Intercostal drainage introduction

INTERCOSTAL DRAIN. Insertion - Management Dr T VAMSHIDHAR DNB Cardiothoracic Surgery CARE Hospitals Basics/Introduction Indications for ICD Pre-Drainage risk assessment Equipment Consent & Premedication Patient Position Insertion of chest tube Management Removal of ICD Basics/Introduction ICD = Intercostal Drainage Indications for Intercostal Drainage Emergency Non-Emergency 1) Pneumothorax. Intercostal Drainage Tube • The concept of chest drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes

Intercostal Drain Clinical Medicine Medicin

Intercostal Chest Drain (Thoracostomy Tube) Spontaneous Pneumothorax Management Intercostal Chest Drain (Thoracostomy Tube) Historically, the treatment for a large pneumothorax was insertion of a large drain (e.g. 28FG) through an incision in the chest wall Intercoastal insertion is one of the commonest procedures in emergency departments performed by emergency care physicians, interns, resident doctors, etc. Although the insertion of the intercoastal drain is a common practice in the medical field, inappropriate insertion may lead to complications intercostal drainage (thoracostomy) by dr. b raja Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. If you continue browsing the site, you agree to the use of cookies on this website Introduction Chest drains also known as under water sealed drains (UWSD) are inserted to allow draining of the pleural spaces of air, blood or fluid, allowing expansion of the lungs and restoration of negative pressure in the thoracic cavity. The underwater seal also prevents backflow of air or fluid into the pleural cavity

Intercostal Drainage Tube - SlideShar

  1. Anterior intercostal veins (ventral view) Drainage. The posterior intercostal veins drain into the azygos (right side) and hemiazygos and accessory hemiazygos vein (left side).The name azygos originates from the Greek word 'Zyg' meaning paired and A means not. The azygos vein does not have a pair (instead there are two separate veins that drain the left posterior thorax and abdomen i.e.
  2. Introduction Print Section Listen The concept of chest tube drainage was first advocated by Hippocrates when he described the treatment of empyema by means of incision, cautery, and insertion of metal tubes.1 The technique was not widely used until the influenza epidemic of 1917 which saw an increased use of intercostal drainage for postpneumonic empyema.
  3. Introduction: Chest drain insertion is a common procedure, which may be carried out in clinical areas. Most are planned, but some may need to be done as emergencies. When they are not inserted properly, they may puncture major organs such as heart, lungs, liver and spleen
  4. Indications for the insertion of an intercostal chest drain are listed in Table 1. The most common include pneumothoraces, complicated parapneumonic effusions or empyemas, hemothoraces, bedside pleurodesis, and following cardio-thoracic surgery or thoracoscopic procedures to allow for appropriate lung re-expansion2
  5. insert drain until an adequate length is within the pleural cavity (will depend of patient habitus) suture in place and dress with a sterile dressing. connect to underwater seal drain (connections should be stable and easy to attach in a sterile manner) CXR should be formed to check adequate positioning and detect complications
  6. A chest tube (chest drain, thoracic catheter, tube thoracostomy, or intercostal drain) is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax), fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space

Introduction Be aware of the risks associated with pleural drains Pleural procedures which involve the insertion of intercostal catheters into the pleural cavity incur a high risk of adverse outcomes including death Introduction Penetrating injuries to the chest are usually associated with hemothorax or pneumohemothorax, and the standard of care is the placement of an intercostal chest drain This malformation is generally confused with pneumothorax of the lung and most often, the placement of an intercostal drainage tube is entertained in an emergency situation, but the non- improvement of the distress and non-expansion of the lung are eye openers for a treating paediatrician An intercostal drainage or chest Introduction: Intercostal Drainage or chest tube drainage or under water seal drainage system [UWSDS] has a paramount importance in critical care environment. Staff nurses being the caregivers require wholesome knowledge regarding the management of patients with ICD

Objectives International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases Introduction: Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods: This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results: A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male An intercostal drainage tube (ICD) was inserted and 350 mL of serosanguineous fluid was instantly drained whilst suction of 15 cm H 2 O was applied. A second chest X-ray showed a fully re-expanded left lung (Fig. 2) and oxygen saturation was 100% with 2 L of oxygen Introduction. Insertion of an intercostal chest drain (ICD) is a common intervention in the management of either blunt or penetrating thoracic trauma. It is frequently performed by junior medical personnel, 76% of insertions in one large study,1 as an emergency procedure during the initial resuscitation period and often within a stressful. Arteries and veins of the thoracic wall. The thoracic wall or chest wall is a musculoskeletal structure that has a vast vascular supply. Most of the arteries of the thoracic cavity arise directly from the thoracic aorta; while others arise from its branches.On the other hand, the veins of the thoracic wall eventually coalesce to drain into the vena caval system

Intercostal Chest Drain (Thoracostomy Tube) - RCEMLearning

Introduction: Trauma is one of the most common causes of death in low- and middle-income countries, with thoracic injury accounting for 20-25% of these deaths worldwide. The current management of a life-threatening pre-hospital pneumothorax is with a needle chest decompression, however, definitive care for a pneumothorax and/or haemothorax is still the insertion of an intercostal chest drain If the intercostal drain was inserted for a haemothorax and there is heavy bleeding, the patient will need a thoracotomy to control the bleeding vessel. Clinicians must consider a thoracotomy if there is more than 1500 mL immediate blood loss, or more than 200 mL/hour blood loss over 2 to 4 hours The intercostal catheter's (ICC) perforators were intrathoracic but close to the chest wall and the drainage system was bubbling and swinging suggesting a patent functioning chest tube

This video covers the anatomy of the external, internal and innermost intercostal muscles, their origin, insertion, innervation and functions. Test yourself. Intercostal Drainage Tube Insertion. exp date isn't null, but text field is. Gentle rotation of the dilators around the central wire will facilitate introduction (Fig 5). Make sure each dilator is passed just until its maximum diameter is through the tract. There should be enough guide wire in the chest to prevent the dilator advancing. First described for the drainage of an empyema in 1876 by both Hewett in England and Bulau in Germany, the ICD consists of an intercostal tube and a drainage system (5, 6). The latter requires an underwater seal which acts as a one-way valve (7). Alternatively, a drainage bag which contains a flutter valve can be used as a drainage system (6)

Intercostal Catheters and UWSD Updated 27/11/2010 Page 3 of 22 INTRODUCTION There are many reasons that patients develop a pneumothorax and require an Intercostal catheter (ICC). They may occur spontaneously, as a result of trauma, as a complication of a medical procedure or secondary to a disease process. removal of a chest drain. Keywords Chest drain, pleural effusion, pneumothorax, respiratory medicine Introduction Chest drains were first documented for the treatment of empyema by Hippocrates. He described the process of incising the chest and inserting a metal tube to allow drainage.1 However, chest drains only becam Thoracic ultrasound should be available and used where intercostal catheters are inserted for drainage of pleural fluid. Mandate a 'Time out'™ period prior to insertion to confirm the correct side and site both clinically and radiologically. Check coagulation profile prior to insertion or removal of a pleural drain spreading of the intercostal muscles on the superior surface of the ribs to avoid injury to the intercostal vessels and nerves that run below the inferior border of the ribs. Alternatively a small bore chest drain using the Seldinger technique may be used. All drain holes need to be in the pleural cavity for the drainage system to work effectively

Intercostal Drain Insertion (Mattress Suture Technique

Intercostal drainage - SlideShar

Background Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. Objectives We explored clinicians' attitudes, experience and knowledge relating to pleural. Introduction. Pleural effusion and pneumothorax are common conditions presenting to secondary care and accounted for over 29 000 admissions in the period 2011-2012 within the National Health Service in England [].First line management is usually conservative, needle aspiration or by medical teams utilizing small bore Seldinger intercostal chest drains []

The intercostal spaces are filled with intercostal muscles, with the vein, artery, and nerve lying in the costal groove along the inferior margin of the superior rib from above downwards and situated between the second and the third layer of muscles (Figure 1). To avoid the neurovascular bundle, it is normally advocated that the drain be. Keywords: pleural effusion; pneumothorax; intercostal drain; thoracocentesis 1. Introduction The incidence of pleural disease is rising and is estimated to be 3000 per million patients in the United Kingdom (UK) alone [1]. The presence of air (pneumothorax) or fluid (pleural effusion) in the pleural space or the development of benign, malignan

Spontaneous Pneumothorax Management Intercostal Chest Drain (Thoracostomy Tube) Lesson Progress 0% Complete Historically, the treatment for a large pneumothorax was insertion of a large drain (e.g. 28FG) through an incision in the chest wall. During the last decade there has been a move towards inserting smaller drains percutaneously. Small drains (e.g. 8-14FG) have been shown [ Introduction: A recent audit of ICD's for pleural effusions in our 800 bedded tertiary centre revealed that in a 2 month period a significant proportion of drains were being managed on non respiratory wards (44% oncology & 16% other medical wards). Guidelines recommend that ICD's are nursed on wards familiar with drains and their management. Method: We carried out an anonymised survey of. Introduction Intercostal tube drainage of pleural air or fluid is an essential tool in the management of respiratory patients. A common complication of drain insertion is accidental removal of the drain, usually as a result of inadequate securing techniques, with rates of up to 21% quoted in the literature.1,2 This often results in the need for further pleural procedures (including drain re. INTRODUCTION. Placement of a thoracostomy tube (diameter ≥16 French) or thoracostomy catheter (diameter ≤14 French) through the chest wall into the pleural cavity is a common procedure to drain air (ie, pneumothorax), simple fluid (ie, effusion), pus (ie, empyema), or blood (ie, hemothorax), or to instill medications into the pleural space (eg, pleurodesis, fibrolysis) nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible. INTRODUCTION International guidelines exist for chest drain inser

Clinical Guidelines (Nursing) : Chest drain managemen

Intercostal veins: Anatomy, drainage, clinical aspects

Objectives The ideal invasive management as initial approach for pneumothorax (PTX) is still under debate. The purpose of this systematic review and meta-analysis was to examine the evidence for the effectiveness of intercostal tube drainage and other various invasive methods as the initial approach to all subtypes of PTX in adults. Methods Three databases were searched from inception to May. Parasternal lymph nodes (anterior view) This is also referred to as the internal thoracic nodes.There are 4 or 5 parasternal nodes along each internal thoracic artery, at the anterior ends of the intercostal spaces.They drain afferents from the breast, deeper structures of the supra-umbilical anterior abdominal wall, the superior hepatic surface (through a small group of nodes behind the. 1.Introduction Tube thoracostomy is the most commonly performed surgi- The intercostal spaces are filled with intercostal muscles, with the vein, artery, and nerve lying in the costal groove intercostal drain revealed that 45% were placed outside the safe area of chest drain insertion with the most commo Introduction. The mortality and the loss of blood flow to the spinal cord after the period of aortic cross-clamping because of failure to reattach the intercostal and lumbar arteries that are critical to the spinal cord blood supply. They reported that quick oversewing of the intercostal arteries with CSF drainage and naloxone.

Pleuropulmonary aspergillosis is a rare entity and usually occurs in a patient with preexisting lung disease or surgery. A 29-year-old pregnant woman with 16 weeks of gestation presented with shortness of breath, right-sided chest pain, and productive cough of 2 weeks' duration Intercostal drain blockage is an example of such an imbalance, and in one series of 25 patients who had subcutaneous emphysema following ICD insertion, drain blockage was the root cause in 6 cases . Subcutaneous emphysema can also arise from migration of the side port of the ICD into the chest wall [ 3 ] (suggesting inadequate anchorage) and. Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected Hydropneumothorax. A hydropneumothorax with white arrow point to the lung's pleura. Specialty. Emergency medicine. Hydropneumothorax is defined as the presence of both air and fluid within the pleural space. An upright chest x-ray will show air fluid levels. The horizontal fluid level is usually well defined and extends across the whole length.

Techniques for Pleural Drainage and Chest Tube Management

Introduction Transcatheter arterial embolization (TAE) for treatment of thoracic disease is mainly applied in the setting of massive hemoptysis and progressively enlarging hemothorax. Progressive hemothorax is known to have a variety of etiologies; usually the sources of bleeding are the aorta and intercostals and pulmonary vessels ( 1 ) prevention of complications of intercostal drainage among post-operative CABG patients admitted in selected hospital Ashish Deshmukh, Dr. Sadhana Adhyapak, Dr. Nisha NaiK and Dr. Rupali Salvi Abstract Introduction Coronary heart disease is a condition in which a substance called plaque builds up inside the coronary arteries. Plaque is made up. Drainage Tube, Thoracotomy. INTRODUCTION The pleural cavity is also known as the pleura space, it is the thin fluid fill space between the two pulmonary pleurae of each lung. A pleura is a serous membrane which Intercostal drainage tube are inserted as an invasive procedure for removal of fluid, ai Introduction. The posterior intercostal veins drain the thoracic wall. On the two sides of the thorax, the first posterior intercostal vein directly drains into the brachiocephalic vein. The second and third and occasionally fourth intercostal veins join together to form the superior intercostal vein, which drains into the brachycephalic vein. Pain after cardiac surgical procedure could be as a result of sternotomy, intercostal drain sites, or saphenous vein harvesting websites incisions. By the time she displays on occasions in 2019, she has developed an identity as a feminist, who regrets her earlier actions

Introduction. Breast cancer is the correspondent to the level of 5-8 intercostal space. The main lymphatic drainage of the breast is ipsilateral axilla, internal mammary chain is the main extra-axillary drainage, and to a lesser extent drains into the intramammary, sub-clavicular, interpectoral, and supraclavicular lymph nodes.. Complications (pleural breeching, internal mammary vessel damage) Visualization and Retrieval of Sentinel Lymph Nodes of the intercostal surgical exploration were rare; in in the IM Chain (Fig. 1) particular there were no pneumothoraxes or bleeding SLNs were visualized on preoperative lympho- complications necessitating drainage or reoperation. Introduction to Legal Systems and Methods (LAW100) Health Behaviour (HBS110) Organisational Behaviour (BMA247) indigenous people of Australia law (LLW2009) Applied Business Challenge 3 (BPD3100) Metabolism (300848) Psychology and Law (CRM309) History: Ancient History (Year 12 - Unit 3) Nursing Patients With Acute Illness A (NSG2ANA

Online Course on Intercostal Drain Removal(Simple Technique

lines the thoracic wall. covers the thoracic surface of the diaphragm and lateral aspect of mediastinum and thoracic outlet. Visceral pleura. inner layer covers the lungs. Pleural cavity (space) what separates the parietal and visceral layers. Clinical significance of pleural cavity (space Fig. 1. Introduction of Malecot catheter into pleural cavity. //~~k\ ~!fY \ r~J1_~Jd \--. : =--\ I::l \ It is presently generally accepted that a haemothorax or pneumothorax radiologically greater than 15% should be treated by intercostal drainage.' Some still advocate aspiration of a haemothorax of under 50°0: but this ma

Introduction: Intercostal chest drain (ICD) insertion carries a small but significant risk to patients when not performed properly. We re-audited the practice of ICD insertion in our hospital following several implementations since a previous audit in 2007-08. These implementations include drain insertion in specialised areas i.e. respiratory unit treatment room, strict sterility, ultrasound. Intercostal drainage, thoracentesis and fibrinolytics. Dr. NavdeepSingh. Introduction of 18-gauge needle into the pleural space. C: Insertion of wire with end into the pleural space. D: With guidewire in place, the tract is enlarged by advancing progressively larger dilators over the wire guide. Introduction of the dilators is facilitated. Intercostal Drainage Management 2018 - introduction aim definition of terms indications for insertion insertion set up management removal of chest drain complications and troubleshooting family centred care' 'NUR450 Final Exam Blackboard posted questions and cas

Introduction and Objectives Dislodgement of intercostal chest drains (ICDs) is common, affecting up to 21% of ICDs.1 Why ICDs dislodge is not well understood. The optimum technique for securing ICDs has never been the subject of a randomised trial. Current BTS guidelines recommend '0' or '1' sutures and caution against excessive adhesive dressings Intercostal Drainage Management Pneumonectomie — Wikipédia. Management of anticoagulant April 29th, 2018 - A Chest Tube Chest Drain Thoracic Catheter Tube Thoracostomy Or Intercostal Drain Is A April 30th, 2018 - Introduction Aim Definition of Terms Indications for Insertion Insertion Set Up Management Removal of chest drai

Chest Tube Drainage of the Pleural Space: A Concise Review

Intercostal Catheter (Chest Drain) • LITFL Medical Blog • CC

  1. Postural drainage is the positioning of a patient with an involved lung segment such that gravity has a maximal effect of facilitating the drainage of broncho-pulmonary secretions from the tracheobronchial tree. It is based on the concept of gravity-assisted mobilization of secretions and transport it for removal
  2. Intercostal chest drain (ICD) insertion is an essential skill in the management of trauma patients. However, the procedure is associated with a complication rate that may be as high as 30%. 1-3 Numerous case reports have documented individual cases of fatal complications such as ventricular perforation 4 and pulmonary artery injury following ICD insertion. 5 In light of this, the correct.
  3. drain, Physiotherapy INTRODUCTION The thoracic cavity is lined by the pleural membrane and the space between the layers of pleura contains pleural fluid. In diseases like pleural effusion, pneumothorax, hydropneumothorax there is collection of air or fluid in the pleural space. [1-3] Intercostal drain (ICD) is inserted to drain this fluid
  4. of chest drain insertion. The site for chest drain insertion is just anterior to the mid-axillary line in the 4th or 5th intercostal space. The site should be formally located by palpating the angle of Louis, moving laterally into the 2nd intercostal space, counting down to the 4th space and rechecking the position
  5. 10.6 Chest Tube Drainage Systems. A chest tube, also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. The pleural space is the space between the parietal and visceral pleura, and is also known as the pleural cavity. A patient may require a chest drainage system any time the.
  6. Intercostal chest drainage (ICD) for hemo/pneumothorax is simple and effective; the main problem is residual hemothorax, which can cause lung collapse and empyema. Aims: Our study aimed to analyze the relationship between radiological chest tube parameters (position and intrathoracic length) and the frequency of residual hemothorax
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INTRODUCTION. Tube thoracostomy is a common procedure in which a thoracostomy tube or catheter is placed through the chest wall into the pleural cavity to either drain an indication (eg, pneumothorax, hemothorax, effusion, empyema) or instill medication (eg, talc, doxycycline, fibrinolytic agent) Introduction Intercostal chest drain (ICD) insertion is a complex and potentially harmful procedure, most commonly required for patients within acute medical specialties (e.g., respiratory, A+E and acute medicine) but also in surgical specialties, in particular cardiothoracic surgery. The Introduction. STUDY. Flashcards. Learn. Write. Spell. Test. PLAY. Match. Gravity. Created by. drain lymph from major portions of the body: jugular - head/neck subclavian - upper limb, outer thoracic wall inferior & medial intercostal trunk --> thoracic duct superior intercostal trunk - ipsilateral bronchomediastinal trunk.

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Introduction. Thoracocentesis is a 7-8th intercostal space on the left or 6-7th intercostal space on the right midway between the shoulder and the elbow. (the dyspnoeic cat in particular) who is too unstable to undergo radiography or similar diagnostic tests as drainage of pleural fluid will both provide a preliminary diagnosis and. The major type of laparoscopic hepatectomy was partial hepatectomy (91%). In the majority of cases (66%) the number and size of intercostal trocars was a single 5-mm port. The median operative time and blood loss were 232 min and 50 mL, respectively. A chest drain was placed via the hole of the intercostal port on the chest wall in two cases (6. intercostal drainage of the effusion. Based on these findings, conservative management appears to be the first option for postoperative chylothorax.5,6 Here, we report successful treatment of postoperative chylothorax following the repair of late presenting CDH with intercostal drainage, broad-spectrum antibiotics, fluid sup Large collections require intercostal drainage with antibiotics. Differential diagnosis. On imaging consider. non-infected hydropneumothorax (no pleural thickening) peripheral lung abscess; previous empyema with iatrogenic introduction of air (e.g. drain insertion or diagnostic aspiration etc.

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Used for the evacuation of air from the pericardial sac or the drainage of air or fluid from the pleural space. Features and benefits. • Seldinger placement facilitates controlled, minimally invasive catheter introduction. • The catheter is available in a variety of sizes, ranging from 5-12 Fr, to cater to different patient anatomies Pleurodesis Pleurodesis is the artificial obliteration of the pleural space by adhesion of the two pleurae The role of pleurodesis Chemical pleurodesis with talc slurry to obliterate the pleural space is recommended when a patient is not suitable for VATS pleurodesis (video-assisted thorascopic surgery) It should only be performed under the supervision of a respiratory team Pleurodesis [ DESIGN: We performed a prospective, observational study using a structured survey and asked a group of JDs INTRODUCTION (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest Intercostal chest drain (ICD) insertion is a common drain insertion Pneumothorax, or a collapsed lung, is the result of a change in pressure around the pleural cavity which prevents the diaphragm from opening the lung, making breathing more difficult. Pneumothorax treatment include a simple operation, called aspiration, which reduces air pressure and releases any trapped air in the pleural cavity Intercostal neuralgia is a rare condition that causes pain along the intercostal nerves. Intercostal nerves are located between your ribs. Ribs are long, slender bones that curve around your chest to create your rib cage. The top 10 ribs on both sides of your body attach to your thoracic (midback) spine and breastbone (sternum)

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INTRODUCTION . Intercostal catheters are sometimes required in newborn infants to allow air or fluid to drain from the pleural space. 1. AIM • To guide the safe insertion of the Safe-T-Centesis intercostal catheter 2. PATIENT • Newborns . 3. STAFF • Medical and nursing staff . 4. EQUIPMENT • Hat & mask • Sterile gown and gloves (x2 » Introduction : Chylothorax is an infrequent cause of pleural effusion in children. He was referred with an intercostal drainage tube in situ which was draining chylous fluid. Biochemical investigations established the diagnosis of chylothorax . A tru-cut biopsy from the conglomerate lymph nodal mass in the left cervical region was. The posterior intercostal arteries are branches of the costocervical trunk and thoracic aorta. The musculophrenic, lower posterior intercostal and inferior phrenic arteries supply the diaphragm. Tributaries of the internal thoracic and azygos veins drain the chest wall. The musculophrenic and inferior phrenic veins drain the diaphragm Lateral holes of the intercostal drain are outside the chest, a common cause for surgical emphysema. Should the need arise for a second drain to replace a dysfunctional one due to, e.g. blockage or kinking, the second drain should not be introduced at the site of the removed first one to reduce the risk of empyema US2867213A US665364A US66536457A US2867213A US 2867213 A US2867213 A US 2867213A US 665364 A US665364 A US 665364A US 66536457 A US66536457 A US 66536457A US 2867213 A US2867213 A US 2867213A Authority US United States Prior art keywords valve pleural cavity drainage catheter intake Prior art date 1957-06-12 Legal status (The legal status is an assumption and is not a legal conclusion Introduction. Ultrasound-guided percutaneous catheter drainage (PCD) for pyogenic liver abscess has been accepted as a safe procedure in clinical settings, because of real-time monitoring for guiding the insertion of the needle at the target liver lesion. 1, 2 Severe complications related to PCD, such as hepatic rupture, hepatocolic fistula, and upper gastrointestinal bleed, have been reported.