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in the head down (Trendelenburg) position, having the patient perform a Valsalva maneuver as the catheter is being withdrawn, application of pressure to the catheter-entry site as the catheter is being withdrawn, placement of an air-occlusive dressing over the site after removal, and a period of postprocedure monitoring.11If VAE occurs, interventions should include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.