How to Order an IR CVC Exchange
When ordering an IR CVC exchange, you must explicitly specify whether you want a guidewire exchange at the same site versus placement at a completely new site, as this distinction fundamentally impacts infection risk and patient outcomes. 1
Critical Decision Point: Exchange vs. New Site
Order a CVC at a NEW SITE (not guidewire exchange) when:
- Suspected or confirmed catheter-related bloodstream infection (CRBSI) is present 1
- Purulence or signs of infection exist at the exit site or tunnel 1
- Persistent bacteremia/fungemia despite treatment 1
- Infection with S. aureus, Pseudomonas aeruginosa, or fungi 1
- Patient is hemodynamically unstable 1
- Evidence of infection at the catheter site 2
Replacement at a new site decreases infection risk compared to guidewire exchange 2, 1
Consider guidewire exchange at the SAME SITE when:
- Catheter malfunction without any signs of infection 1
- Coagulase-negative staphylococcus infection in a stable patient 1
- Difficult venous access with no signs of local infection 1
- No purulence at exit site or tunnel 1
- Intrinsic CVC-related thrombosis requiring treatment 2
Guidewire exchange is safe and effective for preserving the exit site in patients with limited central venous access sites 2
Essential Order Components
For New Site Placement:
Write the order as "CVC insertion at new site" or "CVC placement - new location" rather than "CVC exchange" 1
Explicitly state: "Do NOT exchange over guidewire" to ensure the interventionalist understands a completely new insertion site is required 1
For Guidewire Exchange:
Specify "CVC exchange over guidewire" if this is truly indicated 1
Request fibrin sheath evaluation and disruption if detected, as this prevents early CVC failure after exchange 2
Required Order Elements
Clinical Information:
- State the indication clearly (e.g., "for hemodialysis access," "catheter malfunction," "suspected CRBSI") 1
- Include relevant infection history and culture results if applicable 1
Site Selection Guidance:
- Internal jugular vein (right side preferred) for prolonged use >3 months 1
- Subclavian vein may be used but avoid if future AV access anticipated due to stenosis risk 1
- Femoral vein for short-term use <1 month when preserving upper extremity vessels is critical 1
Technical Specifications:
- Request "ultrasound-guided CVC placement" for all insertions 1
- Specify catheter type: "tunneled, cuffed catheter" for long-term use vs. "non-tunneled" for short-term 1
- Indicate desired catheter size 1
- Request tip position confirmation at cavoatrial junction or lower SVC 1
- Order post-procedure chest X-ray to confirm position 1
Special Considerations for Guidewire Exchange
If fibrin sheath is detected on angiogram during exchange, it should be disrupted by angioplasty before completing the exchange 2
This approach provides:
- Longer median time to repeat CVC dysfunction (373 days with disruption vs. 98 days without, though not statistically significant) 2
- No increased risk of bacteremia 2
- Preservation of the exit site 2
Common Pitfalls to Avoid
Never order routine CVC exchange without specific clinical indication, as this does not reduce infection rates and may increase complications 2
Guidewire exchange is absolutely contraindicated in the presence of infection at the catheter site or proven CRBSI 2
Do not use vague terminology like "CVC exchange" without specifying the method, as this can lead to inappropriate guidewire exchange when a new site is needed 1
For dialysis patients, protect stenotic vessels by placing a wire across any stenosis to prevent thrombosis and preserve future access options 2