PICC Line Care and Maintenance

Core Maintenance Protocol

• The American College of Cardiology recommends flushing PICC lines with normal saline after each use, changing transparent dressings weekly or when soiled, and using single-lumen catheters whenever possible to minimize complications 1

Flushing Technique

• The Infusion Nurses Society recommends using normal saline exclusively for maintaining catheter patency, as heparin is not recommended for routine PICC maintenance 1
• The Society of Interventional Radiology suggests using a 10 mL or larger syringe to prevent excessive pressure that could rupture the catheter 1
• The American Society of Parenteral and Enteral Nutrition recommends employing a turbulent push-pause flushing technique for optimal clearance of the lumen 1

Dressing Management

• The Centers for Disease Control and Prevention recommend applying sterile gauze between the PICC entry site and adhesive dressing for the first 1-2 days post-insertion, then transitioning to transparent dressings 1
• The Association for Vascular Access suggests changing transparent dressings weekly or when they become soiled, loose, or damp 1
• The World Health Organization recommends cleaning the insertion site with chlorhexidine solutions containing alcohol before each dressing change 1

Catheter Securement

• The Society of Interventional Radiology recommends using sutureless stabilization devices rather than sutures to secure PICCs 1
• The Association for Vascular Access suggests employing manufactured catheter stabilization devices such as StatLock instead of sterile tapes 1

Lumen Selection and Management

• The American College of Cardiology recommends defaulting to single-lumen devices to reduce complications unless there is a documented rationale for multilumen PICCs 1
• The Infusion Nurses Society suggests dedicating one lumen specifically for parenteral nutrition if multilumen catheters are necessary 1

Tip Position Verification

• The Society of Interventional Radiology recommends verifying catheter tip position radiologically with intraoperative fluoroscopy or post-operative chest X-ray 1
• The American Society of Parenteral and Enteral Nutrition suggests that the ideal tip position is the lower third of the superior vena cava or cavoatrial junction 1

Prevention of Complications

• The Centers for Disease Control and Prevention recommend using infusion pumps for continuous parenteral nutrition and following appropriate flushing protocols to prevent intraluminal obstruction 1
• The Association for Vascular Access suggests avoiding routine use of the catheter for blood product infusion, blood withdrawal, or contrast medium injection 1

Management of Suspected PICC-Related Infection

• The Infectious Diseases Society of America recommends that in patients with confirmed PICC-related bloodstream infection, treatment should not continue using the affected PICC, and guidewire exchange or placement of a new device in the contralateral arm should not occur without documented clearance of infection 2
• The Society for Healthcare Epidemiology of America suggests that after a line-free interval and negative blood cultures, placement of a new PICC is appropriate only if an indication warranting central catheter use remains present 2

PICC Removal Criteria

• The American College of Physicians recommends that PICC removal without physician notification is inappropriate 2
• The Society of Hospital Medicine suggests removing the PICC when it has not been used for any clinical purpose for 48 hours or longer, the patient no longer has a clinical indication, or the original indication has been met 2

Management of PICC Line Occlusions

Immediate Management of Flushing Resistance

• The American Society for Parenteral and Enteral Nutrition recommends that a PICC line with resistance during flushing should not be used until the obstruction is properly evaluated and cleared using appropriate pharmacological agents with a 10 mL or larger syringe 3, 4
• Resistance indicates intraluminal obstruction from lipid aggregates, drug precipitates, blood clots, or contrast medium, and forcing fluid through an obstructed catheter can cause catheter rupture, extravasation, or embolization of clot material 3, 4

Pharmacological Clearance Protocol

• The Infusion Nurses Society recommends attempting pharmacological clearance for PICCs or long-term venous access devices where preservation of the line is important, using agents such as ethanol for lipid aggregates, urokinase or recombinant tissue plasminogen activator (rTPA) for blood clots, NaOH or HCl for drug precipitates, and NaHCO3 for contrast medium 3, 4
• The Society of Interventional Radiology recommends using a 10 mL or larger syringe for any flushing or clearance attempts to avoid excessive pressure that may damage the catheter 3, 4

Prevention of Future Occlusions

• The American College of Clinical Pharmacy recommends using normal saline exclusively for maintaining catheter patency, and employing a turbulent push-pause flushing technique for optimal lumen clearance 5
• The Association for Vascular Access recommends avoiding routine use of the PICC for blood product infusion, blood withdrawal, or contrast medium injection, and avoiding direct contact between lipid parenteral nutrition and heparin solutions 3, 4

Clinical Decision Algorithm

• The Society of Hospital Medicine recommends stopping immediately if resistance is encountered during flushing, assessing for infection signs, determining obstruction type, and attempting pharmacological clearance using a ≥10 mL syringe only 3, 4
• If clearance fails, the society recommends exchanging over guidewire (if no infection) or removing the PICC 3, 4, 5