CVC Removal Guideline

Guideline · Aug 2019 · 1 min read

In brief

Clinical protocol for safe removal of central venous catheters, covering indications, technique, and complication prevention in hospitalized patients.

Written by the GCMD Library team from the guideline.

Initial Assessment for Line Removal

Algorithm begins with three primary indications: therapy completion, infection, or line malfunction. For therapy completion, lines should be removed if no longer needed, with consideration for removal after ≥48 hours without use in NICU/ICU settings. All decisions must account for ongoing access needs and high-risk patient criteria before proceeding with removal.

Line Malfunction Evaluation

Non-infectious line problems include vessel thrombosis, catheter occlusion, and position-related issues. Per ACCP guidelines, troubleshooting includes flushing/aspirating, verifying tip placement, and assessing patient symptoms before removal. Chest x-ray should be obtained to evaluate position-related problems, with options for repositioning or power flush before definitive removal.

High-Risk Patient Identification

High-risk criteria for line insertion include ≥3 prior tunneled lines, history of venous thrombosis, documented abnormal vascular anatomy, congenital heart disease or cardiac surgery history, and history of difficult access. These patients require special consideration for line preservation and careful planning for replacement access before removal.

Infection Management: Dialysis-Dependent Patients

Dialysis-dependent patients with uncomplicated infections (coagulase-negative staph, enterococcus) should maintain line and treat for 7-10 days if fever resolves within 72 hours. For Staph aureus, gram-negative bacilli, or fungal infections, line removal is indicated with 7-10 days treatment. Complicated infections (septic thrombosis, osteomyelitis, endocarditis) require line removal and 4-6 weeks of treatment.

Infection Management: Non-Dialysis Patients

Treatment approach varies by organism: coagulase-negative staph and Staph aureus receive 10-14 days treatment with line retention if responsive, while gram-negative bacilli follow similar protocol. Enterococcal infections warrant 10-14 days treatment with consideration for ID consultation in non-high-risk patients. All fungal infections require line removal regardless of patient type.

Treatment Response Assessment

Uncomplicated infection is defined as fever resolution within 72 hours with no other intravascular hardware present. Non-responsive infection indicators include clinical deterioration, relapsing/persistent bacteremia, fever >72 hours, or conversion to complicated infection. Critical lines in high-risk patients may be maintained despite infection if responsive to treatment.

Complicated Infection Criteria

Complicated infections include tunnel infections, port abscesses, septic thrombosis, osteomyelitis, and endocarditis, all requiring line removal. Treatment duration extends to 4-6 weeks for these complications. Special consideration for line replacement is needed in patients receiving high-dose immunosuppression (e.g., BMT) even after cultures clear.

Antibiotic Lock Therapy Considerations

Antibiotic or ethanol lock therapy should be considered as adjunctive treatment in appropriate cases. Treatment should continue until completion or at least 48 hours of negative cultures. The guideline references a separate VAT (Vascular Access Team) guideline for specific lock therapy protocols.

Statements in this guideline

Consider removing the line if it has been unused for 48 hours or more in NICU and ICU patients.
RecommendationSTART
Always consider ongoing access needs and whether the patient meets high-risk criteria for access prior to removal.
RecommendationPrior to Removal
High-risk criteria for line insertion include three or more prior tunneled lines, history of venous thrombosis, documented abnormal vascular anatomy, history of congenital heart disease or cardiac surgery, or history of difficult access.
EstablishedPrior to Removal
For catheter occlusion, consider flushing and aspirating, verifying tip placement is appropriate, and assessing the patient's symptoms such as pain per ACCP guideline.
RecommendationCatheter occlusion
For position-related issues, remove, replace, or reposition as possible and consider power flush.
RecommendationPosition related issue
For vessel thrombosis, use the ACCP guideline to determine if removal and hematology consult are needed.
RecommendationVessel thrombosis
For coagulase-negative staph or enterococcus infection in non-dialysis-dependent patients, maintain the line and treat for 7 to 10 days.
RecommendationType of infection
For Staph aureus, gram-negative bacilli, or fungal infection in non-dialysis-dependent patients, remove the line and treat for 7 to 10 days.
RecommendationType of infection
For tunnel infection or port abscess, remove the line and treat for 7 to 10 days.
RecommendationType of complication
For septic thrombosis, osteomyelitis, or endocarditis, remove the line and treat for 4 to 6 weeks.
RecommendationType of complication
Uncomplicated infection is defined as fever resolution within 72 hours with no other intravascular hardware.
EstablishedComplicated infection?
A patient is non-responsive to treatment if there is clinical deterioration, relapsing or persistent bacteremia, fever lasting more than 72 hours, or conversion to complicated infection.
EstablishedResponse to treatment
For uncomplicated infection in a critical line in a high-risk line insertion patient who is responsive to treatment, keep the line.
RecommendationResponse to treatment
For uncomplicated infection in a critical line in a high-risk line insertion patient who is non-responsive to treatment, remove the line.
RecommendationResponse to treatment
For dialysis-dependent patients with coagulase-negative staph, Staph aureus, or gram-negative bacilli infection, treat for 10 to 14 days.
RecommendationPatient type
For dialysis-dependent patients with enterococcus infection, treat for 10 to 14 days.
RecommendationPatient type
For dialysis-dependent patients with fungal infection, remove the line.
RecommendationPatient type
Consider antibiotic or ethanol lock therapy for dialysis-dependent patients.
RecommendationPatient type
Complete treatment or achieve at least negative cultures for 48 hours before discontinuing therapy.
RecommendationPatient type
If the patient is to receive high-dose immunosuppression such as bone marrow transplant, consider replacing the line even if cultures become negative.
RecommendationPatient type

Full text

Care Algorithm for Determining Line RemovalDRAFTv.2017 0424START Indication for line removal Ongoing access needs Therapy Complete*1 A No Utilize “Line Selection Tool” to determine appropriate accessYes Remove line InfectionOngoing access needsLine is not functioning Remove line No Yes Vessel thrombosis Catheter occlusion Ensure appropriate new accessYes No NoYesUse VAT Guideline Page 1 of 2 *1. Consider removing line if ≥48h w/o use for NICU and ICU.Prior to Removal:Always consider ongoing access needs and if patient meets high risk criteria for accessIf Patient in need of new access, utilize line stratification tool Per ACCP Guideline, consider:-Flushing and aspirating-Tip placement appropriate-Patient’s symptoms (e.g. pain) Obtain chest x-ray Position related issueRemove/Replace reposition as possible (consider power flushNo Yes Remove/replace vs. reposition as possible(*consider power flush) Use ACCP guideline to determine if removal and Hem consult need Updated 1/2019

Care Algorithm for Determining Line RemovalDRAFTv.2017 0424 Patient typeDialysis dependent A Maintain line, treat for 7-10 days *1 Staph aureus, gram negbacilli, fungal Complicatedinfection? Other Yes Type of infection Response to treatment Yes No Coagnegstaph, enterococcus Tunnel infection,port abscessType of complication Remove line/treat for 7-10 days Remove line/treat for 4-6 weeks Septic thrombosis, osteomyelitis,endocarditis Uncomplicated infection:Fever resolution within 72 hours with no otherintravascular hardware Critical line in high risk line insertion patient Non-responsive to treatment if: -Clinical deterioration-Relapsing/persistent bacteremia-Fever >72 hours-Conversion to complicatedinfectionKeep line Remove lineNon-responsive Responsive No Type ofinfection Treat 10-14 days*1Treat 10-14 days*1 Remove lineFungal Enterococcus Coagnegstaph, staph aureus,gram negbacilli Page 2 of 2 *1-Consider antibiotic/ethanol lockComplete treatment or at least negative cultures for 48h.If patient to receive high dose immunosuppression (i.e. BMT), consider replacing line even if cultures become negative T BD High risk criteria for line insertion:-≥3 prior tunneled lines-History of venous thrombosis-Documented abnormal vascular anatomy-History of congenital hearth disease or cardiac surgery-History of difficult access Question for ID-Enterococcus for non-high risk-When to consult

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