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

PICC Line Care and Maintenance

Core Maintenance Protocol

Flush PICC lines with normal saline (not heparin) after each use, change transparent dressings weekly or when soiled, and use single-lumen catheters whenever possible to minimize complications. 1

Flushing Technique

• Use normal saline exclusively for maintaining catheter patency—heparin is not recommended for routine PICC maintenance 1
• Always use a 10 mL or larger syringe to prevent excessive pressure that could rupture the catheter 1
• Employ a turbulent push-pause flushing technique for optimal clearance of the lumen 1
• For PICCs not in active use, perform weekly flushes with normal saline 1
• Flush with 10 mL saline before and after each infusion, or 20 mL after blood sampling or blood product administration 2

Dressing Management

• Apply sterile gauze between the PICC entry site and adhesive dressing for the first 1-2 days post-insertion, then transition to transparent dressings 1
• Change transparent dressings weekly or when they become soiled, loose, or damp 1
• Clean the insertion site with chlorhexidine solutions containing alcohol before each dressing change 1
• Allow adequate drying time after antiseptic application to ensure effectiveness and avoid blood contamination 1
• Use transparent dressings that permit continuous visual examination of the insertion site 1

Common pitfall: Routine use of chlorhexidine-impregnated dressings is inappropriate unless basic infection-prevention measures have failed or catheter-related bloodstream infection rates are documented as high 1

Catheter Securement

• Use sutureless stabilization devices rather than sutures to secure PICCs 1
• Employ manufactured catheter stabilization devices such as StatLock instead of sterile tapes 1
• For medium to long-term PICCs (>1 month duration), use subcutaneously anchored stabilization devices to prevent migration and reduce time during dressing changes 1

Lumen Selection and Management

• Default to single-lumen devices to reduce complications unless there is a documented rationale for multilumen PICCs 1
• If multilumen catheters are necessary, dedicate one lumen specifically for parenteral nutrition 1
• Collaborate with pharmacists or vascular access specialists before ordering a PICC to clarify device needs and avoid unnecessary multilumen placement 1

Tip Position Verification

• Verify catheter tip position radiologically with intraoperative fluoroscopy or post-operative chest X-ray 1
• The ideal tip position is the lower third of the superior vena cava or cavoatrial junction 1
• Adjust the PICC when the tip is positioned in the upper or middle third of the superior vena cava or extends into the right ventricle 1

Critical warning: Never advance a migrated PICC—instead, perform guidewire exchange if there are no signs of infection 1

Prevention of Complications

Mechanical Complications

• Use infusion pumps for continuous parenteral nutrition and follow appropriate flushing protocols to prevent intraluminal obstruction 1
• Avoid routine use of the catheter for blood product infusion, blood withdrawal, or contrast medium injection 1
• Never use syringes smaller than 10 mL for flushing or clearance attempts to avoid catheter damage from excessive pressure 1

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
• 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
• Do not routinely apply topical antimicrobial ointments to the insertion site 1

Management of Suspected PICC-Related Infection

• In patients with confirmed PICC-related bloodstream infection, do not continue treatment using the affected PICC, perform guidewire exchange, or place a new device in the contralateral arm without documented clearance of infection 3
• After a line-free interval (typically 48-72 hours) and negative blood cultures, placement of a new PICC is appropriate only if an indication warranting central catheter use remains present 3
• Prefer peripheral IVs whenever possible in patients recovering from PICC-related infections 3

PICC Removal Criteria

• PICC removal without physician notification is inappropriate 3
• After physician notification, remove the PICC when: 3
  • The PICC has not been used for any clinical purpose for 48 hours or longer
  • The patient no longer has a clinical indication, or the original indication has been met (e.g., antibiotic course completed)
  • The PICC is only used for routine blood sampling in a hemodynamically stable patient with available peripheral veins
• Remove PICCs as soon as they are no longer clinically necessary to minimize complication risk 1
• Only clinicians trained specifically in PICC removal should perform the procedure—training in general CVC removal is insufficient 3