Bed Rest After Removing Central Arterial and Venous Access Devices

Q How long should bed rest be maintained after removal of a chest tube, central catheter (internal jugular or subclavian), femoral arterial catheter, or femoral intra-aortic balloon pump?A Julie Miller, BSN, RN, CCRN, replies:Bed rest has been prescribed to treat many illnesses since Hippocrates.1 In recent years the damaging effects of prolonged immobility have been identified, and interventions to promote early mobilization to improve patient outcomes have been implemented.2 However, bed rest is still recommended at times to prevent untoward complications.Bed rest is recommended after the removal of central venous and central arterial access catheters to prevent venous and arterial gas embolism.3–5 According to numerous evidence-based articles and procedures, bed rest is recommended after central venous catheter, femoral arterial catheter, femoral intra-aortic balloon pump, or femoral cardiac catheterization sheath removal.3–6 The duration of bed rest and the patient’s position vary depending on hospital protocol, the size of the catheter, and the catheter’s purpose. The Table presents recommendations for bed rest after catheter removal.For central venous catheters (either internal jugular or subclavian), the AACN Procedure Manual for Progressive and Critical Care recommends the catheter be removed while the patient is performing the Valsalva procedure or during inspiration for a patient receiving invasive mechanical ventilation.3 A sterile occlusive dressing should be applied, and the patient should remain supine with the head of the bed flat for a minimum of 30 minutes or per institutional protocol. This procedure reduces the risk for venous gas embolism. If venous gas embolism is suspected, the patient should be placed in the left lateral Trendelenburg position and the clinician notified immediately. The occlusive dressing should remain in place for at least 24 hours, and the insertion site should be assessed for closure. A new sterile occlusive dressing should be applied if the insertion site is still open.3For removal of a femoral artery intra-aortic balloon pump, the AACN Procedure Manual recommends that bed rest and immobility of the affected limb be maintained for a minimum of 8 hours with the head of the bed no higher than 30° or per institutional protocol.4 Additional recommendations for removal with femoral and arterial venous sheaths should be followed.For femoral arterial catheters and femoral arterial and venous sheaths after interventional catheterization procedures, the AACN Procedure Manual recommends removing the arterial sheath during exhalation to prevent the patient from bearing down and causing bleeding.5 The venous sheath should be removed 5 to 10 minutes after the removal of the arterial sheath. Once hemostasis is achieved, the head of the bed may be elevated to 30°. Bed rest should be maintained for 1 to 6 hours or per institutional protocol. Busca et al6 suggest that a bed rest duration of 2 hours is sufficient and safe to prevent complications.For radial arterial sheaths after an interventional catheterization procedure, bed rest is not recommended once hemostasis has been achieved.7In the literature, there is no recommendation for or against bed rest after the removal of chest tubes.8 However, in personal communications, practitioners familiar with the process recommend keeping the patient on bed rest until the post–chest tube removal radiograph has been read and shows no pneumothorax. During removal, the clinician should remove the chest tube and suture the insertion site closed.9 A sterile occlusive dressing should be applied.10 In a blog post, Rafols11 describes chest tube management and care.Bed rest is recommended to prevent venous and arterial gas embolism after the removal of central arterial and central venous catheters. Mobilization may occur after chest tube removal once the postremoval radiograph has been read. The AACN Procedure Manual for Progressive and Critical Care is a good resource for more in-depth details on the removal process for each type of catheter.3–5,7,8Early mobilization is a key intervention to improve outcomes in acutely and critically ill patients. However, a period of bed rest to prevent complications is still indicated after central arterial and venous catheter removal.MILLER