What are the steps for removing a Peripherally Inserted Central Catheter (PICC) line?

PICC Line Removal Procedure

To safely remove a PICC line, position the patient lying flat with the exit site below the heart level to reduce the risk of air embolism, then apply firm digital pressure for at least 5 minutes after removal, followed by an occlusive dressing. 1

Standard PICC Removal Procedure

Patient Preparation

• Position patient lying flat (supine)
• Place the arm with PICC line below heart level to prevent air embolism
• Explain procedure to patient
• Gather necessary supplies (sterile gloves, gauze, occlusive dressing)

Removal Steps

1. Pre-removal assessment

   • Verify that the PICC line is no longer needed
   • Check for any contraindications (coagulopathy requiring correction)
   • Confirm patient identity and procedure

2. Execution of removal

   • Wash hands and don sterile gloves
   • Remove existing dressing carefully
   • Inspect insertion site for signs of infection
   • Gently and steadily pull the catheter using continuous traction
   • Monitor for resistance (do not force if resistance is encountered)

3. Post-removal care

   • Apply firm digital pressure at the exit site for at least 5 minutes 1
   • Apply an occlusive dressing after bleeding has stopped
   • Inspect the removed catheter to ensure it's intact and complete
   • Document the procedure, including catheter integrity and site condition

Special Considerations

Coagulopathic Patients

• Routine reversal of coagulopathy is only necessary if:
  • Platelet count < 50 × 10⁹/L
  • aPTT > 1.3 times normal
  • INR > 1.8 1
• Consider having an experienced operator perform the removal
• Have blood products available if needed rather than administering prophylactically

Difficult Removals

• If resistance is encountered, do not apply excessive force
• For adherent catheters:
  • Cuffed devices may require surgical cut-downs due to fibrin sleeves and scar tissue 1
  • Very long-term catheters may become attached to vessel walls and cannot be removed by traction alone
  • Seek advice from vascular surgery or interventional radiology if difficulties occur 1

Complications to Monitor

• Air embolism (prevented by patient positioning)
• Bleeding (may require extended pressure or rarely a skin stitch) 1
• Catheter fragmentation (inspect catheter after removal to ensure integrity)
• Venous thrombosis (may require anticoagulation if symptomatic) 2

After Removal

• Monitor the site for:
  • Persistent bleeding
  • Signs of infection
  • Thrombosis symptoms (arm swelling, pain, discoloration)
• Document catheter removal, site condition, and any complications
• Routine culture of catheter tips is not considered necessary 1

Pitfalls to Avoid

• Never forcefully remove a catheter that meets resistance (risk of catheter breakage)
• Don't forget to position the patient properly to prevent air embolism
• Don't neglect to apply adequate pressure after removal (minimum 5 minutes)
• Avoid removing PICC lines in patients with uncorrected severe coagulopathy without proper preparation

By following these steps, PICC line removal can be performed safely with minimal risk of complications.