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                                                                  PICC EXCHANGE

                                                        Jamie Bowen Santolucito,CRNI

                                  Oregon Health Sciences University Hospital

                                                                                Portland, Oregon

   PICC exchange was first described by Fabian in 1995.1    Since then additional articles describing this procedure have appeared throughout the literature. 2,3,4   In general PICC exchange is reserved for those patients who lack alternative sites for insertion of a new PICC.   A new catheter inserted in a new site is preferable to catheter exchange.    

Indications for PICC exchange include:

1.           primary or secondary catheter malposition

2.           irreparable catheter fracture or damage

3.           change in catheter gauge size or number of lumens

4.           persistent intraluminal catheter occlusion not associated with extraluminal thrombotic event

5.           microbiologic analysis of catheter tip  

Contraindications for PICC exchange include:

1.           phlebitis

2.           extraluminal thrombotic event

3.           confirmed catheter-related infection and/or s/s of infection at the catheter exit site      

The following information describes a procedure for PICC exchange.   The procedure should be performed by qualified practitioners and in accordance with institutional policies and procedures.  

1.           Explain procedure to patient and obtain informed consent.   Risks vs. benefits of catheter exchange are discussed as well as alternative options.

2.           Gather supplies.   Extra sterile powder-free gloves (three pairs) and extra sterile barriers (two) are required in addition to the standard supplies needed for PICC insertion.

3.           Perform pre-insertion measurement as per institutional protocol.

4.           Don patient’s mask and clinician mask and eye protection.

5.           Wash hands thoroughly with antimicrobial soap for 60 seconds.

6.           Don clean gloves.

7.           Remove PICC dressing and inspect site and accessed extremity, shoulder, neck, chest, back for redness, edema, warmth/coolness, discoloration, drainage or tenderness.   The presence of such s/s may indicate phlebitis, thrombosis and/or infection and are considered contraindications for catheter exchange.

8.           Vigorously prep insertion site from mid-upper arm to mid-lower arm per institutional policy and procedure.

9.           Discard gloves.

10.   Don gown.

11.   Don sterile powder-free gloves.

12.   Draw up flush solution and anesthetic agent.

13.   Prime new catheter with flush solution observing for catheter integrity.

14.   Grasp hub end of inserted catheter with sterile 4x4 and lifting catheter upward apply   sterile barrier under catheter.   Pull catheter out of vein, maintaining approximately 20 cm of catheter length indwelling in the vein.   Discard 4x4 away from sterile field.

15.   Re-prep insertion site.

16.   Don second pair of sterile gloves.

17.   Apply fenestrated drape over accessed extremity so that approximately 10 cm of catheter length is exposed.

18.   Administer anesthetic agent to catheter insertion site.   Caution must be used to avoid                   puncturing catheter.

19.    Remove the needle from the introducer and place the introducer on the sterile drape                   near the insertion site.

20.   Grasp the catheter near the insertion site and trim the catheter maintaining approximately 10 cm of catheter external from the insertion site.   The trimmed portion of the catheter will fall underneath the fenestrated drape.

21.   Advance the introducer over the trimmed end of the exposed catheter and into the insertion site.   Applying traction to the skin and utilizing a twisting motion of the introducer may facilitate advancement.  

22.   The exposed catheter is wrapped in a sterile 4x4 and secured with a hemostat. Note:   The trimmed catheter must be secured at all times to avoid inward catheter migration and potential catheter embolus.

23.   Don third pair of sterile gloves.

24.   Remove old catheter by grasping the hemostat with a sterile 4x4 and gently withdrawing the remaining portion of the catheter.   Discard away from sterile field.

25.   Proceed with PICC insertion as per institutional protocol.  

References:  

1.           Fabian, B.   Peripherally inserted central catheter exchange using a breakaway sheath:   A new approach.   Jour of Intravenous Nursing 18(2)92, 1995

2.           Goodwin, M., Carlson, I.   The peripherally inserted central catheter:   A retrospective look at three years of insertions.     Jour of Intravenous Nursing 16(2)92, 1993

3.           Richardson, D. Chiu, M.   Nurse performed overwire exchanges:   An advanced practice procedure.   Jour of Vascular Access Devices 2(2)8, 1997

4.           Collinson, S.   Groshong PIC catheter exchange.   BAVIEWS (A publication of the Bay Area Vascular Network) 1(1)1, 1997
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