Complications of Central Line Removal-The 'CVC Removal Distress Syndrome'
ABSTRACT & COMMENTARY
Synopsis: Proposed guidelines to ease maintenance and removal of central venous catheters (CVC) and prevent complications and possibly death.
Source: Kim DG, et al. The CVC removal distress syndrome: An unappreciated complication of central venous catheter removal. Am J Surg 1998;64:344-347.
Kim and associates reported a disturbing group of eight patients who appeared to suffer significant problems when their central lines were removed. The complications included paresis, (4 patients), respiratory failure (4 patients), shock (2 patients), and one patient who died later of pulmonary sepsis. Seven of the lines were in the right internal jugular vein-the other was in the right subclavian. The complications occurred after removal of the catheter (4 patients), after exchange of catheters over a guide wire (3 patients), and after detachment of the side port of the Swan introducer in one patient. The reactions usually occurred within minutes of catheter removal. In five who were being monitored in the intensive care unit, all experienced tachycardia and hypoxia, while four had elevated blood pressure. Of the four patients with neurologic complications, all recovered except one who had residual weakness of the left hand.
Kim et al speculate that the most likely cause of these events was air embolism. Other considerations included emboli from the vascular end of the catheter, dislodgment of an atherosclerotic plaque or thrombus in the carotid artery, and bradycardia from stimulation of the carotid sinus.
Kim et al propose guidelines for central venous catheter removal, which include placing the patient in a flat or Trendelenberg position, being sure that the patient is well hydrated, and asking the patient to hold their breath while the catheter is being pulled out. They also suggest that the catheter lumen and exit site be held closed with a gloved fingertip and then covered with an airtight dressing for at least 12 hours. They also suggest avoiding undue pressure over the carotid sinus and that the patient remain recumbent for 30 minutes after the procedure.
COMMENT BY ALAN D. TICE, MD, FACP
The observations reported here are of concern. Most of the reports in the literature have been related to catheter insertion problems-particularly with central lines, which may produce bleeding and pneumothorax and nerve injuries.1 Even peripheral catheters have been known to cause a systemic reaction that may be fatal.2
Problems with catheter removal, however, have not been widely appreciated. Kim et al point out the devastating results that can occur with catheter removal if it is not done properly. Kim et al postulate that most of the problems occur from air embolism is probably correct, as the line tract may be open if the catheter insertion site is not covered for a period of time. They were also able to put together a review of the literature and found 18 publications reporting 22 patients with CVC removal complications with an overall mortality rate of 57%. Earlier studies suggest that as little as 70-105 mL of air injected intravenously is sufficient to kill a human but smaller volumes could certainly embolize the lungs, or paradoxically, the brain3 through a patent foramen ovale, which may occur in 10-24% of the population.4 The positioning of the patient for catheter removal may also be important. Air emboli can best be controlled in the lying position with the left side down.
This information adds to the concerns of central catheter maintenance and removal. Not only is there a need for careful catheter insertion and repeated evaluations during the course of therapy, but also for careful removal at the end of treatment. This article focuses on the problems of non-tunneled central lines, but there are problems with tunneled catheters as well. Peripherally inserted central catheters (PICC) may have problems as well with breakage and can become stuck in the vein.5 The guidelines proposed for the withdrawal procedure seem quite reasonable.