What are the guidelines for PICC (Peripherally Inserted Central Catheter) line care and maintenance?

PICC Line Care and Maintenance

For PICC line maintenance, flush with normal saline (not heparin) after each use, change transparent dressings weekly or when soiled, and use a dedicated lumen for parenteral nutrition if multilumen catheters are employed. 1

Flushing Protocols

Use normal saline rather than heparin to maintain catheter patency and prevent lumen occlusion. 1 This represents a shift from older practices and is now the standard recommendation across multiple guidelines.

• Flush with 10 mL saline before and after each infusion 2
• After blood sampling or blood product infusion, use 20 mL saline flush 2
• For PICCs not in active use, perform weekly flushes 1
• Always use a 10 mL or larger syringe to avoid excessive pressure that could damage the catheter 1, 3
• Employ turbulent push-pause flushing technique for optimal clearance 3

The evidence strongly supports saline over heparin, with multiple high-quality guidelines converging on this recommendation. The larger syringe requirement is critical—smaller syringes generate excessive pressure that can rupture the catheter.

Dressing Management

Apply sterile gauze between the PICC entry site and adhesive dressing for the first 1-2 days post-insertion, then transition to clear transparent dressings. 1

• Use transparent dressings that permit visual site examination 1
• Change dressings weekly or more frequently if wet, loose, or soiled 1
• Clean the insertion site with chlorhexidine solutions with alcohol 1
• Allow adequate drying time after antiseptic application to avoid blood contamination 1

Routine use of chlorhexidine-impregnated dressings is inappropriate without documented adherence to basic infection-prevention efforts or in the absence of high catheter-related bloodstream infection rates. 1 This is an important cost-containment measure—don't default to expensive antimicrobial dressings when basic practices aren't optimized first.

Catheter Securement

Use sutureless stabilization devices rather than sutures to secure PICCs. 1 Sutures increase the risk of local thrombosis and phlebitis.

• Manufactured catheter stabilization devices (e.g., StatLock) are preferred over sterile tapes 1
• For medium to long-term PICCs (>1 month), subcutaneously anchored stabilization devices can prevent migration and save time during dressing changes 1
• Sutureless devices decrease the risk of catheter-related bloodstream infection and dislocation 1

Lumen Selection and Management

Without a documented rationale for multilumen PICCs (such as multiple incompatible fluids), default to single-lumen devices to reduce complications. 1

• Inserting multilumen PICCs solely to separate blood sampling from infusions or to ensure a "backup" lumen is inappropriate 1
• In multilumen catheters, dedicate one lumen specifically for parenteral nutrition 1
• Collaborate with pharmacists or vascular access operators before ordering a PICC to clarify device needs 1

The evidence here is clear: more lumens equal more complications. Single-lumen devices should be the default unless there's a specific clinical need documented in advance.

Tip Position Verification and Management

Verify catheter tip position radiologically with intraoperative fluoroscopy or post-operative chest X-ray. 1 The ideal position is the lower third of the superior vena cava or cavoatrial junction 1.

• Right atrium positioning is acceptable and does not warrant adjustment in the absence of contraindications 1
• Adjust the PICC when the tip is in the upper or middle third of the superior vena cava or right ventricle 1
• Electrocardiographic guidance can substitute for radiographic verification if proficiency is demonstrated and adequate P-wave deflections are observed 1

This represents a notable departure from older recommendations that considered right atrial positioning problematic. Contemporary evidence does not support routine repositioning from the right atrium.

Prevention of Mechanical Complications

Intraluminal obstruction can be prevented by using infusion pumps for continuous parenteral nutrition and following appropriate flushing protocols. 1

• Avoid routine use of the catheter for blood product infusion, blood withdrawal, or contrast medium injection 1
• Never advance migrated PICCs—perform guidewire exchange instead if there are no signs of infection 1
• Do not use PICCs for power injection of contrast medium unless specifically certified as "power injectable" 1

If obstruction occurs, use a 10 mL or larger syringe for clearance attempts to avoid catheter damage from excessive pressure. 1 Select the appropriate solution based on the presumed obstruction type: ethanol for lipid aggregates, urokinase or recombinant tissue plasminogen activator for clots, NaOH or HCl for drug precipitates, and NaHCO₃ for contrast medium 1, 3.

Infection Prevention

Collect paired blood cultures from the catheter and peripheral vein before starting antibiotics if catheter-related bloodstream infection is suspected. 1

• Use alcohol, iodine tincture, or alcoholic chlorhexidine (≥0.5%) rather than povidone-iodine for skin preparation 1
• If peripheral cultures are unavailable, draw two blood samples at different times from different catheter lumens 1
• Take a swab of any exudate at the exit site for culture and Gram staining 1

Antimicrobial prophylaxis is not recommended for PICC insertion or maintenance. 1 This is a firm recommendation to avoid unnecessary antibiotic exposure and resistance development.

Common Pitfalls to Avoid

• Never use syringes smaller than 10 mL for flushing or clearance attempts—the excessive pressure can rupture the catheter 1, 3
• Avoid femoral vein insertion due to increased infection and thrombosis risk 1
• Do not routinely apply topical antimicrobial ointments to the insertion site 1
• Remove PICCs as soon as they are no longer clinically necessary to minimize complication risk 1