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In this article, Wayne Meehan, Clinical Risk Advisor, and Dr Natasha Coen, Senior Clinical Risk Manager, discuss the risks of air embolism when removing Central Venous Access Devices, and how those risks may be mitigated.

Air embolism is a rarely encountered but potentially catastrophic complication of central venous line placement that can cause serious harm and death.1

An air embolism, which may be venous or arterial, occurs when air enters the circulation. The resulting air bubble can subsequently occlude blood flow, resulting in respiratory, cardiac or neurological injury. Small amounts of air introduced into the blood stream may be tolerated with no symptoms. However, as the volume of air increases, so too does the risk of a more severe injury. In addition, the closer to the heart the air enters the circulation, the smaller the volume of air required to precipitate a poor patient outcome.2

A Central Venous Access Device (CVAD) is a catheter introduced via a large vein into the superior vena cava or right atrium. 2 CVADs are frequently used in patient care in both the acute and community setting and are used for the administration of medications, fluids, parenteral feeding and blood products or for the measurement of central venous pressure.2,3

The State Claims Agency has noted the reporting of five serious incidents related to air embolism on NIMS, the National Incident Management System, over a three-year period.

Risk Factors

A number of risk factors, which may result in an air embolism when removing a CVAD, have been identified.

  • Incorrect positioning of patient prior to removal of CVAD2
  • Patient not adequately hydrated1
  • Patients with high risk factors e.g. right-to-left shunt anatomy, including patent foramen ovale (PFO), atrial septal defect (ASD)1
  • Device (connector and attachment) issues2
  • Inadequate training / experience in performing the procedure2
  • Lack of specific air embolism prevention protocols in policies and procedures for CVAD insertion, management, and removal2
  • Lack of provision of patient information about routine CVAD care, to include removal of the device2

Minimising the risks

With correct technique and appropriate precautions, an air embolism is a preventable patient safety event.2 The State Claims Agency, in consultation with the College of Anaesthesiologists of Ireland, has prepared the following advice for practitioners to reduce the risk of air embolism when removing CVADs.

  • Ensure adequate training and supervision of healthcare professionals managing CVADs1,3
  • Adequately hydrate to prevent hypovolemia prior to insertion and removal of the catheter1
  • Confirm correct patient positioning prior to removal of CVAD1:
    • For jugular and subclavian sites, it is preferred to keep the patient in a supine position with his/her head down or Trendelenburg position (15° head down)
    • For the femoral location, the supine position is preferred
  • Ask the patient to perform the Valsalva maneuver during removal of the CVAD1
  • Once CVAD is removed, be alert to signs and symptoms of air embolism including dyspnoea, hypotension, chest pain, reduced level of consciousness / unconsciousness, neurological deficits from transient ischemic attack or stroke and sudden cardiac arrest1,2
  • Use equipment with safety features that are designed to prevent air embolism e.g. vascular access catheters and caps with self-sealing one-way valves2
  • Educate patients and carers on the risks of air embolism and associated complications, signs, and symptoms2
  • Ensure CVAD policies and procedures include protocols for prevention, recognition, and management of air embolism2

References available on request.

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