Central Venous Catheter/Port Removal Operative Note

Procedure: [Procedure name with device type and laterality]

Date/Time: [Date and time]

Location: [OR / IR suite / bedside / clinic procedure room]

Proceduralist: [Name, credentials]

Assistant(s): [Names and roles, or "None"]

Patient: [Name, MRN]

Pre-Procedure

• Pre-op Diagnosis/Indication: [Reason for device removal] (Specify: end of therapy, malfunction, suspected/confirmed infection with site, thrombosis, device damage, or other.)
• Post-op Diagnosis: [Diagnosis after procedure] (Usually mirrors pre-op unless modified by intraoperative findings.)
• Consent: [Consent status and discussion] (Document informed consent with risks discussed: bleeding, infection, air embolism, catheter fracture/retained fragment, vessel injury. If emergent or verbal consent, document rationale.)
• Time-out: [Verification completed] (Confirm correct patient, procedure, site/side, positioning, equipment.)
• Anticoagulation Status: [Anticoagulant/antiplatelet use and peri-procedural management] (If not relevant, state "None" or omit.)

Anesthesia/Sedation

[Anesthesia type: local only / local with moderate sedation / MAC / general] (If local given by proceduralist, specify agent and volume. If anesthesia team managed, state "per anesthesia record" with type summary. If moderate sedation billed by proceduralist, document intraservice time and agents or reference separate sedation record.)

Procedure

Positioning and Preparation: [Patient position, skin prep, sterile technique] (Include Trendelenburg if used for CVC. For CVC removal, document infusions stopped and line clamped prior to removal.)

Technique: (Include only the applicable device type.)

• Non-tunneled CVC: [Suture removal if present; withdrawal with breathing coordination (Valsalva or breath-hold); immediate occlusive pressure to venotomy site; dressing placement]
• Tunneled/cuffed catheter: [Incision location; dissection to free catheter and cuff; removal with breathing coordination; cuff adherence management; venotomy pressure and dressing]
• Implanted port: [Incision over pocket; dissection through capsule; method of freeing catheter from venous entry; en bloc removal if applicable; pocket irrigation if performed; hemostasis; closure layers]

Adhesions/Resistance: [None / location and description] (If present, describe what was attempted, outcome, and any escalation required. State device was not forcibly removed if applicable. If incomplete removal, document what remained, management, imaging ordered, and follow-up plan.)

Catheter/Device Integrity: [Inspection findings] (Required: Explicitly state whether catheter removed grossly intact with tip intact based on visual inspection. Include removed catheter length if measured. For ports, confirm reservoir and catheter removed. If concern for fracture or retained fragment, document concern, actions taken, and imaging obtained.)

Hemostasis: [Method: manual pressure with duration / electrocautery / ligation / topical agents] [Adequacy: hemostasis achieved / describe ongoing issues and management]

Closure and Dressing: [Closure: primary / secondary intention] [Suture type if used] [Dressing type] (For CVC sites, specify occlusive dressing. For infected pockets left open, document packing.)

Findings

[Notable intraoperative findings] (Examples: purulence present/absent, pocket capsule characteristics, exit-site erythema/drainage, suspected fibrin sheath. Omit section if no notable findings.)

EBL

[Minimal / numeric estimate in mL]

Specimens

[Specimen type, destination, and indication] (If catheter tip or port sent for culture, state indication such as suspected infection. If device disposed per policy or returned to patient, document. If none, state "None.")

Complications

[None / description] (Document adverse events: bleeding requiring intervention, suspected air embolism, catheter fracture, retained fragment, arrhythmia, need for imaging/escalation. Distinguish from technical difficulty documented under Adhesions/Resistance.)

Disposition

[Condition: stable / guarded] [Destination: PACU / floor / home / ICU] [Post-procedure monitoring if ordered]

Post-Procedure Care

• Dressing: [Keep clean and dry; occlusive dressing duration for CVC sites per protocol; dressing change instructions if applicable]
• Activity: [Lifting/activity restrictions if incision performed; bathing/showering guidance]
• Warning signs: [Return precautions: recurrent bleeding, increasing pain, redness, warmth, swelling, drainage, fever, shortness of breath; contact information]
• Medications: [Analgesics as needed; anticoagulant/antiplatelet resumption timing or "per managing service"]
• Follow-up: [Wound check timing; suture removal if non-absorbable; culture/pathology result follow-up if applicable]