subclavian: classically landmark. Enter a centimeter inferior to the clavicle at the junction of its middle and medial thirds, aim at the sternal notch, and keep the needle flat, walking under the clavicle. Every degree of downward angulation is a degree toward the pleura.

Femoral: below the inguinal ligament, vein medial to the artery. Ultrasound matters here because the vessels overlap in a substantial minority of patients, and because in a code the pulse you palpate may be someone's compressions.

The steps, in order

1. Consent, labs, time out. Trendelenburg for IJ and subclavian, to fill the vein and keep air out of it, head turned slightly away and no more, because overrotation flattens the vein onto the artery. Flat for femoral.
2. Prep widely, let it dry, full barrier, drape the whole bed, sterile probe cover.
3. Anesthetize generously. A patient who jumps at the introducer needle is a patient whose vein you will miss.
4. Advance the introducer needle under continuous negative pressure, watching the needle tip on the screen, not the shaft. Dark, non-pulsatile blood that fills the syringe easily is venous.
5. Remove the syringe and thread the wire. It should advance with no resistance. Any resistance: stop, reattach the syringe, confirm blood return, adjust. Never force a wire, never pull it back through the needle, never let go of it. Ectopy means the wire is tickling the right ventricle; withdraw a few centimeters.
6. Confirm the wire in the vein with ultrasound in two planes before you dilate. The single step that prevents arterial dilation, and it costs ten seconds.
7. Nick the skin against the wire, then dilate: a centimeter or two through the vessel wall with a twist. The dilator makes a track, it does not need to reach the atrium.
8. Thread the catheter over the wire, keeping hold of the wire, and seat it: roughly 13 to 15 cm for a right IJ, 15 to 17 for a left, 14 to 16 for a right subclavian, hub-deep for femoral. Remove the wire and say "wire out" so the room hears it.
9. Aspirate and flush every port, cap, suture, chlorhexidine disk, occlusive dressing.
10. Chest film for IJ and subclavian lines: tip at the cavoatrial junction, no pneumothorax. Femoral lines need no film. Do not infuse anything critical through an unconfirmed thoracic line unless the alternative is losing the patient.

What goes wrong

The note: indication, consent, time out, site and side, ultrasound use with an image saved, barrier used, number of passes, wire confirmation method, catheter type and depth, ports aspirated and flushed, complications or "none," and the film result. The procedure note template has the skeleton.

Arterial line Radial and femoral

Indications and contraindications

Beat-to-beat blood pressure on vasopressor or vasodilator infusions, frequent arterial gases in respiratory failure, and any patient in whom the cuff is unreliable or the decisions are too fast for it. Avoid a site with infection, absent distal perfusion, a dialysis fistula on that arm, or prior vascular surgery on that vessel. The modified Allen test is commonly documented and poorly predictive; do not let it substitute for examining the hand afterward.

Radial

The workhorse. Kit is an integrated catheter-over-wire device or a plain angiocath, plus the transducer setup someone assembles while you scrub. Position is everything: wrist dorsiflexed over a rolled towel, taped to an armboard. Palpate the pulse or, better, put the probe on it; ultrasound roughly doubles your first-pass rate in the hypotensive patients who need the line most.

1. Prep, sterile gloves and drape, a small bleb of lidocaine even in the obtunded, because arterial spasm from pain costs you the vessel.
2. Enter at 30 to 45 degrees, bevel up, along the artery. Flash of pulsatile blood: drop the angle nearly flat and advance a millimeter so the tip, not just the bevel, is intraluminal.
3. With an integrated device, advance the wire and slide the catheter over it. With an angiocath, thread directly, or transfix: pass through the back wall deliberately, withdraw until pulsatile flow returns, then thread.
4. Connect, look for a crisp waveform, secure, splint the wrist in neutral.

Zero the transducer and level it at the phlebostatic axis, again every time the bed moves. A transducer on the floor reads a hypertensive crisis; one taped to an IV pole reads a code. Waveforms, damping and the square-wave flush test are on the arterial line and CVP page; learn to recognize a damped trace before you treat a fake blood pressure.

Femoral

For the shocked patient whose radials are clamped down. Full Seldinger kit with ultrasound: common femoral artery, below the inguinal ligament and above the bifurcation, at or above the femoral head on your screen. Too low is the superficial femoral, which thromboses; too high bleeds into the retroperitoneum where you can neither see nor compress it. In shock the femoral trace also sits closer to central aortic pressure than a spasming radial, which can read 20 or 30 mm Hg below the truth.

What goes wrong

• Distal ischemia and thrombosis: a pale, cool, painful hand or a dusky finger. Check the hand daily and pull the line at the first sign. Most radial occlusions recollateralize; the ones that do not were left in too long.
• Retroperitoneal hemorrhage after a high femoral stick: falling hemoglobin, hypotension, flank pain, a low threshold to scan.
• Pseudoaneurysm and AV fistula: a pulsatile mass or new bruit at an old site, days later.
• Accidental intra-arterial injection. Label the line at the hub. Drugs pushed into an artery cause distal necrosis, and the person who pushes them is usually not the person who placed the line.
• Infection, less common than with central lines but real; same daily question of necessity.

The note: indication, consent or emergency justification, site and side, ultrasound use, technique, catheter gauge, number of attempts, waveform confirmed, distal perfusion intact afterward, complications or "none."

Lumbar puncture

Indications and contraindications

Suspected meningitis or encephalitis, suspected subarachnoid hemorrhage with a negative CT, opening pressure in suspected idiopathic intracranial hypertension, and diagnostic taps for the neurology consult's differential. In suspected bacterial meningitis, the antibiotics do not wait for the needle: culture the blood, treat, then tap. A sterilized culture is a small price; a dead patient with pristine timing is not a trade anyone accepts.

• Do not tap a brain that is about to herniate. CT first in anyone with focal deficits, new seizures, papilledema, immunocompromise, known CNS disease, or a depressed level of consciousness. A mass lesion plus a hole in the lumbar sac is how herniation happens.
• Coagulopathy. Spinal epidural hematoma is rare and catastrophic. Common practice holds therapeutic anticoagulation, wants platelets above roughly 50,000 and an INR near normal, and times the tap around heparin doses. The numbers are institutional; the principle is that you cannot hold pressure here.
• Infection over the site: another level or another plan.

Positioning and landmarks

Lateral decubitus, fetal position, shoulders and hips square to the bed, is the only position in which an opening pressure means anything. Sitting, leaning over a table, opens the interspaces and is easier in the obese, but a seated manometer reading is a number you cannot interpret. If you need the pressure, get the patient lateral with legs extended before you connect the manometer.

The cord ends around L1 to L2 in adults, so work at L3-L4 or L4-L5. The intercristal line crosses roughly L4. Palpate, mark before you prep, and take your time: the usual reason an LP fails is that the needle started in the wrong place in the wrong plane. Ultrasound to mark midline and interspace earns its keep in obese patients.

The kit and the steps

The tray: antiseptic, drape, lidocaine, a 20 to 22 gauge spinal needle with stylet, manometer with stopcock, four numbered tubes. Given the choice, an atraumatic pencil-point needle measurably reduces post-LP headache.

1. Position, mark, prep, drape, anesthetize skin and the deeper track.
2. Needle midline, bevel parallel to the long axis of the spine if it is a cutting needle, angled slightly cephalad toward the umbilicus.
3. Advance in small increments. Resistance at the ligamentum flavum, often a subtle give entering the space. Withdraw the stylet and look; no fluid, replace it, advance, look again.
4. Bone means off midline or off angle. Withdraw to subcutaneous tissue, re-palpate, redirect.
5. Clear fluid: connect the manometer and read the opening pressure with legs extended and quiet breathing. Normal is roughly 10 to 20 cm of CSF in a relaxed lateral adult. Record it now; you cannot go back for it.
6. Collect tubes 1 through 4, one to two milliliters each, more if cytology is planned: tube 1 cell count, tube 2 glucose and protein, tube 3 Gram stain and culture, tube 4 repeat cell count, local lab preferences governing.
7. Replace the stylet before withdrawing the needle, dress the site.

What goes wrong

• Post-dural puncture headache: positional, worse upright, better flat, starting hours to days later. Fluids, caffeine and analgesia first; severe or persistent headache gets anesthesiology for a blood patch. Smaller and atraumatic needles are the prevention.
• Traumatic tap: bloody fluid that clears across the tubes, which is why you count cells in tubes 1 and 4. Blood that does not clear, with xanthochromia in the spun supernatant, argues for true subarachnoid blood.
• Dry tap: usually position and angle. Reposition, change a space, sit the patient up, or hand it to fluoroscopy rather than making the back look like a dartboard.
• Spinal hematoma: new back pain, leg weakness or sphincter symptoms afterward, especially in the anticoagulated. Emergency MRI and a spine surgeon, not a note for the day team.
• Herniation and infection: rare, mostly prevented by the contraindication paragraphs above.

The note: indication, consent, imaging reviewed if done, position, level, needle type and gauge, attempts, opening pressure and the position it was measured in, fluid appearance, tubes and where they went, complications or "none."

Thoracentesis

Indications and contraindications

Diagnostic: any new effusion without an obvious explanation, and any effusion in a febrile patient, because an undrained empyema does not get better on antibiotics. Therapeutic: dyspnea from a large effusion. Contraindications are the usual relatives: uncorrected severe coagulopathy, an infected chest wall, and an effusion too small or loculated to hit safely, a call you make with the probe, not the radiograph.

Ultrasound marking, done correctly

• Scan and stick in the same position. Mark with the patient sitting up and leaning on a table, then needle them in exactly that position. An X marked in one position and needled in another is a mark on the spleen. If the patient moves, rescan.
• Choose a pocket, not a shadow: several centimeters of fluid through the whole respiratory cycle. The pocket that looks generous in expiration can vanish in inspiration.
• Note the depth from skin to pleura and pleura to lung, out loud, before you start.
• The usual site is the posterior axillary line, one or two interspaces below the top of the fluid, never below the ninth interspace without a very good ultrasound reason.

The steps

1. Position, mark, prep, drape. Anesthetize the skin, then walk the needle over the top of the rib, anesthetizing periosteum and pleura. The neurovascular bundle runs under the rib above; going over the rib below is the entire safety geometry of the chest wall.
2. Aspirate as you advance. When you get fluid, note the depth.
3. Advance the catheter-over-needle along the same track with aspiration; when fluid returns, slide the catheter in and withdraw the sharp. From here there is plastic, not steel, against the lung.
4. Drain by syringe and one-way valve or vacuum bottle. Send the first fluid: pH on ice, LDH, protein, glucose, cell count and differential, Gram stain and culture, cytology if malignancy is in play, with serum LDH and protein the same day so Light's criteria can be applied.
5. Withdraw the catheter at end-expiration, occlusive dressing, then confirm lung sliding on ultrasound, a reasonable substitute for the routine film in an uncomplicated tap.

What goes wrong

• Pneumothorax: new cough, pleuritic pain, hypoxia, or lost lung sliding. Small and asymptomatic can be observed; on positive pressure, plan the tube.
• Re-expansion pulmonary edema: cough, frothy sputum and hypoxia during or after a large-volume tap. Supportive care and oxygen.
• Bleeding: the intercostal artery, which in older patients can run exposed below the rib margin even at the "safe" spot. Falling hemoglobin or reaccumulating dense fluid is a hemothorax until proven otherwise.
• Solid-organ puncture: liver or spleen, almost always a marking or positioning error.
• Dry or failed tap: loculations, a rind, a pocket that moved. Rescan, and involve interventional colleagues before attempt number four.

The note: indication, consent, ultrasound findings and marked site, position, catheter used, fluid appearance and volume removed, studies sent, post-procedure lung sliding or film, complications or "none."

Paracentesis

Indications and contraindications

Diagnostic: every admitted cirrhotic with ascites gets a tap, full stop, because spontaneous bacterial peritonitis presents as encephalopathy, as renal failure, as "just not right," and only occasionally as an abdomen that tells you. New-onset ascites gets a tap plus a SAAG. Therapeutic: tense ascites causing pain, dyspnea or early satiety.

Contraindications are few. Cirrhotics live with abnormal INRs and low platelets, and routine correction before paracentesis is not standard practice; the bleeding that matters comes from hitting a vessel, not from the numbers. Avoid infected skin, scars with possible adherent bowel, visible collaterals, and massive ileus. DIC with clinical bleeding is the coagulopathy that should actually stop you.

Site, kit and steps

The classic site is the left lower quadrant, two to three centimeters medial and cephalad to the anterior superior iliac spine, lateral to the rectus sheath, which keeps you off the inferior epigastric arteries. Ultrasound first: a pocket several centimeters deep, no bowel in the path, marked in the position you will use.

1. Supine, slightly rotated toward the tap side. Prep, drape, anesthetize.
2. Use a Z-track: pull the skin a couple of centimeters caudad, advance, release after the catheter is in. The offset track closes over itself, your main defense against a persistent leak.
3. Advance the catheter-over-needle with aspiration until fluid returns, a few millimeters more, thread the catheter, withdraw the needle.
4. Diagnostic samples first: cell count and differential, albumin and total protein, and culture inoculated into blood culture bottles at the bedside, which meaningfully improves the yield. A PMN count above 250 per cubic millimeter is SBP and gets treated tonight, not after the culture.
5. For a therapeutic tap, connect to vacuum bottles or a drainage bag.
6. Catheter out, dressing on. If the site keeps leaking, an ostomy bag and patience beat repeated dressing changes.

What goes wrong

• Bleeding: an abdominal wall hematoma, or the rarer intraperitoneal bleed presenting as hypotension and a falling hemoglobin hours later. Cirrhotics compensate quietly and then abruptly do not.
• Persistent leak: the most common nuisance, mostly prevented by the Z-track.
• Bowel perforation: rare with ultrasound; new pain, fever, or feculent fluid. Surgery consult, not observation.
• Circulatory dysfunction: the delayed hypotension and creatinine bump above, mostly prevented by the albumin rule.

The note: indication, consent, ultrasound used, site, Z-track, appearance of fluid, volume removed, studies sent including bedside culture bottles, albumin given with the dose, complications or "none."

Chest tube and pigtail

Indications

• Pneumothorax: tension after needle decompression, any pneumothorax on positive pressure, large or symptomatic spontaneous, and traumatic by trauma criteria.
• Hemothorax, for the lung and so you can measure the output, which drives the thoracotomy conversation.
• Empyema and complicated parapneumonic effusion: pus, a positive Gram stain, or a pleural pH below about 7.2 in the right setting. Antibiotics do not sterilize an undrained space.
• Large recurrent effusions needing more than serial taps.

Tension pneumothorax will not wait for a kit: obstructive shock plus a silent hyperexpanded hemithorax gets needle or finger decompression immediately, then the tube. It is one of the classic night calls where the treating happens before the imaging.

Pigtail or surgical tube

The old reflex was that everything got a large surgical tube. Practice has moved. A small-bore pigtail, 8 to 14 French, placed by Seldinger technique, handles air and free-flowing fluid well and hurts dramatically less. A large-bore surgical tube, 28 French and up, remains the choice for hemothorax, thick empyema and trauma, where clot and pus plug small tubes.

Landmarks and positioning

The triangle of safety: anterior border of latissimus dorsi behind, lateral border of pectoralis major in front, the fifth intercostal space below, apex toward the axilla. Entering here keeps you above the diaphragm. Arm abducted behind the head, head of bed up. Ultrasound before you cut, because a diaphragm riding high changes everything.

The steps: surgical tube

1. Consent unless the patient is dying faster than you can talk, time out, prep and drape widely. Anesthetize generously: skin, track, periosteum, pleura. This is the most painful procedure on this page; analgesia plus sedation in anyone with a blood pressure.
2. Incise 2 to 3 cm along the rib below your target interspace.
3. Blunt dissect with a Kelly clamp over the top of the rib until you feel the pleura.
4. Pop through close to the rib's superior edge and open the clamp to enlarge the tract. A rush of air or fluid says you are in.
5. Finger sweep: a gloved finger through the tract, confirming lung or free space rather than adhesion or abdomen, which is why the tube goes where you think it goes.
6. Direct the tube with the clamp, apically for air, posteriorly and basally for fluid, until all side holes are inside the chest.
7. Connect to the drainage system, look for fogging, swinging and output. Stay stitch, occlusive dressing, film for position.

The steps: pigtail

Pure Seldinger, familiar from the central line: ultrasound the pocket, anesthetize over the rib, needle in with aspiration until air or fluid returns, wire, nick, dilator, pigtail over the wire, wire out, connect and secure. Never force the wire.

The drainage system

Three chambers: collection, a water seal acting as a one-way valve, and suction usually at negative 20 cm of water. Tidaling with respiration means the tube is patent. Bubbling in the water seal means air leaving the chest, expected early in a pneumothorax; a continuous vigorous leak means check the connections and the side holes before you blame the lung. A tube that neither tidals nor drains is blocked, and a blocked tube in a patient with an ongoing air leak is a tension pneumothorax being assembled.

What goes wrong

• Malposition: in the fissure, the soft tissue, or subdiaphragmatic. Suspected when the tube does not do its job, confirmed on film or CT. A tube in the abdomen is a surgical consult, not a bedside adjustment.
• Organ injury: lung laceration with a persistent leak; diaphragm, liver or spleen from a low insertion. The finger sweep and the ultrasound are your prevention.
• Bleeding: brisk sanguineous output that does not slow. Trend it; your center has thresholds that trigger the thoracic surgery call.
• Re-expansion pulmonary edema after rapid drainage, same physiology as after thoracentesis.
• Subcutaneous emphysema: spreading crepitus, usually a partially migrated tube. Check the last side hole is inside the chest.
• Infection, prevented by sterile placement and by not leaving tubes in longer than they earn.

The note: indication, consent or emergency exception, side confirmed, ultrasound findings, sedation used, tube type and size, technique including the finger sweep, immediate return of air or fluid, suction level, the confirming film, complications or "none."

Intubation, from the proceduralist's side

This is not an airway course. This is the frame for the person at the head of the bed: what to prepare, what to push, and how to prove the tube is where you say it is.

The decision

The indication is one of three failures: failure to oxygenate, failure to ventilate, or failure to protect the airway, plus the anticipated version of each. The only near-absolute contraindication in the ICU is a documented decision against it; check the code status before the crisis, not during it. In the crashing patient, the real question is rarely whether to intubate but whether you have optimized the physiology enough to survive the attempt.

Preparation, which is most of the procedure

• People: a designated operator, a backup plan and its executor, someone on drugs, someone on the monitor. Say it out loud: "Plan A video laryngoscope, plan B bougie, plan C supraglottic airway, and if I say surgical airway nobody argues."
• Equipment, checked with your own hands: suction on and under the pillow, laryngoscope with a backup blade, tubes in two sizes with cuffs tested, stylet or bougie, oral airway, bag-valve-mask, supraglottic airway in reach, capnography connected.
• Preoxygenation: several minutes of high-flow oxygen with a tight seal, head of bed up. Denitrogenation buys safe apnea time, and the sick ICU patient has far less of it.
• Physiology: the hypotensive, acidotic, hypoxemic patient is the one who arrests on induction. Fluids or a pressor running before the drugs, push-dose vasopressor drawn up, an honest look at whether the pH tolerates an apneic minute.
• Assessment: a quick look for the difficult airway: mouth opening, neck mobility, beard, obesity, prior radiation. Finding it after the paralytic is the wrong time.

The drugs

Induction. Etomidate around 0.3 mg/kg is the hemodynamically forgiving default. Ketamine 1 to 2 mg/kg supports blood pressure and is favored in shock and bronchospasm. Propofol drops the pressure of a shocked patient like a stone. In profound shock, halve the induction dose and have the pressor ready: the sedative requirement of a dying brain is small.

Paralysis. Succinylcholine 1 to 1.5 mg/kg is fast on and fast off, contraindicated in hyperkalemia and the receptor-upregulated states: burns and denervation beyond the first days, prolonged immobilization, some myopathies. Rocuronium 1.2 mg/kg gives comparable conditions without the potassium problem, at the price of a long duration, acceptable because your backup plans do not depend on the patient waking up.

The attempt and the confirmation

1. Drugs in sequence, wait for full relaxation, ear at the level of the sternal notch.
2. Laryngoscopy, video by preference, deliberate rather than fast. Tube through the cords under vision, cuff up, depth about 21 to 23 cm at the teeth for an average adult.
3. Confirm with continuous waveform capnography. A sustained CO2 waveform over multiple breaths is the standard. Colorimetric change is a backup that fails in low-flow states. Misting in the tube and "I saw it go through" convince the operator and no one else.
4. Then the clinical checks: bilateral breath sounds, no gurgling over the stomach, chest rise, saturation trend. A chest film for depth; the film confirms position, not tracheal placement, which capnography already did.
5. Secure the tube, start sedation before the paralytic wears off, and set the ventilator deliberately, as on the ventilator settings and ABG page.

What goes wrong

• Esophageal intubation: no waveform, falling saturation, rising abdomen. The failure is not the misplacement, it is the delay in recognizing it.
• Right mainstem: tube too deep, absent left breath sounds. Pull back and recheck depth.
• Peri-intubation hypotension and arrest: induction drugs plus positive pressure in a preload-dependent patient. Fluid, pressors, and a hard look for tension pneumothorax, breath stacking, and a migrated tube.
• Aspiration: gastric contents at laryngoscopy, new infiltrate later. Suction ready and a decompressed stomach are the prevention.
• Failed airway: the reason plans B and C were said out loud. Call for help early. Ego has a body count in airway management.

The note: indication, pre-intubation vitals, drugs and doses, device, grade of view, number of attempts, tube size and depth, confirmation by waveform capnography and auscultation, post-intubation vitals, film ordered, complications or "none."

NG and OG tubes, and confirming them

The least glamorous procedure here and the one most often done carelessly, which is how a tube ends up in a bronchus with feeds running into a lung.

Indications and contraindications

Decompression of ileus, obstruction or gastric distension; enteral feeding and medication access; lavage in select overdoses. Contraindications: no nasal tube in midface trauma or suspected basilar skull fracture; use the oral route. Recent esophageal or gastric surgery means the surgeon places or blesses the tube. Varices are a relative caution, not the absolute bar trainees imagine. Intubated patients get an orogastric tube, which spares the sinuses.

Placement

1. Measure nose to earlobe to xiphoid, then a few centimeters more. Most adults land around 55 to 65 cm.
2. Lubricate; in the awake patient, topical anesthetic in the nostril and a straw of water.
3. Pass along the floor of the nose, straight back, not upward. At the pharynx, have the awake patient flex the chin and swallow while you advance.
4. Coughing, choking or a voice change means the airway: pull back to the pharynx and start again. An endotracheal cuff does not reliably keep a small-bore tube out of the trachea.
5. Advance to the mark, secure temporarily, and confirm before anything goes down it.

Confirmation

• The standard before feeding is a radiograph showing the tube descending in the midline, crossing the diaphragm, tip clearly in the stomach, the whole course reviewed. Small-bore stylet tubes have punctured pleura on the way to a film nobody checked; see the film before the first mL of feed.
• Aspirate pH below about 5.5 supports gastric placement, blurred by acid suppression.
• Electromagnetic guidance systems supplement rather than replace the film in most policies.
• Reconfirm at the mark every shift and before feeds. A tube in the stomach on Monday can be in the esophagus by Wednesday after one good cough and a loose piece of tape.

New respiratory distress during placement or feeding, or feed in the tracheal suction, means stop the feed and get the film. A large gastric residual is a management question; formula in a lung is a catastrophe.

What goes wrong

• Tracheopulmonary misplacement: cough, distress, desaturation, or nothing at all in the sedated patient, which is why the film is mandatory.
• Epistaxis: common, usually from passing upward instead of straight back. Pressure and patience.
• Coiling in the pharynx or esophagus: the tube keeps coming and nothing aspirates. Check the mouth.
• Sinusitis and pressure necrosis of the naris with prolonged nasal tubes; check the nose on rounds.

The note: indication, route, tube type and size, depth at the naris or lips, tolerance, confirmation with the film explicitly reviewed and by whom, and whether feeding may start.

Intraosseous access Thirty seconds to a line

When the patient is coding or crashing and there is no IV, stop hunting veins. The IO drill takes seconds, and essentially every resuscitation drug, fluid and blood product can run through it at pressure. Proximal tibia is the default site: two fingerbreadths below the patella and a fingerbreadth medial, on the flat part of the bone. Confirm by stability of the needle and the ability to flush. Awake patients feel infusion pain, so a slow flush of preservative-free lidocaine through the IO, per your local protocol, is a kindness. Replace it with definitive access within about a day.

The emergency procedures Know the first move

These are not procedures you master from a website. They are procedures where knowing the first move and the phone number is the trainee's whole job.

The complications table What to watch for tonight

Post-procedure orders are part of the procedure: the confirming x-ray, the pressure dressing check, the repeat hemoglobin after a bloody tap, the neuro checks after an LP on a patient you worried about. Write them before you leave the bedside, because the covering intern at 3 a.m. will not know what you were worried about unless you say so. The night calls guide is full of pages that better post-procedure orders would have prevented.

The procedure note

Every procedure ends the same way: a note written before you leave the unit, while the details are still true rather than reconstructed. The procedure note template exists so you never invent the skeleton at midnight. The elements:

Write the note as if the reader is deciding, five years from now, whether you were careful. One day, for one of these procedures, someone will be.