What are the steps to troubleshoot a non-functioning Peripherally Inserted Central Catheter (PICC)?

Troubleshooting a Non-Functioning PICC Line

When a PICC line is not functioning properly, a systematic approach should be followed to restore function, with guidewire exchange being the appropriate intervention if the catheter remains non-functional despite troubleshooting measures. 1

Initial Assessment Steps

• Assess for mechanical causes of occlusion such as kinking of the external portion, clamps left in closed position, or dislodgement of the catheter 1
• Check for potential migration of the catheter by examining the external length marking and comparing to documentation from insertion 1
• Attempt to aspirate blood and flush with normal saline using a 10 mL syringe or larger to avoid excessive pressure that could damage the catheter 1
• Position the patient in different positions (e.g., raising or lowering the arm) to attempt to restore function 1

Management of Catheter Occlusion

Thrombotic Occlusion

• If thrombotic occlusion is suspected, instill Alteplase at a concentration of 1 mg/mL into the catheter lumen 2:
  • For patients weighing ≥30 kg: 2 mg in 2 mL
  • For patients weighing <30 kg: 110% of the internal lumen volume, not to exceed 2 mg in 2 mL
• Allow the solution to dwell for 30 minutes, then attempt to aspirate blood 2
• If function is not restored after 30 minutes, reassess at 120 minutes 2
• If still non-functional, a second dose of equal amount may be administered 2
• Clinical studies show restoration of function in 75% of patients after one dose and 85% after two doses of Alteplase 2

Non-Thrombotic Occlusion

• For lipid precipitate occlusion: consider ethanol instillation 1
• For medication precipitate occlusion: consider sodium hydroxide (NaOH) or hydrochloric acid (HCl) solution 1
• For contrast medium occlusion: consider sodium bicarbonate (NaHCO₃) solution 1

When to Replace the PICC

• If the catheter remains non-functional despite troubleshooting measures, guidewire exchange is appropriate, provided that 1:
  • There are no signs of local or systemic infection
  • There is a continued clinical need for the PICC
• Never attempt to advance a migrated PICC regardless of how far it has been dislodged 1
• For damaged external portions of the catheter, repair kits may be used for PICCs and tunneled catheters 1

Assessing for Complications

• Evaluate for signs of infection at the exit site (redness, swelling, purulent discharge) 3
• If exudate is present at the exit site, obtain a swab for culture and Gram staining 3
• Monitor for systemic signs of infection (fever, chills, hypotension) 3
• Assess for signs of venous thrombosis (arm pain, swelling, discoloration) 3
• If symptoms of venous occlusion are present, consider ultrasound evaluation 3

Prevention of Future Complications

• Use normal saline rather than heparin to maintain catheter patency and prevent lumen occlusion 1
• Ensure proper dressing care with clear, transparent dressings that permit site examination 1
• Change dressings weekly or more frequently if wet, loose, or soiled 1
• Consider single-lumen PICCs when multiple lumens are not clinically necessary to reduce complication risk 1
• Avoid using the PICC for infusion of radiological contrast medium during CT or MR unless it is specifically certified as "pressure injectable" 1
• Proper stabilization of the catheter is essential to prevent dislocation, with manufactured catheter stabilization devices preferred over stitches 1

Common Pitfalls to Avoid

• Never use syringes smaller than 10 mL for flushing to avoid excessive pressure that could damage the catheter 1
• Never forcefully flush a catheter that is meeting resistance, as this could lead to catheter rupture 1
• Never attempt to reinsert a self-removed or dislodged PICC 3
• Avoid placing a new PICC in the same vein if there are signs of thrombosis or infection 3
• Do not delay assessment for potential complications such as air embolism or bleeding if the catheter has been dislodged or removed 3