PROCEDURE: REMOVAL OF CENTRAL VENOUS CATHETERS (JUGULAR, SUBCLAVIAN, FEMORAL)

Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies

PROCEDURE FOR REMOVAL OF CENTRAL VENOUS CATHETERS (JUGULAR, SUBCLAVIAN, FEMORAL)

 
  1. Apply Related Procedures and Policies
  2. Check Coagulation Tests
  3. Prepare Bedside
  4. Prepare Tray
  5. Remove Dressing
  6. Cleanse Site and Remove Suture
  7. Remove Catheter
  8. Ensure Hemostasis
  9. Apply Occlusive Dressing
  10. Post Removal Assessment
  11. Document

RNs in CCTC may removed temporary central venous access devices including: PICC, Internal Jugular (IJ), Subclavanian (SC) and Femoral. 

Nurses may remove temporary hemodialysis cathers, but should be aware of the large catheter size increases the risk for both bleeding and air embolism.

Nurses in CCTC are not approved to removed tunneled catheters or implantable ports.  This includes perm cath dialysis lines.

PROCEDURE

 1.

Apply Related Procedures and Policies

Confirm order

Follow LHSC policies for hand hygiene and infection control before, during and after procedure. Perform hand hygiene and don a mask with eye shield and non-sterile gloves prior to blood sampling.

Confirm 2 patient identifiers as per LHSC Policy for Patient Identification

NURSES DO NOT REMOVE A CVC THAT HAS BEEN INADVERTENTLY PLACED INTO AN ARTERY. VASCULAR CONSULT SHOULD BE PERFORMED FOR ARTERIAL CANNULATION ONCE THE VESSEL HAS BEEN DILATED.

 2.

Check Coagulation Tests/Medications

Check INR/PTT and platelets. If INR/PTT is prolonged (INR > 1.5) or platelets < 50,000 review orders with physician.

If patient is receiving any medications that affect coagulation (e.g., anticoagulants, fibrinolytics, antiplatelet agents), review with physician prior to removal.

To reduce risk for bleeding. If the patient has a significant coagulopathy the removal order should be reviewed to determine whether treatment is warranted (e.g. administration of plasma or platelets) or whether removal should be delayed.  Medications that interfere with clotting should also be reviewed.

The catheter site may also influence bleeding risk. Additional site pressure may be required.

 3.

Prepare Bedside and Assess Patient

If removing a femoral venous catheter, obtain a bedside stool. A stool helps to position health care provider into optimal position for pressure application and reduces back straing. Adequate and direct presure is required to stop bleeding from a central venous or arterial catheter.

Assess patient to determine ability to remain flat during application of pressure and obtain assistant if required for positioning. An assistant will be required if tip culture has been ordered. 

Administer analagesic and sedative (if indicated). Field contamination and inadquate hemostatic control can occur if patient is restless, improperly positioned or has pain.

 4.

Prepare Tray

Perform hand hygiene and open central line dressing change tray.

Don non-sterile gown, gloves, bouffant and mask with face shield.

Perform hand hygiene and prepare dressing tray aseptically using transfer forceps to add supplies.

  1. Add sterile scissors for sutured line
  2. Add additional chlorhexidine for removal of securement device if required.
  3. Open STERILE petroleum gel and apply a small amount in the centre of the gauze square.
  4. Add the transparent dressing to the tray.

Bacteria can access the catheter tract until it has healed completely. Petroleum gel will create an barriere to prevent the entry of air. Petroleum jelly may make hemostasis more difficult. Hemostasis is paramount to the prevention of air entry into the tract.  Care must be taken to ensure that petroleum does not enter the tract before clotting has begun to avoid entry into the bloostream. 

 5.

Remove Dressing

Remove old dressing wearing non-sterile gloves and discard. 

Use a CHG swabstick with a shoveling technique to loosen the CHG pad.

Discard dressing appropriately and perform hand hygiene.

6.

Cleanse Site

Don sterile gloves and cleanse site. Wait until chlorhexidine has completely dried (minimum 2 minutes)..

Remove sutures with scissors. 

If adhesive securement device is in place, use a chlorhexidine swab stick to loosen adhesive before attempting removal.

7.

Remove Catheter

Jugular, Subclavian or PICC

  1. Lower head of bed. Position insertion site below the patient's heart level or use trendelenberg posiiton if tolerated.
  2. Apply DRY gauze over insertion site and gently attempt to withdraw the catheter 2.5 cm to assess for easy of removal. If resistance is met, notify physician and do not attempt removal.
  3. Ask the patient to breath hold during removal or remove at the end of inspiration if mechanically ventilated.
  4. Pull the catheter in a slow but steady withdrawal motion, applying immediate and directly pressure slightly above the insertion site upon removal
  5. If resistance is met, stop procedure and notify physician.
  6. Apply continuous and direct pressure for a minimum of 5 minutes before assessing for bleeding.
  7. Inspect catheter for intactness. Notify physician Immediately if catheter is damaged.
  8. Send tip for culture if ordered.

Femoral Line Removal

Follow above procedure. Healthcare provider should be positioned directly over the femoral site to ensure direct application of pressure at 90 degrees.

EMERGENCY RESPONSE

Catheter Breakage:

Apply direct pressure above the puncture site to occlude blood flow. Postion patient on left side with head down (trendenlenburg position) and notify physician STAT.

If catheter fracture is palpable, apply additional pressure to prevent catheter migration.

Air Embolism :

Suspect air embolism for sudden respiratory symptoms during removal, disconnection or access of central venous line.

If possible, aspirate large volume of blood from catheter until no air bubbles are detected.

Initiate 100% oxygen and position patient head down on their left side (L decubitus trendelenburg). Notify physician STAT.  If patient has cardiac arrest, prolonged CPR may break air bubbles apart to open up pulmonary blood flow obstruction.

Air embolism risk increases when heart pressure is less than atmospheric pressure. 

Risk for air embolism increases when the catheter insertion site is above heart level (e.g., in a sitting position), if the patient is hypovolemic or during spontaneous inspiration.

Breath holding or valsaval maneuvre will increase intracardiac pressures. Immediate occlusion is required to prevent air embolism.

It takes only a 5 cmH20 pressure gradient across a 14 gauge needle to permit 100 cc of air/second to enter a central venous catheter.

THROMBOSIS/PE:

Clots on the tip of a central venous catheter can be dislodged during removal and cause small pulmonary emboli.

Left side down trendelenburg position places the right ventricle higher than the pulmonary circuit to potentially trap air, fractured catheters or clot and prevent pulmonary embolization.

8.

Ensure Hemostasis
 

Maintain direct pressure firmly and continuously for a minimum of 5 minutes BEYOND the point when hemostasis has been achieved.

Carefully check site every 5 minutes and reapply pressure for 5 more minutes if any oozing is observed.

The only way to stop bleeding and ensure occlusion of catheter tract is through direct presure until hemostasis is achieved. Adequate hemostasis also protects against air entry into the tract.

Inadequate hemostasis can facilitate hematoma formation with subsequent vessel occlusion, limb ischemia or fistula formation.

9.

Apply Occlusive Dressing

When bleeding has stopped, carefully replace the dry gauze with the gauze square with petroleum. The petroleum should be positioned directly over the insertion site.  Be careful to minimize the area exposed to the petroleum as it will impact adherence of the dressing.

Cover the small gauze square with a transparent dressing.  Ensure that an occlusive seal is maintained around the edge.

(the petroleum may provide protection against air entry into any residual tract in the event that hemostasis is disrupted and the tract opens). Immediate and effective hemostasis is the priority for preventing air entry.

Do not apply bulky dressings or sandbag to site. This may delay detection of bleeding and will not stop bleeding from a large vascular site. Direct pressure is required until bleeding has stopped. The occlusive dressing allows visualization of site while preventing pathogens from entering tract.

Remove gloves and perform hand hygiene.

10.

Post Removal Assesssment

Keep patient flat with minimal activity for at least 1 hour following subclavian or jugular line and 2 hours following femoral line removal.  Do not allow patient to lift head independently (nurse can provide a pillow).

Assess site for bleeding or hematoma q 5 minutes X3, q 15 minutes X 4 then q 1 h X 4.

Assess distal extremity and monitor for signs of shortness of breath. Report changes in respiratory status immediatley.

11.

Document

Document procedure and follow-up assessment in clinical record.
 

 

References:

1. O'Dowd, L. et al. (October 2013). Air embolism. Up-to-Date.

2.  LHSC Procedure for Central Line Management.

2. Kaye, W. (1985). Venous and arterial catheterization. In Sprung, C., and Grenvik, A. Eds: Invasive procedures in critical care. Churchill Livingston: New York p. 13.

3.  Daily, E., and Schroeder, J. (1994). Techniques in Bedside Hemodynamic Monitoring (5th Ed.). Mosby: Toronto. p. 71.

4.  LHSC PCVC Guidelines

 

Developed: November 2000 (Morgan, B)
Revised: March 2010
Last Update: January 29, 2020


Brenda Morgan RN BScN MSc CNCC, CCTC