Clamping Central Venous Catheters Before Removal
Yes, you must clamp the central venous catheter before removal to prevent venous air embolism, a potentially fatal complication that can occur at any time during the removal process. 1
Critical Safety Steps for CVC Removal
Mandatory Pre-Removal Positioning and Clamping
Position the patient flat or in 5-10 degrees Trendelenburg (head-down position) with the exit site below the level of the heart to reduce the risk of air entrainment into the venous system 1, 2
Close the clamp on all CVC lumens before disconnecting or removing the catheter to prevent air from entering through the catheter during removal 1
Instruct cooperative patients to perform the Valsalva maneuver during catheter withdrawal to increase intrathoracic pressure and further reduce air embolism risk 2
The Removal Technique
Apply firm digital pressure for at least 5 minutes at the exit site immediately after catheter removal, followed by application of an occlusive dressing 1
The patient should remain flat during and after the procedure, as air embolism can occur not only during removal but also in the immediate post-removal period 1
Why This Matters: The Air Embolism Risk
Venous air embolism may be fatal and can occur at any time from insertion to removal, with an incidence as high as 0.8%. 1 The evidence demonstrates that:
Multiple case reports document serious outcomes including cerebral infarction, cardiovascular collapse, and death from air embolism during CVC removal 3, 4
A survey of 140 physicians found that only 26% cited concern for air embolism during CVC removal, and 9% incorrectly elevated the head of the bed during removal—a practice that increases risk 4
Paradoxical systemic air embolism can occur in patients with undiagnosed atrial septal defects or other right-to-left shunts, leading to multi-organ damage 3
Common Pitfalls to Avoid
Never elevate the head of the bed during CVC removal, as this creates negative intrathoracic pressure that facilitates air entrainment into the venous system 4
Do not remove the catheter without ensuring the clamps are closed, even if you plan to remove it quickly—air can enter in milliseconds 1
Avoid removing CVCs in hypovolemic patients without first correcting their volume status, as hypovolemia increases negative venous pressure and air embolism risk 2
Special Considerations for Long-Term Catheters
Cuffed devices and ports require surgical cut-down for removal due to complex adherent fibrin sleeves and scar tissue formation 1
Very long-term catheters may become attached to the superior vena cava or right atrial wall and cannot be removed by traction alone—seek vascular surgery or interventional radiology consultation if difficulties occur 1
Persistent bleeding after removal may require a skin stitch, but the occlusive dressing remains essential for air embolism prevention 1
Post-Removal Monitoring
Keep the occlusive dressing in place and monitor for signs of air embolism including sudden respiratory distress, cardiovascular collapse, altered mental status, or neurological deficits 1, 3
If air embolism is suspected after removal, immediately place the patient in head-down left lateral position and attempt aspiration of air through any remaining venous access 1