as in discontinuing (removal) a central venous access device. Certainly, many of us have discontinued a central venous access device (central line) before. No big deal, right?  One key element to remember when discontinuing a CVAD is to include precautions to prevent air embolism.

Air embolism from removal of central lines can occur when a bolus of air enters the vascular system, then propelled into the heart, creating an intracardiac air lock at the pulmonic valve that prevents the ejection of blood from the right side of the heart. The right side of the heart overfills with blood  and the force of right ventricular contractions increases in an effort to eject blood past the air lock. Forced contractions cause small air bubbles to break loose from the air pocket and they are pumped into the pulmonary circulation. This creates an obstruction to forward blood flow resulting in tissue hypoxia.  Pulmonary hypoxia results in vasocontriction of lung tissue, further increasing the workload of the right ventricle. Cardiac output is diminished and shock and death may occur unless immediate interventions are taken.

So what then are the best practices for the prevention of air embolism during central line removal?

• Position the patient. What position?  “Supine” according to the INS Textbook 2010 Chapter 25 pg 511. INS standard of Practice 2011 states “position the patient so the CVAD insertion site is at or below the level of the heart”. Other publications states “tredenlenburg” position.  What is your organization’s policy on patient position when removing a central line?

• Instruct patient to do Valsalva’s manuever as the catheter is being withdrawn. If unable, have the patient exhale during the procedure.

• Cover the exit site and apply gentle pressure while removing the catheter in a slow, constant motion.

• Apply pressure to the exit site until hemostasis is achieved. How long should pressure be applied? One reference states 1-5 minutes*.

• Instruct the patient to do Valsalva’s manuever again and apply antiseptic ointment, gauze dressing and tape to site. One reference states applying a sterile occlusive dressing vs plain gauze as the plain gauze dressings have been associated with air passing through a persistent catheter tract into the bloodstream resulting in air embolism.*

• Leave dressing in place for at least 24hours. Change the dressing every 24 hours until the exit site has healed. Occlusive dressings left in for shorter periods of time have been associated with  air passing through a persistent catheter tract into the bloodstream resulting in air embolism.*

• Have the patient stay in supine position or lying flat for 30 minutes after removal of the catheter.

Just to clarify, the central venous access devices the nurses can remove or discontinue are the “non-tunneled catheters” which includes, PICCs and percutaneous central lines, not the tunneled or implanted ports.

It is also important to note that the  risk of air embolism can also occur during insertion and care and maintenance of CVADs. Hence, it is just as important to take precautions to reduce the risk of air embolism.

Aside from the nurses taking these precautions, it is also important for the organization to have policies and procedures that contain specific air embolism prevention , treatment and management related to CVADs insertion, maintenance and removal.

Go check your policies and procedures – do you have one?

References:

1. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):S44

2. Gorski L, Perucca R, Hunter, M (2010). Central Venous Access Devices: Care, Maintenance, and potential complications. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R., eds. Infusion Nursing: An Evidence based Practice. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2010:511

3. Feil M. (2012) Reducing Risk of Air Embolism Associated with Central Venous Access Devices. Pennsylvania Patient Safety Advisory, 9(2) 58-62.*