In order to remove central venous catheters, there are a few tools that would be required. This might include, non sterile gloves, transparent occlusive dressing, 2 – 4 X 4 sterile gauze squares, chlorhexidine 2 % and 70 % alcohol swabs, sterile tray with suture removal scissorsm sterile gloves and lastly bedside stool.
Nurses could remove any of the central venous line which might include pulmonary artery intrdocuers, triple lumen catheters or dialysis line. However an order prior to the removal is require from the patient. On the other hand, nurses may not remove sheaths which are large catheters and usually take a long time to stop bleeding. This could only be performed by a nurse with certificate in sheath removal.
Now lets look at the procedure and its rationale:
1. Check INR/PTT. If INR/PTT is continuous or maybe if the patient has a bleeding problem, notify the physician. This is done so that risk of bleeding could be reduced.
2. In the case of femoral venous catheters, obtain a bedside stool if require to make sure that the nurse is positioned correctly and above the femoral when applying pressure. In obese patients, direct and downward pressure is required to compress the vein.
3. Make sure your hands are clean, open the tray and set up the field. Remove the old ressing and discard the dressing and gloves. This is done to reduce the risk of transmission or microorganisms and secretions.
4. As mentioned above in tools required, cleanse site with 2% chlorhexidine and 70% alcohol swab. This is recommended because it has anti staphylococcus properties that are equal to alcohol or Providine. It is less irritating to the skin than iodine preparations and also has longer residual action than alcohol.
5. In the process of jugular or subclavian venous catheters, ask the patient to take a deep breath and hold it. Gently withdraw the catheter while applying direct pressure with the sterile guaze. After this is done ask the patient to breath normally. Do inspect the catheters for clots and make sure that the entire cathter has been removed.
However in the process of cathether fracture, apply direct pressure over the site and notify the physician immediately. If this catheter fragment is palpable, apply additional pressure distal to the catheter to prevent migration. During the process of spontaneous breathing, negative intrathoraic pressure can also encourage air to enter the insertion site and cause air embolism.
6. Pressure needs to applied slightly above puncture site to occlude blood flow. However if oozing continues compress fro another 5 minutes and then check again. Direct pressure shall stop bleeding from a large vein. Bleeding from a subclavian catheter can imapir ventilation. Significant occult blood loss might occur mostly in obese patients.
7. When bleeding stops, apply a transparent occlusive dressing over the site and sure that it stays intact. For jugular or subclavian catheters, the petroleum guaze can be applied over the site to reduce the entry of air into the site. Be sure to not apply bulky pressure dressing. It should be applied to the prevent the pathogens from the entering the insertion site. Pressure dressing can increase patient discomfort and delay the detection of bleeding.
8. Remove the non sterilized gloves and re-perform hand hygiene. This is an effort to reduce risk transmission of microorganisms and secretions as mentioned before.
9. Do not make an activity for at least one hour of post removal. In cases of fermoral venous catheters, do not allow hip flexion during this period. If possible place a sandbag over groin and restrain leg by bed linen tuck. This would to reduce bleeding as hip flexion or any avticity would trigger bleeding.
10. Asses the site of bleeding, monitor respiratory status, report any changes to the physician immediately.