How to manage a leaking Peripherally Inserted Central Catheter (PICC) line?

Management of a Leaking PICC Line

A leaking PICC line requires immediate intervention to prevent serious complications such as extravasation injury, infection, or catheter embolism, with the most appropriate action being to clamp the catheter proximal to the leak and seek urgent clinical assessment for repair or replacement.

Initial Assessment and Immediate Actions

When a PICC line leak is identified:

1. Immediately clamp the catheter proximal to the leak site to prevent:

   • Air embolism
   • Further extravasation of infusate
   • Potential bloodstream infection

2. Discontinue all infusions through the affected catheter

3. Apply pressure and wet dressings to the leak site 1

4. Apply an occlusive dressing over the leak site temporarily 1

Determining the Cause of Leakage

The management approach depends on identifying the cause of leakage:

External Catheter Damage

• Common causes include:
  • Inappropriate use of scissors during dressing changes
  • Chemical damage from organic solvents or ethanol
  • Excessive pressure during flushing (using syringes smaller than 10mL)
  • Mechanical stress at connection points 1

Catheter Migration or Displacement

• May result in a luminal hole positioned outside the vein
• Can be identified by:
  • Loss of venous waveform from the proximal lumen
  • Chest X-ray showing catheter migration 1
  • Pain or swelling at insertion site

Extravasation

• Leakage of infusate at the insertion site suggests extravasation
• High-risk infusates include those with high/low pH, high osmolality, vasopressors, and chemotherapy agents 1

Management Options

For PICCs with External Damage

1. For long-term PICCs: Repair with specific repair kits if available 1

   • This is appropriate for minor external damage to tunneled catheters or PICCs

2. For short-term non-tunneled CVCs: Exchange over a guidewire is more cost-effective 1

   • This approach is appropriate when the catheter remains clinically necessary

For Catheter Migration

• Guidewire exchange is rated as appropriate when a PICC has migrated, provided there are no signs of local or systemic infection 1
• Never attempt to advance a migrated PICC as this is rated inappropriate regardless of displacement distance 1

For Non-functional PICCs

• If the PICC is no longer functional due to the leak, exchange over a guidewire is appropriate if continued PICC use is indicated 1

Special Considerations

High-Risk Infusates

• For leaks involving high-risk infusates (vesicants, chemotherapy):
  • Follow specific extravasation protocols
  • Consider plastic surgical referral if tissue injury occurs 1
  • Document the nature and estimated amount of extravasated fluid

Infection Risk

• A leaking catheter increases infection risk
• Monitor for signs of infection (fever, erythema, purulence)
• If infection is suspected, blood cultures should be drawn and the catheter may need to be removed rather than repaired 2

Prevention Strategies

To prevent future PICC line leaks:

1. Proper catheter stabilization using manufactured catheter stabilization devices rather than stitches 1

2. Appropriate nursing protocols for catheter maintenance:

   • Always use 10mL or larger syringes for flushing to avoid high pressure damage 1
   • Avoid using scissors near the catheter during dressing changes
   • Avoid chemical exposure to the catheter material
   • Do not use PICC lines for high-pressure contrast injections unless specifically rated for power injection 1

3. Secure fixation to minimize withdrawal and catheter migration 1

4. Proper tip positioning in the lower third of the superior vena cava or at the atrio-caval junction 2

When to Remove vs. Repair/Replace

Remove the PICC when:

• Signs of infection are present
• The catheter is no longer needed
• Extensive damage has occurred that cannot be repaired
• There is evidence of catheter embolism

Consider repair or guidewire exchange when:

• The PICC remains clinically necessary
• Damage is limited to the external portion
• There are no signs of infection
• The patient has poor peripheral access and would likely need another PICC 1

By following these guidelines, healthcare providers can effectively manage leaking PICC lines while minimizing risks to patients and preserving vascular access when appropriate.