1. Central Venous Catheter Removal Office of Graduate Medical Education Perelman School of Medicine University of Pennsylvania

2. Which CVC Catheters are at risk of venous air embolism complication? Internal Jugular and Subclavian Central Venous Catheters – Both during insertion and removal

3. Removing a CVC Catheter: Best Practice for Safe Removal and Prevention of Venous Air Embolism Step 1: Gather Equipment – Suture removal kit, petroleum gauze and 4 x 4 combination, occlusive dressing Step 2: Notify RN so that they can be available for pt monitoring Step 3: Place patient in Trendelenburg position – If patient is unable to tolerate trendelenburg, the patient should be placed supine. Never remove a CVC in the sitting/upright position. Step 4: Ask patient to forcibly exhale (hum) or valsalva (bear down). During these maneuvers intrathoracic pressure is great than atmospheric pressure. Step 5: Quickly remove catheter Step 6: Secure petroleum gauze 4 x 4 combination with an occlusive dressing over site. Apply firm pressure. If the patient is coagulopathic, apply pressure for a longer time period (several minutes)

4. What is Venous Air Embolism? Serious complication of CVC insertion or removal Air can enter the vascular space if a needle or catheter is left open to atmospheric pressure. Factors that increase the risk of air embolism: – Upright position – Hypovolemia – Inhalation during instrumentation – Inattention to catheter seals and insertion/removal technique

5. What are the Signs and Symptoms of Venous Air Embolism? Chest pain Shortness of breath Coughing Tachyarrhythmias Syncope Anxiety Confusion or change in mental status Respiratory distress or cardiovascular collapse *Any of these symptoms or signs in association with central line insertion or removal are highly suspicious for venous air embolism

6. What Should I Do If I Suspect Venous Air Embolism in my Patient? Place patient in the left lateral decubitus position and in the Trendelenburg position – In attempt to trap air in the right ventricular apex Place patient on 100% non-rebreather mask Administer IVF Always notify the patients’ nurse, your resident/fellow, and attending so that they can provide more help. Depending on the severity of the patients’ signs and symptoms, consider calling a rapid response.