What is the process for discontinuing a tunneled Central Venous Catheter (CVC)?

From the Guidelines

The process for discontinuing a tunneled Central Venous Catheter (CVC) should always begin with ruling out other possible sources of infection and inspecting the catheter insertion site for signs of local infection, as recommended by the 2014 guidelines from the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology 1.

Pre-Removal Steps

Before removing the CVC, it is essential to:

• Rule out other possible sources of infection by clinical examination and imaging procedures, if necessary.
• Inspect the catheter insertion site or pocket or tunnel for signs of local infection and palpate the pocket or tunnel.
• Take one pair of blood cultures (aerobic and anaerobic) from the catheter and one from a peripheral vein for microbiological evaluation, and determine the differential time to positivity (DTTP) between the peripheral and catheter blood culture sample, as suggested by 1.

Removal Procedure

The actual removal process involves:

1. Obtaining informed consent from the patient.
2. Positioning the patient supine with slight Trendelenburg if possible.
3. Using sterile technique throughout the procedure.
4. Cleaning the exit site and surrounding skin with chlorhexidine or povidone-iodine solution.
5. Administering local anesthesia (e.g., 1% lidocaine) around the exit site and along the tunnel tract.
6. Removing any sutures securing the catheter.
7. Gently pulling the catheter while applying pressure over the tunnel tract to prevent air embolism.
8. Once removed, applying firm pressure to the exit site for 5-10 minutes to achieve hemostasis.
9. Applying a sterile dressing to the site.
10. Confirming catheter tip integrity to ensure complete removal.

Additional Considerations

• Performing the procedure in a controlled setting with emergency equipment available.
• Monitoring the patient for signs of bleeding or air embolism during and after the procedure.
• Instructing the patient to keep the site dry for 24-48 hours and report any signs of infection. This process, guided by the most recent and highest quality evidence available, such as the guidelines from 1, ensures safe removal of the CVC while minimizing risks such as bleeding, infection, or air embolism. The sterile technique and pressure application are crucial to prevent complications.

From the Research

Discontinuation Process for Tunneled Central Venous Catheter (CVC)

The process for discontinuing a tunneled Central Venous Catheter (CVC) involves several steps and considerations to ensure safe removal and minimize complications.

• Pre-removal assessment: Evaluate the patient's condition and the catheter's status to determine the best approach for removal 2, 3.
• Removal techniques: Various techniques can be used to remove a stuck CVC, including:
  • Endoluminal dilatation technique: This involves using a balloon catheter to dilate the catheter and surrounding tissue, allowing for safe removal 3.
  • Intraluminal percutaneous transluminal angioplasty: This technique can be used as a first-line treatment for stuck catheters 2.
  • Open surgery: This may be necessary in cases where other techniques fail or are not feasible 2.
• Complication management: Be prepared to manage potential complications, such as bleeding, infection, or catheter breakage 2, 4, 5.
• Post-removal care: Apply pressure to the site to aid hemostasis and monitor the patient for any signs of complications 3.

Considerations for Stuck Catheters

Stuck catheters can pose significant challenges during removal, and careful consideration must be given to the approach used to minimize the risk of complications.

• Assessing the degree of adherence: Evaluate the extent to which the catheter is stuck to determine the best removal technique 2, 3.
• Avoiding forced traction: Avoid using excessive force to remove the catheter, as this can lead to serious complications, such as catheter breakage or damage to surrounding tissue 2, 5.
• Collaboration with multidisciplinary specialists: In complex cases, collaboration with specialists from various disciplines may be necessary to ensure safe and effective removal of the stuck catheter 2.