What are the key components to include when writing an order for a Central Venous Catheter (CVC) exchange?

How to Write a CVC Exchange Order

When writing a CVC exchange order, you must explicitly specify whether you want a new insertion site or a guidewire exchange, as the default terminology "CVC exchange" can lead to dangerous misinterpretation—always write "CVC insertion at new site" for infection-related replacements or "CVC exchange over guidewire" only when preserving venous access in patients with limited sites. 1

Critical Decision Point: New Site vs. Guidewire Exchange

Order a NEW SITE insertion when:

• Suspected or confirmed catheter-related bloodstream infection (CRBSI) is present 1
• Purulence, erythema, or signs of infection exist at the exit site or tunnel 1
• Any evidence of catheter site infection is present 1
• Guidewire exchange is absolutely contraindicated in these scenarios and increases infection risk significantly 2, 1

Consider guidewire exchange ONLY when:

• Patient has limited central venous access sites and catheter malfunction (not infection) is the indication 1, 3
• No signs of infection are present at the catheter site or systemically 1
• Preserving the existing exit site is clinically necessary 3

Important caveat: Replacement at a new site decreases infection risk compared to guidewire exchange (infection rate 1.8% vs. 19.5% in one study), making new site insertion the safer default choice 3.

Essential Order Components

1. Specify the Exact Procedure Type

Write one of these explicit phrases 1:

• "CVC insertion at new site" or "CVC placement - new location" (NOT "CVC exchange")
• Add: "Do NOT exchange over guidewire" to prevent misinterpretation 1

OR if guidewire exchange is truly indicated:

• "CVC exchange over guidewire" 1

2. Specify Catheter Type

• "Tunneled, cuffed catheter" for long-term use (>6 months) 2, 1
• "Non-tunneled catheter" for short-term use 2, 1
• For long-term home parenteral nutrition, specify tunneled CVCs (Hickman, Broviac, or Groshong) or totally implantable ports 2

3. Specify Insertion Site Preference

• "Right internal jugular vein" or "Right subclavian vein" (right-sided access preferred to reduce thrombosis risk) 2
• Avoid femoral vein in adults due to high infection and thrombosis risk 2
• Avoid subclavian site in hemodialysis patients or those with advanced kidney disease to prevent subclavian vein stenosis 2

4. Specify Catheter Characteristics

• "Single lumen catheter" (preferred to minimize infection risk) 2
• Specify catheter size (e.g., "7 French" or "9 French") 1
• "Minimum number of lumens essential for patient management" 2

5. Request Ultrasound Guidance

• "Ultrasound-guided CVC placement" (reduces cannulation attempts and mechanical complications) 2, 1

6. Specify Tip Position

• "Tip position at cavoatrial junction" or "Tip at superior vena cava-right atrium junction" 2, 1
• This positioning minimizes thrombosis risk 2

7. Request Post-Procedure Confirmation

• "Post-procedure chest X-ray to confirm catheter position and rule out pneumothorax" 1

8. Specify Sterile Technique Requirements

• "Use maximal sterile barrier precautions" (cap, mask, sterile gown, sterile gloves, full body drape) 2
• "Prepare skin with 0.5% chlorhexidine preparation with alcohol" 2
• "Allow antiseptic to dry per manufacturer recommendations before catheter insertion" 2

Special Considerations for Guidewire Exchange

If guidewire exchange is performed 1, 4:

• Request fibrin sheath disruption by angioplasty if detected on angiogram during exchange (provides longer time to repeat dysfunction) 1
• Use Trendelenburg position (5-10 degrees) to reduce air embolism risk 4
• Direct puncture of previous CVC venous lumen for guidewire insertion rather than cutting the CVC first 4
• Light manual compression of internal jugular vein venotomy site after catheter removal 4

Sample Order Template

For infection or new site needed:

"CVC insertion at new site. Do NOT exchange over guidewire. Right internal jugular vein preferred. Ultrasound-guided placement. Tunneled, cuffed, single-lumen catheter, 9 French. Tip position at cavoatrial junction. Use maximal sterile barrier precautions. Prepare skin with 0.5% chlorhexidine with alcohol. Post-procedure chest X-ray for position confirmation."

For guidewire exchange (no infection, limited access):

"CVC exchange over guidewire. Right internal jugular vein. Ultrasound-guided. Tunneled, cuffed, single-lumen catheter, 9 French. If fibrin sheath detected, perform angioplasty disruption before completing exchange. Tip position at cavoatrial junction. Use maximal sterile barrier precautions. Post-procedure chest X-ray."

Critical Pitfalls to Avoid

• Never order routine CVC exchange without specific clinical indication—this does not reduce infection rates and may increase complications 2, 1
• Never use vague terminology like "CVC exchange" without specifying new site vs. guidewire method 1
• Never perform guidewire exchange in presence of infection—this is absolutely contraindicated 1
• Never forget to specify ultrasound guidance—landmark technique has higher complication rates 2, 1
• Do not place catheters inserted during medical emergencies without replacing them within 48 hours using proper aseptic technique 2