To the Editor: 

The recently published Practice Guidelines for Central Venous Access provide a valuable resource for anesthesiologists and others who insert and maintain central venous catheters (CVCs).1We commend the members of the American Society of Anesthesiologists Task Force on their efforts.

Although the guidelines deal extensively with insertion and maintenance of CVCs, there is no discussion of removal of those CVCs. There is considerable anecdotal evidence and a plethora of published case reports highlighting the occurrence of adverse events during CVC removal, including bleeding and venous air embolism.2,3Venous air embolism, which occurs as a result of entrainment of air when an open vein is above the level of the heart, has the potential to result in cardiorespiratory compromise, devastating neurologic sequelae, and death.4,,10A failure to appreciate the potential for, and cause of, venous air embolism may result in improper practices during CVC removal. In some circumstances, inexperience, unfamiliarity, and lack of education or training may play a role.

Although there are many steps in the process of CVC removal, essential elements of the procedure include (for internal jugular and subclavian CVCs), positioning of the patient in the head down (Trendelenburg) position, having the patient perform a Valsalva maneuver as the catheter is being withdrawn, application of pressure to the catheter-entry site as the catheter is being withdrawn, placement of an air-occlusive dressing over the site after removal, and a period of postprocedure monitoring.11If VAE occurs, interventions should include placement of the patient in the head-down, left-side-down position, administration of 100% O2, and appropriate cardiopulmonary resuscitation.3,12 

As part of an initiative to optimize and standardize practice with a goal of improving patient safety, our institution – similar to other medical centers – has developed and implemented a policy for removal of CVCs.13In addition to the placement of written practice guidelines in appropriate locations on our internal Web site, a mandatory educational module for those who remove CVCs has been developed. Furthermore, we have incorporated essential supplies and informational materials into a “CVC removal kit.” These initiatives are being incorporated into our institutional global “CVC educational module” targeted at those who insert CVCs, but are also independently directed at those who remove but do not insert CVCs.

We appreciate the efforts of those involved in the production of the Practice Guidelines. We respectfully suggest that, when the guidelines are revised and updated in the future, a section relating to safe removal of carefully placed and carefully maintained CVCs be included.

American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark JB, Morray JP, Nickinovich DG, Tung A: Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. ANESTHESIOLOGY 2012; 116:539–73
Peter DA, Saxman C: Preventing air embolism when removing CVCs: An evidence-based approach to changing practice. Medsurg Nurs 2003; 12:223–8
Mirski MA, Lele AV, Fitzsimmons L, Toung TJ: Diagnosis and treatment of vascular air embolism. ANESTHESIOLOGY 2007; 106:164–77
Heckmann JG, Lang CJ, Kindler K, Huk W, Erbguth FJ, Neundörfer B: Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000; 28:1621–5
Ely EW, Hite RD, Baker AM, Johnson MM, Bowton DL, Haponik EF: Venous air embolism from central venous catheterization: A need for increased physician awareness. Crit Care Med 1999; 27:2113–7
Novack V, Shefer A, Almog Y: Images in cardiology. Coronary air embolism after removal of central venous catheter. Heart 2006; 92:39
McCarthy PM, Wang N, Birchfield F, Mehta AC: Air embolism in single-lung transplant patients after central venous catheter removal. Chest 1995; 107:1178–9
Mennim P, Coyle CF, Taylor JD: Venous air embolism associated with removal of central venous catheter. BMJ 1992; 305:171–2
Phifer TJ, Bridges M, Conrad SA: The residual central venous catheter track–an occult source of lethal air embolism: Case report. J Trauma 1991; 31:1558–60
Brouns R, De Surgeloose D, Neetens I, De Deyn PP: Fatal venous cerebral air embolism secondary to a disconnected central venous catheter. Cerebrovasc Dis 2006; 21:212–4
Wysoki MG, Covey A, Pollak J, Rosenblatt M, Aruny J, Denbow N: Evaluation of various maneuvers for prevention of air embolism during central venous catheter placement. J Vasc Interv Radiol 2001; 12:764–6
Muth CM, Shank ES: Gas embolism. N Engl J Med 2000; 342:476–82
Pronovost PJ, Wu AW, Sexton JB: Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004; 140:1025–33