How do I write an order for a Central Venous Catheter (CVC) evaluation for new site placement instead of just exchanging the existing one?

How to Write an Order for CVC Evaluation for New Site Placement

When ordering a CVC for new site placement rather than exchange, specify "CVC placement at new site" or "de novo CVC insertion" with explicit instructions to avoid guidewire exchange, as replacement at a new site decreases infection risk compared to exchange over a guidewire, though exchange may be reserved for patients with difficult venous access. 1

Key Order Components

Specify the Procedure Type Clearly

• Write "CVC insertion at new site" or "CVC placement - new location" rather than "CVC exchange" to ensure the interventionalist understands you want a completely new insertion site 1
• Explicitly state "Do NOT exchange over guidewire" if you want to avoid any confusion about using the existing site 1
• Include the clinical indication (e.g., "for hemodialysis access," "for parenteral nutrition," "suspected catheter-related infection") as this guides site selection 1

Site Selection Guidance

For prolonged use (>3 months), specify site preference in this order: 1

• Internal jugular vein (first choice) - right side preferred over left due to more direct anatomy 1
• External jugular vein
• Femoral vein
• Subclavian vein (note: higher risk of central stenosis, avoid if future AV access anticipated) 1

For short-term use (<1 month) when preserving upper extremity vessels is critical: 1

• Femoral vein may be acceptable unless contraindicated by BMI >35 kg/m², chronic diarrhea, or known iliac/femoral pathology 1

Essential Order Elements

Include these specific components in your order:

• "Ultrasound-guided CVC placement" - this is strongly recommended for all insertions to reduce complications 1, 2
• Desired insertion site (e.g., "right internal jugular vein preferred") 1
• Catheter type and size (e.g., "tunneled, cuffed catheter" for long-term use vs. "non-tunneled" for short-term) 1
• "Confirm tip position at cavoatrial junction or lower SVC" 1, 3
• "Post-procedure chest X-ray to confirm position" 1, 4

Clinical Decision Algorithm

When to Order New Site vs. Exchange

Order CVC at NEW SITE when: 1

• Suspected or confirmed catheter-related bloodstream infection (CRBSI)
• Purulence or signs of infection at exit site or tunnel 1
• Persistent bacteremia/fungemia 48-72 hours after antibiotics 1
• Infection with S. aureus, Pseudomonas aeruginosa, or fungi 1
• Patient hemodynamically unstable 1
• Metastatic complications (endocarditis, suppurative thrombophlebitis) 1

Guidewire exchange at SAME SITE may be considered when: 1

• Catheter malfunction without infection
• Coagulase-negative staphylococcus infection in stable patient 1
• Difficult venous access with no signs of local infection 1
• No purulence at exit site or tunnel 1

Sample Order Language

Example 1 (Hemodialysis patient): "Ultrasound-guided tunneled, cuffed CVC insertion at NEW SITE - right internal jugular vein preferred (avoid subclavian to preserve vessels for future AV access). Confirm tip position at cavoatrial junction. Post-procedure CXR. Indication: malfunctioning existing catheter."

Example 2 (Suspected infection): "CVC placement at NEW SITE - do NOT exchange over guidewire. Right internal jugular vein preferred. Ultrasound guidance. Post-procedure CXR to confirm tip position. Indication: suspected CRBSI."

Example 3 (Short-term access, preserve upper extremity): "Ultrasound-guided non-tunneled CVC insertion - femoral vein (right preferred). Duration <1 month. Confirm tip above renal veins (L1 level). Post-procedure imaging. Indication: temporary access while awaiting AV fistula maturation."

Common Pitfalls to Avoid

• Don't write "CVC replacement" - this term is ambiguous and may be interpreted as either exchange or new site placement 1
• Avoid subclavian site in dialysis patients when possible, as it increases risk of central venous stenosis that compromises future AV access 1
• Don't assume "new CVC" means new site - explicitly state this to prevent guidewire exchange at the infected/problematic site 1
• Remember to specify laterality (right vs. left) as right-sided access has more direct anatomy and lower complication rates 1
• Don't forget to document the patient's "ESKD Life-Plan" or long-term vascular access needs in dialysis patients, as this fundamentally changes site selection 1