The removal of a central venous catheter (CVC) is a common procedure but can result in rare complications. Air embolisms can have important outcomes. One case was reported that lead to cerebral air embolism post-CVC removal in a patient that had underlying idiopathic pulmonary fibrosis, pneumomediastinum, subcutaneous emphysema, and the possibility of a intrapulmonary shunt. Even though the patient was treated with systemic antibiotics and maximum ventilator care, he succumbed to the cerebral air embolism that occurred to do the removal of his CVC. This anecdotal case is just one example of embolism that occurs due to the removal of CVC and proves the necessity of building protocols and strict adherence to them for the safety of patients . Other professionals have noted that embolism is a known complication that can occur during the removal of CVC, further supporting the need for fully researched and supported removal protocols .
An embolism occurs when air enters the circulatory system of the body. An embolism in the venous circulation will travel to the right side of the heart where it can lead to ventricular outflow tract obstruction and severe pulmonary hypertension due to pulmonary vasoconstriction. These conditions lead to pulmonary venous compromise as blood returns to the left side of the heart. Cardiac output is reduced significantly, and the full collapse of the cardiovascular system can occur. Patent foramen ovale or septal defects can pass air to the left side the heart. Once an embolism passes to the arterial circulation, it can travel o the arteries of the cerebrum or the heart leading to death in either circumstance. Therefore preventing the production of an embolism is imperative .

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Other complications regarding CVC include thrombotic occlusions within the line that need to be resolved. Cummings-Winfield and Mushani-Kanji found that there was a lack of protocols regarding best practices to resolve clot occlusions. These nurses did provide signification information about how to remove a clot in CVC lines but did not indicate any patient positioning tips. Patency of the line is imperative to provide treatment and care, especially in oncology cases, but a through protocol cannot be developed without regarding the position of the patient .

Complications beyond embolism associated with CVCs include blood infections. Intravenous catheter-related bloodstream infection (CRBSI) are most commonly related to the use of CVCs. An IV dressing comprised of a semi-permeable transparent adhesive dressing in conjunction with a gel pad and chlorhexidine gluconate 2% has been the product of choice to prevent CRSBIs. Again, no suggestions about patient positioning have been made .

Surgically placed central venous catheters (SCVCs) and percutaneously inserted central catheters (PICCs) are two different forms of CVC. Previous assumptions indicated that SCVCs were associated with more complications than PICC lines and therefore nonelective removal was necessary. On the contrary, SCVCs were found to be safer for neonatal patients than PICC and PICC lines had to be removed more frequently in these patients. Unforatnetly, there was no indication as to best practices when removal was necessary to neonatal patients .

Protocols for placing CVC has long been created to prevent the insertion of an air embolism, but less data is available for the removal of the device. Tenedelenburg position should be used prior to insertion. Lumens should be preflushed and clamped. The patient should then be placed in lateral decubitus position . Even continuing education articles do not address the safe removal of CVCs. Medical professional brushing up on their knowledge of CVC placement and maintenance can learn about international guidelines, insertion procedures, infection, and complication prevention but the removal of the device are ignored by McCann and colleagues .

Management of the instrument to prevent complications during the use of the CVCs has been discussed widely. In her study of more than 1300 patients, Meyer determined that find the location of the central tip location and using ultrasound for guide PICC placement are efficient practices to reduce deep vein thrombosis. Measuring the diameter of veins prior to catheter insertion is imperative to ensure the catheter lumen is half the width. These maintenance parameters are important for ongoing care but do not address the removal process of the catheter .

Smith developed an all-encompassing care bundle for CVC maintenance and nursing interventions. The six-step process was made to prevent infection, thrombus occlusions, and other complications. First, effective hand hygiene must be utilized prior to any procedure involving the CVC. Skin antiseptic should include 0.5% chlorhexidine gluconate in 70% alcohol. Strict use of barrier or aseptic techniques should be followed when the CVC is inserted. CVC dressings should be changed every 7 days or when soiled. ANTT2, an anticoagulant should be effectively used when the CVC is access or manipulated to prevent thrombosis. The necessity of the line remaining in place should be evaluated every day. Following the six steps has been researched to be best practice for CVC health and patency .

In conjunction with the lack of written protocols, it can be difficult to study what position works best for the removal of CVC because nurses do not always document every detail of their tasks. One study found that only 40% of nursing actions that were completed were documented in medical records. This number includes 37% of nursing assessments and 45% of interventions completed by nurses. This is a significant study as it shows there could be difficulty in developing a positioning protocol .

Time and again, there is significant evidence and research regarding the best practices to prevent and treat different types of complications associated with CVC, but there is a little indication what practices are recommended for the removal of the catheter. This lack of data leads to a gap in knowledge about how to best remove the catheter to prevent the potential for complications. The severity of consequences of an air embolism is noted and development of supported protocols to prevent them is important. Study regarding the best procedures to remove CVCs is warranted and as one aspect of that research is associated with the positioning of the patient. In the adult patient population does the position of the patient at the time of central venous catheter removal affect the incidence of adverse events from January 2017 to April 2017?

    References
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