For many years, since attending Navan conference in Vancouver, I have not practiced exchanges unless there is no other option. Â I see catheter exchange mentioned from time to time on this site, and am wondering how the rest of you use it in your practice. Â When and if you exchange a line, do you do it through an introducer if possible, or do you use the over the wire technique? Â Under what circumstances will you perform an exchange? Â
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Halle Utter, RN, BSN
Intravenous Care, INCÂ
the only time we perform an exchange is when a catheter has been pulled partially out and is no longer in the SVC. We are usually called right away and we inform the RN to cover the entire exposed catheter under a new sterile dressing.
Occassionally, we will do a wire exchange to remove a line that a physician suspects for infection, but only if we can not place a new picc in the opposite extremity. We had some concerns about this, but have had no infections in the new picc even if the old had a positive tip culture.
As for our process, we find out the length of the existing catheter and then after setting up our sterile field and scrub, we remove the old catheter to within 10cm of the tip, cut it and then this remaining 10cm now becomes our "needle". We place our guidewire through one of the lumens of the catheter and then remove the final 10cm over the wire and discard. We then continue with our picc insertion as if we had just stuck the patient and successfully placed the guidewire. The whole procedure takes only about 10minutes and is very simple. Occasionally you will run into some complications threading the new catheter, but rarely.
Hallene E Utter, RN, BSN Intravenous Care, INC
People have been doing catheter exchanges for years but it is not talked about nearly enough.
I think that using an MST wire to do the exchange is far superior to using an introducer over the old PICC.
When using an introducer exchange, you cut the old PICC and put a new introducer over the old PICC into the vein. You then thread the new PICC through the new introducer. I have never liked this technique because
1 – The introducer is not designed to be used this way and very well may be an off label use.
2 – While the introducer is tightly fitted to the needle (if you use the old IV type introducer) or the dilator (if you use the sheath/dilator), there may be a “gap” between the introducer and the PICC as you thread it over. This may lead to a far more traumatic insertion.
3 – The introducer comes into contact with the old PICC and then inoculates the new PICC.
When using MST the new PICC has less contact with the old PICC. This is hard to describe without demonstrating, but I’ll try.
1- The wire goes through the old PICC – wire has touched the old PICC.
2- Dialator/Intoducer is placed over the wire - inside of the dilator has touched the wire which touched the old PICC.
3- Remove the wire by itself. This is important to keep the wire from contacting the introducer
4-Remove the dilator. The inside of the dilator has touched the wire that touched the PICC but the outside of the dilator hasn’t touched anything.
5-You are left with the introducer that has touched the outside of the dilator that has not contacted the wire that contacted the old PICC.
6- The new PICC is threaded through a “clean” introducer.
I have never seen any research on what I describe above but it seems fairly logical.
I’m eager to hear what others think.
It is also still VERY important to check your insertion site. If there are any signs of insertion, or if you even think there might be, you shouldn’t do any kind of exchange. I know this is obvious, but it is the most important thing.
Also: MD Anderson had a poster presentation about catheter exchanges at the last INS in Phoenix. They showed no increase in infection. I was thrilled to see this topic presented.
Thanks,
Mike Brazunas RN
Clinical Specialist
AngioDynamics
Mike,
What you say makes sense to me. You're right. The inside of the new introducer is "clean" in the sense that it hasn't touched the old PICC or the wire. You're certainly right that the introducer method is much more traumatic to the site; it sure doesn't slide right in, especially if the patient has tough thick skin. I wasn't at INS this year so didn't see the presentation you refer to. An earlier response to my topic stated that CDC doesn't recommend re-wiring catheters. I don't think it is probably wise in the presence of a known catheter infection, but there are other circumstances where it is certainly desirable, for both the patient and the inserter. If the patient has no sign of catheter infection it would certainly make an interesting study. When you remove a PICC, any PICC, the fibrin sheath on the outside is stripped away, and must release some of the bacteria into the bloodstream that is trapped in the biofilm & fibrin that coats it. If you stick at a new site, there is still that bacteria (released with removal of the old catheter) into the bloodstream. That bacteria is going to be released no matter how you remove the old PICC. Taking that into consideration, is there any more significance to the bacteria that may be released when you "scrape" the wall of the internal surface of the PICC with a wire when you are doing an over the wire exchange. It is certainly thought-provoking and worthy of more study. Thank you for an interesting discussion. As I mentioned in my post, prior to Vancouver we did do over the wire exchanges for a variety of reasons if there was no sign of infection, and did not see an increase in infection in those lines.
Halle Utter, RN, BSN
Intravenous Care, INC
Hallene E Utter, RN, BSN Intravenous Care, INC
2. Use a guidewire exchange to replace a malfunctioning nontunneled catheter if no evidence of infection is present (135,265). Category IB (emphasis mine)
3. Use a new set of sterile gloves before handling the new catheter when guidewire exchanges are performed (22,71). Category II The third point about changing gloves before handling the new catheter is one that is often overlooked but important for obvious reasons.
The second point makes it clear that a properly done guidewire exchange is a good way to replace a malfunctioning catheter. Notice that there is no mention of using an introducer over the PICC line or doing a "repair"
Catheter exchanges are done fequently by IR docs and they would rarely, if ever, even consider using an introducer over the PICC technique.Thanks, Mike Brazunas RN
MIKE,
I LOST YOU BETWEEN STEP ONE AND TWO
"THE WIRE GOES THROUGH THE OLD PICC" (WHICH WIRE?)
"DILATOR/INTRODUCER IS PLACED OVER THE WIRE"
WHAT HAPPENS TO THE OLD PICC BETWEEN THESE TWO STEPS
ARE YOU SOME HOW REMOVING THE CATHETER WHILE LEAVING THE WIRE IN PLACE?--AND--WHAT HAPPENS IF YOU ARE EXCHANGING FOR THE PURPOSE OF SIZING DOWN YOUR PICC--eg EXCH 5FR DL FOR 4FR SL
NEED CLARIFICATION--THANKS
Robbin George RN VA-BC
Robbin,
For a catheter exchange I would recomend:
1 - remove old dressing and pull PICC out about half way. Tape the PICC hub to the forearm.
2- Set up sterile field in the same way you would when doing a regular insertion. Be sure to prep the portion of PICC that lies in the fenestration - including under the PICC (roll it)
3 - cut the PICC right at the bottom on your fenestration. Hang on to the remaining piece.
4 - slowly pull PICC out until there is aproximantely 10cms left in the vein. Hopefuly you can use the original measurement to know how long the PICC is. Then cut the PICC again, leaving 5-10cms out.
5 - take the MST wire (not the stylette) and thread through the remaining piece. Be very careful and hold on to the remaining piece tightly so that it doesn't get pushed into the site. Some people even hemostat the line to ensure that it doesn't slip back into the site.
6 - Pull the remaining portion of the PICC back out of the body over the MST wire.
You are now left with a wire into the insertion site. From this point on treat it like a regular MST insertion. You should re-lidocaine at this point. The sheath/dialoator insetions will hurt if you don't. Re-nick if necessary (it often is if it has been more than a couple of days or if you are going to a larger Frech size).
It is common to go from a single lumen to a dual lumen if the patient's needs have changed. It is less common but if you go from a 5fr to a 4fr their may be bleeding at the insertion site (especialay if you don't have a reverse taper). Usualy some extra pressure at the site will resolve this.
I hope this helps.
Also: I apologize that the formatting of my second posting. It got all screwy when I cut and pasted.
Feel free to contact me if you have any questions.
[email protected]. If you send me an E-mail, I will send back my phone #.
thanks,
Mike Brazunas RN
Clinical Specialist
Angiodynamics