Central line removal: positioning, Valsalva, occlusive dressing and tip inspection

Why removal is a high-risk moment

When a catheter leaves a large central vein, the tract briefly connects the vein to room air. If pressure inside the chest is lower than atmospheric pressure, as during a deep breath while sitting up, air can be drawn in. The two major removal complications are air embolism and bleeding; haematoma, infection and catheter breakage also occur.

Before starting, confirm the order, check coagulation results and platelet count as your policy requires, and review the insertion record for catheter length. Some guidance advises against proceeding when the patient cannot lie flat, has an uncontrolled cough or is markedly dehydrated, because these increase the air embolism risk. Seek help if those apply. Explain the procedure, gather sterile gauze, an occlusive dressing and, if ordered, a sterile container for tip culture, and make sure a second person is available.

Positioning and breathing during withdrawal

For jugular and subclavian lines, position the patient flat with a head-down tilt if tolerated; this raises venous pressure at the site. Stop infusions, remove the dressing and securement, remove sutures, and clean the site. Explain that you will ask them to take a breath and bear down or hold it at the moment of removal.

The Valsalva manoeuvre raises intrathoracic pressure, making air entry less likely. If the patient cannot perform it, guidance commonly times removal with a specific phase of breathing; follow your protocol. Valsalva may be unsuitable for some patients, such as those with raised intracranial pressure or certain cardiac conditions, so check with the prescriber.

Withdraw, seal and inspect the catheter

Withdraw the catheter in one slow, steady motion. If you feel resistance, stop, do not force it, secure the site and call the responsible team, because pulling against resistance can fracture the catheter. Apply firm pressure with sterile gauze until bleeding stops, longer when coagulation is impaired, then cover the site with a sterile occlusive dressing.

Inspect the tip to confirm it is intact and compare the length with the insertion record. A jagged end or short catheter suggests a fragment may remain in the vein; keep the patient still and call for urgent medical review. Send the tip for culture only when infection is suspected and the order or policy requires it.

After removal: observation and early warning signs

Keep the patient lying flat for about 30 minutes, or semi-recumbent if flat is not tolerated, and take observations during this period. Check the site for bleeding or swelling; with a jugular line, swelling with voice change or breathing difficulty needs urgent help. Keep the dressing intact and dry for the period your policy states, and teach the patient to report bleeding, swelling or breathlessness after they return to sitting or walking.

Air embolism presents with sudden breathlessness, chest pain, falling oxygen saturation, hypotension, tachycardia or altered consciousness. Call for help immediately, cover the site, give high-flow oxygen and place the patient in a left lateral head-down position if protocol directs. Detailed prioritisation of that emergency is covered on a separate page.

Apply the steps to a study scenario

In a hypothetical item, a nurse prepares to remove an internal jugular catheter from a client sitting upright in a chair. Options include removing it while the client is seated and breathing normally, returning the client to bed flat or head down and coaching a Valsalva, or asking the client to take a deep breath in while seated. Returning to bed is correct.

Removal while seated, especially during inspiration, lowers intrathoracic pressure at the site and invites air entry. Afterwards, document the date and time, the client's position and tolerance, the condition of the tip and the measured length, the dressing applied, any culture sent and the observations taken during the period lying flat.

Sources and further reading

NHS Highland: Central venous catheter insertion and removal guidelines. Pre-removal coagulation checks, head-down positioning, Valsalva or expiration timing, pressure, occlusive dressing, 30 minutes flat and haematoma signs.

Sydney Children's Hospitals Network: Removal of a PICC or non-tunnelled CVC (local procedure). Stopping if resistance is felt, tip inspection and length check, air embolism signs and response, and post-removal observation.

American Nurse: Taking action against air embolism. Air embolism presentation, prevention during CVC removal and the immediate nursing response.