Central Venous Catheter Removal: A Procedure Well Performed?

SESSION TITLE: Patient Safety InitiativesSESSION TYPE: Original Investigation SlidePRESENTED ON: Wednesday, October 29, 2014 at 07:30 AM - 08:30 AMPURPOSE: Central venous catheterization (CVC) is performed more than 5 million times a year in the US. The complications of CVC insertion and removal are well known but formal training is typically provided only for CVC insertion and minimal emphasis is placed on CVC removal. Venous air embolism and expanding hematoma are well known complications of improper CVC removal and have been known to cause hypoxemia, airway compression, and death.METHODS: 46 internal medicine residents at a large academic medical center were surveyed. Residents from all three PGY levels were included. A survey consisting of open-ended questions was used to assess the technique used by residents in performing CVC removal and their knowledge of potential complications of the procedure. Study authors coded descriptions to normalize the responses to the open ended questions (e.g. "patient placed in head down position" was coded as "Trendelenburg")RESULTS: 46 internal medicine residents were surveyed, 18 PGY1s, 14 PGY2s, and 14PGY3s. 18 PGY1s, 9 PGY2s, 10 PGY3s listed hematoma as a potential complication; 1 PGY1, 1 PGY2, 4 PGY3 reported checking coagulation parameters prior to CVC removal; 12 PGY1s, 12PGY2s, 12 PGY3s reported holding pressure after removal; 8 PGY1s, 8 PGY2s, 10 PGY3s reported checking the removal site within 30 minutes after removal. 2 residents (both PGY3) reported performing all three steps. 11PGY1s, 9 PGY2s, 8PGY3s listed venous air embolism as a potential complication; 11 PGY1s, 11PGY2s, 10PGY3s reported placing the patient in Trendelenburg or supine prior to CVC removal; 14 PGY1s, 10PGY2s, and 9 PGY3s listed patient breathing as an area of focus, and less than half of all PGYs reported asking the patient to perform the Valsalva maneuver; 11 PGY1s, 6 PGY2s, and 8 PGY3s reported using an air occlusive dressing to dress the site. 39% of PGY1s, 36% of PGY2s, and 29% of PGY3s reported performing all three maneuvers (Trendelenburg, focus on breathing, air occlusive dressing).CONCLUSIONS: The medicine residents surveyed do not perform CVC removal in a manner that optimizes patient safety. Nearly all residents are aware of hematoma and venous air embolism as major complications associated with CVC removal, yet many do not properly perform key steps in the procedure that would minimize those risks.

CLINICAL IMPLICATIONS: The lack of awareness of these serious and often preventable complications of improper CVC removal needs to be addressed by training programs and training in this procedure should be included into the curriculum.DISCLOSURE: The following authors have nothing to disclose: Tarak Rambhatla, Andrew Miller, Bushra MinaNo Product/Research Disclosure Information.