Will PICC (Peripherally Inserted Central Catheter) line removal be effective?

PICC Line Removal Indications and Effectiveness

PICC line removal is effective and appropriate when the original indication for use has been met, when it has not been used for clinical purposes for 48 hours or longer, or when it is only being used for routine blood sampling in a hemodynamically stable patient with available peripheral veins. 1

Appropriate Indications for PICC Line Removal

• PICC removal is appropriate after physician notification when:

  • The PICC has not been used for any clinical purpose for 48 hours or longer 1
  • The patient no longer has a clinical indication for a PICC, or the original indication for use has been met (for example, an antibiotic course has been completed) 1
  • The PICC is only used for routine blood sampling in a hemodynamically stable patient with available peripheral veins 1
  • There is bacteremia with objective evidence of line-related infection 1
  • In patients with PICC-related deep venous thrombosis (DVT), when symptoms of venous occlusion persist despite therapeutic anticoagulation for 72 or more hours 1

• PICC removal is inappropriate in the following scenarios:

  • Without physician notification 1
  • When a functional PICC is still needed for irritants or vesicant infusions 1
  • In patients with poor peripheral venous access requiring frequent phlebotomy 1
  • When performed by clinicians who have received training to remove CVCs but not PICCs 1
  • When symptoms of venous occlusion have minimal improvement but therapeutic anticoagulation has been provided for 72 or fewer hours 1

Management of PICC Complications

PICC-Related Thrombosis

• For PICC-related DVT, provide at least 3 months of anticoagulation at a treatment dose 1
• When treating with warfarin, target an international normalized ratio of 2 to 3 1
• Use low-molecular-weight heparin over warfarin in patients with cancer 1
• Consider urgent referral to interventional radiology for catheter-directed treatment when symptoms of venous occlusion are associated with phlegmasia cerulea dolens 1

PICC-Related Infection

• In patients with confirmed PICC-related bloodstream infection, remove the PICC 1
• After a line-free interval (typically 48 to 72 hours) and negative blood cultures, place a new PICC only if an indication warranting central catheter use is present 1
• Use peripheral IVs whenever possible in patients with previous PICC-related infections 1

Non-Functioning PICC

• For non-functioning PICCs, assess for mechanical causes of occlusion such as kinking or clamps left in closed position 2
• Check for potential migration by examining the external length marking 2
• Attempt to aspirate blood and flush with normal saline using a 10 mL syringe or larger 2
• If the PICC remains non-functional despite troubleshooting, guidewire exchange is appropriate if there are no signs of infection 2

Best Practices for PICC Management

• Use normal saline rather than heparin to maintain catheter patency and prevent lumen occlusion 1
• Use clear, transparent dressings that permit site examination 1
• Never use syringes smaller than 10 mL for flushing to avoid excessive pressure that could damage the catheter 2
• Never forcefully flush a catheter that is meeting resistance 2
• Avoid using the PICC for infusion of radiological contrast medium during CT or MR unless it is specifically certified as "pressure injectable" 2

Considerations for PICC Replacement

• Avoid placement of a new PICC in patients who experienced PICC-related DVT within the past 30 days 1
• If a PICC is absolutely necessary in a patient with recent PICC-related DVT, use the smallest catheter gauge and least number of lumens 1
• Consider placement in a vein in the contralateral arm following at least 3 months of anticoagulation for the PICC-related DVT 1
• For patients requiring long-term vascular access (>3 months), tunneled catheters or implantable ports may be more appropriate than PICCs 3

Common Pitfalls to Avoid

• Never attempt to reinsert a self-removed PICC 4
• Do not delay assessment for potential complications such as air embolism or bleeding after PICC removal 4
• Avoid placing a new PICC in the same vein if there are signs of thrombosis or infection 4
• Do not remove a PICC without considering whether the patient still requires central venous access 3