What do I do if a patient has removed their own Peripherally Inserted Central Catheter (PICC) line?

Management of a Self-Removed PICC Line

When a patient has removed their own PICC line, immediately position the patient flat with the exit site below heart level, apply firm digital pressure for at least 5 minutes, followed by an occlusive dressing to prevent air embolism and control bleeding. 1

Immediate Actions

• Position the patient flat with the exit site below heart level to reduce the risk of air embolism 1, 2
• Apply firm digital pressure at the exit site for at least 5 minutes 1, 2
• Apply an occlusive dressing after bleeding has stopped 1, 2
• Monitor vital signs including temperature, pulse, blood pressure, and respiratory rate every 4 hours 1, 2
• Assess for persistent bleeding, which may require a skin stitch 1, 2

Assessment for Complications

Air Embolism

• Monitor for respiratory distress, chest pain, hypotension, altered mental status, and neurological changes 2
• If symptoms of air embolism are present, place the patient in left lateral decubitus position with head down (Trendelenburg) and administer oxygen 2
• Obtain a chest X-ray if the patient develops dyspnea or chest pain 1, 2, 3

Bleeding

• Evaluate for persistent bleeding from the exit site 1, 2
• For patients with coagulopathy, more vigilant monitoring is required 1

Infection

• Monitor for signs of infection at the exit site (redness, swelling, purulent drainage) 1
• If there is exudate at the exit site, obtain a swab for culture and Gram staining 1, 2
• Monitor for systemic signs of infection (fever, chills, hypotension) 1
• Do not routinely culture the catheter tip unless infection is suspected 1

Vascular Injury

• Assess for signs of vascular injury or thrombosis (arm pain, swelling, discoloration) 2, 4
• If symptoms of venous occlusion are present, consider ultrasound evaluation 2, 4

Follow-up Care

Evaluation of Continued Need for Central Access

• Determine if central venous access is still required for the patient's care 1
• Promptly remove any intravascular catheter that is no longer essential 1
• If central access is still needed, consider the original indication for PICC placement and expected duration of therapy 2

Considerations for PICC Replacement

• If a new PICC is needed, avoid placement in a vein that had a recent PICC-related thrombosis 2, 4
• Consider the size of the catheter when replacing - smaller French sizes (4Fr vs 5Fr or 6Fr) are associated with lower DVT risk 4
• For patients requiring long-term central access, consider tunneled catheters or implantable ports 1, 2
• Use ultrasound guidance for placement of new central venous catheters to reduce mechanical complications 1, 5

Common Pitfalls to Avoid

• Never attempt to reinsert a self-removed PICC 2
• Do not delay assessment for potential complications such as air embolism or bleeding 1, 2
• Do not place a new PICC in the same vein if there are signs of thrombosis or infection 2, 4
• Avoid unnecessary replacement of central lines - only replace if still clinically indicated 1
• Do not underestimate the risk of complications in patients with larger French size PICCs (5Fr or 6Fr) 4