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Evidence-based medicine has been defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett et al., 1996). Evidence-based nursing takes the process one step further by integrating clinical expertise and the data obtained from performance improvement processes with clinical research. The challenge nursing then faces is to translate the evidence into practice. Although central line removal is a fairly common procedure, it is not benign. The authors noted an opportunity for improving central venous catheter (CVC) removal from the subclavian or internal jugular vein. Based upon previously recommended guidelines (Kim et al., 1998), the authors set out to determine the best practice related to CVC removal.
Air embolism is one of the most serious complications that can occur in patients with central venous catheters (CVCs). This uncommon yet potentially catastrophic event occurs as a consequence of the entry of air into the vasculature (Ely et al., 1999). A venous or pulmonary air embolism occurs when the intrathoracic pressure becomes lower than the atmospheric pressure, permitting air to enter through an opening into the systemic venous circulation. For example, if the patient coughs, sneezes, cries, laughs, or takes a deep breath, the change in intrathoracic pressure can draw as much as 10 to 15 cc of air into the venous system via an open tract, resulting in an air embolism. The air may then travel to the heart, creating a lock at the pulmonic valve and preventing blood from being ejected into the right atrium (Jones, 1998). Specific conditions that can cause air embolism are listed in Figure 1. Signs and symptoms associated with venous air embolism following CVC removal include cyanosis, respiratory distress, hypotension, petechiae, feeling of impending doom, gasp reflex, cardiac arrhythmias, mill wheel murmur, elevated central venous pressure, elevated pulmonary artery pressure, loss of consciousness, and neurologic deficits (Dumont, 2001). The distinctive mill wheel murmur is heard over the precordium. It is a continuous, loud, churning, drum-like cardiac murmur caused by a right atrial and right ventricular outflow obstruction, also known as a cog wheel or water wheel murmur. Unfortunately, this classic sign is transient and therefore frequently missed (Andrews, 2002).
Removing a CVC may lead to potentially life-threatening complications,...