Clinical procedure - central venous access device (CVAD) - removal

The following is a list of recommended equipment to undertake this procedure:

• trolley 
• cleaning agent as per local policy 
• waste bag
• personal protective equipment (PPE)
• non-sterile gloves
• sterile gloves
• basic dressing pack
• 2% chlorhexidine gluconate and 70% isopropyl alcohol swab sticks
• 2% chlorhexidine gluconate and 70% isopropyl alcohol solution
• sterile gauze
• transparent occlusive dressing
• stitch cutter, for suture removal if appropriate
• sterile scissors & sterile specimen container for catheter tip culture if ordered

1. Verify medical order to remove the catheter
2. Perform hand hygiene opens in a new tab or window
3. Decontaminate and disinfect trolley as per local policy
4. Gather equipment

Patient preparation

5. Proceed to patient area and perform hand hygiene opens in a new tab or window
6. Explain the procedure, and obtain verbal consent
7. Ensure patient is in comfortable and that the catheter exit site is at or below the level of the heart 

NOTE: It is important that the exit site of the catheter must be below the level of the heart: e.g. supine, left lateral or Trendelenburg position as tolerated, to reduce the risk of air embolism

• PICC: extend patient’s arm to 90 degrees to aid in removal

8. Perform hand hygiene opens in a new tab or window
9. Cease and disconnect infusion/s in progress if present 
10. Perform hand hygiene opens in a new tab or window
11. Using non-touch technique, prepare equipment on tray 
12. Perform hand hygiene opens in a new tab or window
13. Put on PPE including non-sterile gloves

Dressing removal

14. Using a non-touch technique, remove dressing and all other materials, adhesive engineered securement device (ESD) if present, and dispose in clinical waste as per local policy
    1. slowly loosen the edges, support the skin with opposite hand, peel towards the catheter exit site, avoid touching the exit site with gloves
    2. bordered dressings: keep the dressing material close to the skin by pulling it back over itself
    3. non-bordered dressings: stretch the material horizontally: walk fingers under dressing whilst supporting skin with other hand
    4. adhesive engineered securement device: loosen edges and peel back slowly, using adhesive removal wipes if required
15. Remove and discard non-sterile gloves
16. Perform hand hygiene opens in a new tab or window
17. Skin antisepsis: if using clean swab sticks, attend to skin antisepsis at this stage using non-touch technique. Disinfect skin around catheter exit site and under the dressing with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick using gentle friction for at least 30 seconds and allow to fully air dry. (Clean swab sticks are not placed on the Critical Aseptic Field. Swabs are used with clean hands and non-touch technique for skin antisepsis)
18. Perform hand hygiene opens in a new tab or window
19. Put on sterile gloves

Skin antisepsis and catheter disinfection

20. Skin antisepsis: if using sterile swab sticks, attend skin antisepsis at this stage. Clean the skin around catheter exit site and under the dressing with 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick using gentle friction for at least 30 seconds and allow to fully air dry
21. Using non-touch technique, clean the external length of the catheter (and external part of subcutaneous ESD if present) with gauze soaked in chlorhexidine gluconate and 70% isopropyl alcohol solution with excess squeezed out, from exit site towards the needleless connector. Avoid touching catheter with sterile gloves
22. Place cleaned catheter on sterile drape from basic dressing pack

Removal of catheter securement

21. Remove sutures or subcutaneous ESD if present, by educated and competent clinicians only
    1. Removal of subcutaneous ESD:
       • place gauze with 2% chlorhexidine gluconate and 70% isopropyl alcohol or 0.9% sodium chloride (as clinically tolerated) over catheter exit site for 1-2 minutes
       • remove gauze and let air dry
       • remove cover of subcutaneous ESD and discard
       • remove catheter from groove in the base
       • whilst supporting skin at insertion site with non-dominant hand to ensure skin is taut, with dominant hand and in one movement - fold the base of the ESD in middle whilst lifting feet of device from the skin
       • cleanse the site, apply pressure for haemostasis as required
    2. removal of sutures:
       • using suture cutter, snip suture near the skin with the blade facing away from the catheter and remove, taking care near the catheter
       • cleanse the site, apply pressure for haemostasis as required

Catheter removal

22. During catheter removal, ask patient to hold their breath or complete Valsalva manoeuvre movement if possible. If not, complete catheter removal at end of inspiration
23. Hold gauze square near the catheter exit site (Key-Site) with non-dominant hand, remove catheter with slow, gentle traction with dominant hand
24. If resistance is evident, stop, do not apply force:
    1. wait a short time and try again
    2. or for PICC: reposition arm
    3. or apply sterile dressing and place heat over site, if appropriate and retry
    4. if unsuccessful, apply sterile dressing and discuss with vascular access expert, nurse practitioner, clinical nurse consultant and medical team
25. On catheter removal:
    1. apply pressure to the exit site (Key-Site) with sterile gauze until haemostasis achieved
    2. ask patient to breathe normally 
    3. cleanse site if required  
    4. apply a sterile, airtight dressing e.g. petroleum gauze, occlusive dressing to minimise risk of air embolism (see image below)

Dressing covering removed PICC site

© K Curtis 2021

Catheter fracture during removal

Catheters may be damaged prior to removal or may become damaged during removal process e.g. with excessive force

26. If catheter breaks during removal but external catheter length is visible:
    1. clamp catheter between exit site (Key-Site) and fractured end
    2. continue to remove refer to step 24
    3. monitor patient for signs/symptoms of air embolism including sudden onset of dyspnoea, coughing, chest pain, hypotension, tachycardia, altered cognitive state
27. If catheter breaks at the exit site (Key-Site)​, possible catheter embolism
    1. apply pressure over involved vein if appropriate, this may decrease the risk of catheter migration
    2. PICC: consider use of tourniquet above exit site (Key-Site), not occluding arterial flow (check distal pulse)
    3. unless contraindicated, place patient immediately on left side, with head in a declined position below level of their feet, approximate angle of 15 - 30 degrees, in Trendelenburg position
    4. minimise patient movement, and limb for PICC removal
    5. apply sterile dressing over exit site (Key-Site)
    6. organise immediate medical review

Fractured PICC (outpatient): folded over end of PICC and covered with sterile dressing

© K.Curtis 2021

Patient care post removal

28. Ask patient:
    1. to remain in the supine position for 30 minutes post removal, if possible
    2. perform blood pressure, pulse and respirations prior to patient sitting up
29. Inspect the integrity of catheter
    1. avoid touching tip of catheter (Key-Part) if required for culture
    2. if catheter not complete, refer to step 24, 25 and notify medical officer immediately
30. If catheter tip culture required:

NOTE: ensure catheter tip (Key-Part) does not touch skin surface post removal

• using sterile scissors, cut distal end of catheter and place into sterile specimen container

31. Educate patient:
    1. maintain dry dressing
    2. leave dressing intact for at least 48 hours or as per local policy. Potentially increase time if patient has delayed healing
    3. if complications become evident:
       • signs and symptoms of common complications e.g. infection
       • inpatients: notify nurses
       • outpatients: contact details of health service or general practitioner

Procedure completion and documentation

32. Discard waste and clean trolley as per institutional policy
33. Remove PPE and discard
34. Perform hand hygiene opens in a new tab or window
35. Document procedure in the medical record:
    1. condition of the CVAD dressing
    2. reason for removal
    3. time and date
    4. patient assessment including exit site (Key-Site) condition
    5. condition of catheter including integrity, catheter tip (Key-Part), length of catheter, comparison with length at time of insertion
    6. procedural complications and actions required
    7. dressing applied
    8. patient education including any follow up if indicated.

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Version 6

Date	Summary of changes
19/07/2021	Reviewed and updated in tandem with eviQ education CVAD module review. Terminology updated throughout to reflect current evidence base, national and international guidelines. Aseptic Non touch Technique (ANTT®) information and terminology incorporated. Links to CVAD modules added.  Images added relevant to content. Information from ID 905 Clinical procedure - peripherally inserted central catheter (PICC) - removal incorporated and ID 905 archived. Title changed to Clinical procedure - central venous access device (CVAD) - removal. Sections updated as follows: Equipment updated. Procedure information updated and presented in following distinct sections: Patient preparation, Dressing removal, Skin antisepsis and catheter disinfection, Removal of catheter securement, Catheter removal, Catheter fracture during removal, Patient care post removal and Procedure completion and documentation. Links added to new resource - CVAD assessment and documentation tool. Content updated to reflect current evidence and guidelines. References section added. Version number increased to V.6. Next review in 2 years.
02/02/2022	Minor updates to procedure order and some wording.
30/11/2023	Clinical procedure reviewed and updated in tandem with eviQ Education CVAD modules. Post care removal updated, dressing time changed from 24 hours to, at least 48 hours. Skin antisepsis process updated to include using clean and sterile swab sticks. Next review in 2 years.

Version 5

Date	Summary of changes
30/10/2019	Reviewed electronically by Nursing Reference Committee. Minor changes to procedure to align with other clinical resources. Links updated. Next review 2 years

Version 4

Date	Summary of changes
12/07/2011	Reformatted to comply with point of care template. Rationale and references have been moved to the resource document that is linked from this procedure.
13/06/2013	Reviewed and updated with minor changes.
18/11/2014	Added:  Apply pressure to site with an airtight dressing, instruct patient to leave it intact for 24 hours. Instruct patient to breathe normally. Instruct the patient to remain in the supine position (or semi-fowlers if supine not tolerated) for between 30-60 minutes. Perform blood pressure, pulse and respirations prior to sitting the patient up from the supine position. As per the safety notice from NSW health 004/14.
05/03/2015	Minor changes, added new link to supporting document.
31/05/2017	Transferred to new eviQ website.