James M. Cunningham, Clinical Associate Professor of Surgery, Mercer University School of Medicine, Macon, GA
James M. Cunningham, MD
Clinical Associate Professor
Mercer University School
Introduction: Sometimes only a limited number of sites are available for central venous catheter insertion, and a malfunctioning or infected catheter must be replaced using an exchange over a guidewire. This procedure can be awkward, and great care must be taken to minimize the risk of infection.
Results and discussion: This paper details a simple technique of catheter preparation and exchange that is designed to minimize the chance of an infectious complication arising from insertion of a replacement catheter. Although other institutions may use the same or similar approaches to guidewire exchange, the author's literature review did not identify other English-language descriptions of the technique detailed in this article.
Conclusion: Clinicians should consider using the technique described in this paper for any patient who requires exchange of a centrally or peripherally inserted catheter.
Central venous catheters are routinely inserted in the acute care setting for a variety of monitoring and therapeutic indications. Most are used on a short-term basis, but these catheters have become increasingly necessary adjuncts in the management of long-term intensive care unit (ICU) patients. Despite the advent of real-time ultrasound imaging at the bedside, satisfactory peripheral and central venous access sites unfortunately tend to disappear over time in ICU patients. When these devices have to be replaced, it may be necessary to perform the exchange using a guidewire.
A 19-year-old man, weighing approximately 100 kg, was involved in a high-speed motor vehicle collision. He sustained a contained traumatic tear of his thoracic aorta distal to the origin of the left subclavian artery. He also had minimal bilateral pulmonary contusions; moderate hemoperitoneum with no evidence of solid organ injury; a closed, comminuted fracture of his right tibia and fibula; a fracture of his right elbow; and numerous abrasions and contusions. He had no injuries to his central nervous system or vertebral column.
Figure 1 — Chest radiograph shows migration of the right IJV catheter into the patient's neck (arrow).
The aortic injury was repaired using an endograft with access via both femoral arteries. One femoral artery sustained an iatrogenic intimal injury and required open repair. Fluid was obtained during diagnostic peritoneal lavage. Examination of the fluid found only a few red blood cells, no significant levels of amylase, and no particulate matter, and it was decided not to perform exploratory laparotomy. An orthopedic surgeon addressed the extremity fractures, and postoperative hypertension was controlled with an intravenous infusion of esmolol.
Intravenous access was obtained using a 20-gauge, 1¼-inch left forearm catheter and a double-lumen right internal jugular venous (IJV) catheter, which were inserted when the aorta was being surgically repaired. On hospital day 2, an ICU nurse noticed considerable swelling (noncrepitant) at the base of the patient's neck on the right side and significant swelling that encompassed the entire anterior chest wall from his clavicle to his nipples. He had no associated skin discoloration. A chest radiograph showed proximal displacement of the right IJV catheter into the neck and the endoaortic prosthesis, but it was otherwise normal (Figure 1). It is likely that the IJV catheter was malpositioned while the patient was in the radiology suite for a second computed tomography scan of his chest, resulting in fluid extravasation. Blood return via the distal port was minimal, and no blood could be aspirated from the proximal port.
The patient's overall status and medication requirements, combined with the tenuous peripheral venous access in his left arm, indicated the need for continued central venous or large-bore peripheral venous catheterization. Access sites for inserting a new venous catheter were limited; the right upper extremity was unavailable for large-bore peripheral access because of the length of the arm cast. There were no suitable veins in the left upper extremity. The soft tissues covering the upper chest were so swollen that the clavicle and sternal notch could not be palpated to identify safe landmarks for subclavian vein catheterization. Bedside ultrasonography of the left internal jugular vein, which was performed while the patient was in steep Trendelenburg position, showed the fully dilated vein to be only 2 to 3 mm in diameter. The vein was located anteriorly and in close apposition to the internal carotid artery; therefore, no attempt was made to access this vein. It was deemed inappropriate to cannulate either of the femoral veins because of the recent groin incisions made during endograft insertion. Another attempt to aspirate blood from the distal port of the double-lumen catheter was successful, and the decision was made to use the guidewire technique described in this article to replace the right IJV catheter (Figure 2).
In most cases, indwelling central venous catheters function well and do not become a nidus for local infection or a source of sepsis. When catheter-related bloodstream infection is found or suspected, the indwelling catheter is usually removed and a new catheter inserted at a different site. Malfunction or malposition of the catheter may also prompt a search for additional venous access. There are various reasons why an alternative site for central venous catheter insertion cannot always be found.
Numerous reports describe the feasibility and safety of replacing malfunctioning or possibly infected central venous catheters using guidewire exchange techniques in such patients.1-8 Although the exact method of replacement varies, most reports stress the need for strict sterile precautions, which include the use of a cap, mask, gown, double gloves, and chlorhexidine skin preparation. The specifics of cleaning and prepping all surfaces of the indwelling catheter are rarely described in detail.
Several exchange options are available. Shimada and associates describe a technique in which an outer sheath is placed over an existing catheter that is subsequently removed to facilitate replacement with the new catheter.9 In most situations the indwelling catheter is disconnected from the intravenous tubing and subjected to two or three coats of an appropriate prep solution. Whether the catheter to be removed features one or several ports, the application of the prep solution (even when tinted) tends to be less than ideal. Next, the operator passes the exchange wire through the catheter port leading to the distal lumen and removes the "old" catheter. Lastly, the outer pair of gloves is discarded and the "new" catheter is passed over the guidewire and into its proper position. It is usually not necessary to obtain a post-procedure chest radiograph.10
Concerns about the difficulty in thoroughly preparing the existing catheter for exchange inspired me to devise an alternative method of guidewire exchange that minimizes the catheter surface area requiring preparation. This technique is most often used with triple-lumen catheters but can be modified for catheters with fewer lumens. As with the method described previously, the use of a cap, mask, gown, and sterile double gloves is mandatory.
The patient is positioned in the Trendelenburg position during the exchange to prevent air embolism. Any sutures holding the catheter in place are cut and removed, along with all catheter clamps and fasteners.
An assistant holds the catheter up and away from the patient's skin. Next, the first 3- to 4-cm portion of the catheter that exits the skin insertion site is prepped with chlorhexidine. Alternatively, a few centimeters of the catheter can be withdrawn from the insertion site and prepped. (No portion of the central venous catheter was withdrawn for the patient mentioned in this report because of the tenuous nature of the central venous access.) When using this method of exchange, only a small portion of the indwelling catheter needs to be coated with the prep solution. Areas of the catheter that are more difficult to cover with the prep solution, including the connecting ports, will be removed and do not require preparation. The skin surrounding the catheter insertion site is also prepped, and sterile towels are placed appropriately.
The operator holds the catheter close to the skin insertion site as the assistant cuts the proximal por-tion of the prepped catheter with sterile scissors and removes the unprepped segment from the field (Figure 3). Although it is extremely unlikely that the remaining portion of the catheter will migrate beneath the skin when cut, the operator prevents this by holding the catheter as the new guidewire is passed.
The operator inserts the guidewire from the new triple-lumen catheter tray into the largest catheter lumen (Figure 4). This 16-gauge lumen leads to the opening at the tip of the catheter (Figure 5), and the two 18-gauge lumens lead to the catheter side ports. Occasionally, the cut catheter lumens bleed sufficiently to obscure the operator's view during attempts to insert the exchange wire. In this instance, a small disposable hemostat should be used to clamp the catheter near the skin insertion site. Once the guidewire has been introduced into the proper lumen, the hemostat can be released and the wire advanced. The remaining portion of the old catheter is withdrawn, leaving the guidewire in place. The operator removes his or her outer gloves and discards them.
The large drape supplied with the triple-lumen catheter tray can be positioned in the operative field for the remainder of the procedure. The new central venous catheter is inserted in the usual fashion over the guidewire and secured appropriately. Finally, a pad impregnated with chlorhexidine gluconate is placed around the catheter at the insertion site and a transparent sterile dressing is applied.
It is rare that a central venous catheter needs to be replaced using guidewire exchange. In most cases, alternative central or peripheral insertion sites are available. When a guidewire exchange is necessary, it must be performed under sterile conditions to prevent catheter-related bloodstream infections.
When a guidewire exchange is necessary, it must be performed under sterile conditions to prevent catheter-related bloodstream infections.
The preferred technique is one that can be mastered easily and performed consistently among a diverse patient population. Based on my experience, the technique described in this article fulfills these requirements. Although no study has been performed to confirm that this method of guidewire exchange subjects patients to a decreased risk of infection, my experience suggests that this is the case. I have encountered very few cases of catheter-related infection using this aseptic technique.
The author has no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attests that the data meet the requirements for informed consent and for the Institutional Review Boards.