PRO: Central Venous Access Devices - Removing a Non-Tunneled Central Venous Catheter
Approved by NPC 05/17/2012
NATIONAL INSTITUTES OF HEALTH
CLINICAL CENTER
NURSING and PATIENT CARE SERVICES
Procedure: Central Venous Access Devices - Removing a Non-Tunneled Central Venous Catheter
Approved:
//s//
Clare Hastings, RN, Ph.D., FAAN
Chief, Nursing and Patient Care Services
Formulated:
Implemented:
Reviewed:
Revised:
4/1995
6/1995
10/2008, 11/2009, 5/2012
4/1996, 7/1998, 5/1999 (implemented 6/1999), 2/2001, 5/2001, 12/2001, 10/2002, 02/2003, 10/2003; 05/2005,
10/2008, 11/2009, 5/2012
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PRO: Central Venous Access Devices - Removing a Non-Tunneled Central Venous Catheter
Approved by NPC 05/17/2012
Procedure: Central Venous Access Device; Removing a Non-Tunneled Central Venous Catheter
Essential Information
1.
Intravenous Therapy, Blood Draws via a VAD, and Venipuncture Competency required.
2. A medical order to remove VAD is required.
3. Please check coagulation and platelets before removal of any central line.
4. Review chart to obtain total length of catheter from VAD flowsheet
5. Chlorhexidine may cause a chemical burn if it is not allowed to completely dry prior to
application of skin prep or dressing.
Equipment
Sterile, disposable suture removal set (if necessary)
Mask
Sterile Scissors (if culturing catheter tip)
Non-sterile gloves
4 X 4s (3 pkgs.)
One chlorhexidine and alcohol applicator (3 mL)
Sterile gloves
Transparent sterile occlusive dressing
Sterile drape/barrier
Alcohol pads (optional)
Sterile specimen container (if culturing catheter)
Optional: Goggles
Chux optional
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STEPS
1.
Position the patient in bed at a 10-20 degrees
Trendelendberg position. If patient cannot
tolerate Trendelenberg, recline the patient in the
supine position. 1-6
KEY POINTS
1. Trendelenberg position elevates venous pressure
above atmospheric pressure, reducing the risk of
air entry into the wound.
Have patients perform valsalva maneuver to
increase intrathoracic pressure.
Central lines should NOT be removed with the
patient in a non reclining chair or upright
position.
2.
If a femoral line is being removed, positioning
the patient in a bed is required.
2.
3.
Apply mask.
3.
4.
Perform hand hygiene.
4.
5.
Set up sterile field and put on non-sterile
gloves.
5.
6.
Remove the dressing and anchoring devices
other than sutures.
6. Patients should be instructed to turn head away
from insertion site or put mask on. 1, 8
7.
Remove gloves.
7.
8.
Put on sterile gloves
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9.
Cleanse exit site area around catheter insertion
and sutures with chlorhexidine/alcohol
applicator using a bidirectional scrub.
9. Chlorhexidine/alcohol swabs should be applied
to the site as follows:
a. 30 seconds for dry surgical sites such as arm
or abdomen
b. 2 minutes for moist sites such as inguinal or
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PRO: Central Venous Access Devices - Removing a Non-Tunneled Central Venous Catheter
Approved by NPC 05/17/2012
c.
10. Remove sutures, if present.
10.
11. Fold two 4x4 gauze pads in half and place over
the catheter exit site.
12. If removing an internal jugular (IJ) or
subclavian (SC) line:
a. Patient should be instructed to perform a
Valsalva maneuver while removing lines
situated above the diaphragm, (including
PICCS) or to hold their breath.
b. If patient is unable to follow commands,
(e.g. the ventilated patient) remove catheter
during end exhalation. 4, 5, 7
c. While holding slight pressure over the site,
slowly and steadily remove the catheter.
11.
femoral.
Allow site to dry completely. Do not blot or
wipe dry.
12. Educate patient on how to perform Valsalva
maneuver and anticipatory teaching about
catheter removal.
If resistance is met while pulling the catheter,
stop, apply dressing, and notify the Licensed
Independent Practitioner (LIP).
13. If removing femoral lines: while holding
pressure over the site, slowly and steadily
remove the catheter.
13.
14. If removing a PICC:
a. Position patient’s arm so it is gently
extended outwards.
b. Grasp the catheter just below the hub and
then withdraw the PICC, regrasping
catheter closer to insertion site with
removal. 9
c. Using a gentle downward motion, steadily
remove catheter away from the body
toward the patient’s hand.
d. If resistance is encountered, discontinue
catheter withdrawal, reposition patient’s
arm, and try again.
e. If resistance persists, cover the insertion
site with a temporary sterile dressing and
apply a warm pack to the upper arm for 1530 minutes to relax the spasm and allow
easier catheter removal. 5, 9 Reattempt
removal.
14. If 2nd attempt fails, cover site with temporary
sterile dressing, notify LIP and do not reattempt
catheter removal.
15. If a catheter tip is to be cultured, hold it over
sterile specimen container and using sterile
scissors, cut a two (2) inch segment of the tip.
Cover the container and send to the lab at the
completion of the dressing change.
15.
16. When catheter is out, apply firm pressure to the
catheter exit site until hemostasis has been
achieved.
a. If bleeding is noted, continue to apply pressure,
checking at 5-minute intervals until hemostasis
has occurred.
16. Always inspect catheter tip to insure it is intact,
smooth and not jagged and that the length
corresponds to total catheter length upon
insertion for lines placed at NIH 10 For lines
placed outside of NIH with no documentation
of total catheter length inspect the tip for
uneven, jagged edges which may indicate a
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PRO: Central Venous Access Devices - Removing a Non-Tunneled Central Venous Catheter
Approved by NPC 05/17/2012
broken catheter. If you suspect a broken
catheter obtain order for chest x-ray.
17. Once hemostasis has occurred, apply fresh
sterile gauze and a sterile transparent occlusive
dressing over the gauze 1, 4, 6, 11
18. The patient must remain in bed/chair for the
following time periods:
a. PICC, Subclavian, and Internal Jugular
between 30 minutes to one hour.
b. Femoral lines – a minimum of one hour
with assessment of bleeding/hematoma
every fifteen minutes3, 6.
c. Reassess site after patient has been out of
bed.
19. a. For outpatients - Instruct the patient to
leave the dressing in place for a minimum of 24
hours and to check the dressing every few
hours for signs of bleeding.
17. Patients should be advised not to cough, laugh
or sneeze post catheter removal.
If patient develops symptoms of air embolism;
sudden dyspnea, pallor, tachycardia or
coughing, place patient immediately on left side
in Trendelenberg position, call a code and stat
page the LIP
18. Once hemostasis achieved, HOB may be
elevated 30 degrees.
19. If bleeding is noted, instruct the patient/family
member to hold pressure over the site and call
the responsible LIP for further instructions.
b. For inpatients – Dressing should be
changed 24 hours post catheter removal and site
assessed every 24 hours until site is
epithelialized 1, 3 11 Apply new dressing as
needed.
20. Document in approved electronic medical
record.
20.
References:
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9.
Munro N. (2009). Vascular access device care: Discontinuing a central venous catheter. Mosby's
Nursing Skills Online.
Dumont CP. (2001). Procedures nurses use to remove central venous catheters and complications they
observe: a pilot study. American Journal of Critical Care. 10(3):151-155.
Ingram P, Sinclair L, Edwards T. (2006). The safe removal of central venous catheters. Nursing
Standard. 20(49):42-46.
Hamilton H. (2006). Complications associated with venous access devices: part one. Nursing
Standard. 20(26):43-50; quiz 51.
Wysoki MG, Covey A, Pollak J, Rosenblatt M, Aruny J, Denbow N. (2001). Evaluation of various
maneuvers for prevention of air embolism during central venous catheter placement. Journal of
Vascular Interventional Radiology. 12(6):764-766.
Wiegand D, Carlson K. Removal. (2005). AACN procedure manual for critical care. 5th ed. St. Louis:
Elsevier/Saunders; 2005.
Moureau N. (2002). How to remove a PICC with ease. Nursing. 32(5):30.
Elledge NM, Siegel M, Strootman V. (2008). Central vascular access devices: An overview. Nursing
Practice Management. 21(1):4-14.
Infusion Nursing Standards of Practice. (2011), Journal of Infusion Nursing, 34 (1Suppl) S57-58.
Policies and Procedures for Infusion Nursing 4th edition, 2011.pp 92-94.
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