When during withdrawal should the patient perform the Valsalva maneuver?

• A. At the start of withdrawal.
• B. During the entire withdrawal.
• C. As the last 5-10 cm of the catheter is withdrawn.
• D. Never.

Answer: (C)

The key idea is preventing air from entering the venous system during the actual withdrawal of a central line. The Valsalva maneuver increases intrathoracic pressure and central venous pressure, which reduces the pressure gradient that would otherwise pull air into the vein as the catheter tip moves from the vessel into the external environment. Doing this at the point when the catheter is almost out—specifically the last 5–10 cm—provides the best protection, because that’s when the venous entry is most exposed to atmospheric air. If performed earlier or throughout the whole withdrawal, the protective effect is not as focused where the risk is highest. If the patient cannot perform Valsalva, the same principle is applied by coordinating with the removal so that the maneuver coincides with the final part of withdrawal.