Procedure: Removal of Central Venous Catheters (Jugular, Subclavian and Femoral)

Procedure for Removal of Central Venous Catheter (IJ, SC and 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), Subclavian (SC) and Femoral. This includes temporary hemodialysis catheters. Heighten awareness of the increased risk for air entry or bleeding during removal should be identified prior to removal of large central lines (temporary dialysis lines, introducers and 4 or 5 lumen central venous lines).

Pay close attention to all steps that prevent air entry into the vascular tract or bleeding.

Nurses DO NOT remove tunneled catheters or implantable ports.  This includes tunneled dialysis lines (perm caths, Hickman's and Port-A-Caths). These lines are removed surgically.

PROCEDURE

 1.

 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 strain. Adequate and direct pressure 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 analgesic and sedative (if indicated). Field contamination and inadequate 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 barrier 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 bloodstream. 

 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 Trendelenburg position 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. Position patient on left side with head down (Trendelenburg 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 valsalva maneuver 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 pressure 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.

Apply Occlusive Dressing

Immediate and complete hemostasis is the priority for preventing air entry or bleeding. Hemostasis is more difficult for subclavian and femoral insertion sites; inadequate hemostasis can lead to occult bleeding into deep tissues. 

After you have ensured adequate hemostasis, you may place a small gauze square with a "dot" of petroleum over the insertion site, followed by application of an occlusive dressing over the gauze. It is essential to ensure adequate hemostasis is achieved first to prevent entry of petroleum into the vascular tract.  If hemostasis has not been established, petroleum could inhibit clotting.

Post Removal Assessment

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 immediately.

Document

Document procedure and site and limb assessment in the Device Band of the Electronic Health Record.