Can a Peripherally Inserted Central Catheter (PICC) line with resistance during flushing still be used?

PICC Line with Flushing Resistance: Do Not Use Until Properly Assessed and Cleared

A PICC line with resistance during flushing should not be used until the obstruction is properly evaluated and cleared using appropriate pharmacological agents with a 10 mL or larger syringe—never force flush against resistance as this can rupture the catheter and cause serious complications. 1

Immediate Management of Flushing Resistance

Stop and Assess

• Do not continue attempting to flush or infuse through a resistant PICC line. 1
• Resistance indicates intraluminal obstruction from lipid aggregates, drug precipitates, blood clots, or contrast medium. 1
• Forcing fluid through an obstructed catheter can cause catheter rupture, extravasation, or embolization of clot material. 1

Critical Technical Requirement

• Always use a 10 mL or larger syringe for any flushing or clearance attempts to avoid excessive pressure that may damage the catheter. 1, 2, 3
• Smaller syringes generate dangerously high pressures that can rupture the catheter wall. 1

Pharmacological Clearance Protocol

Match the Clearing Agent to the Obstruction Type

The appropriate clearing solution depends on the presumed cause of obstruction: 1

• For lipid aggregates: Use ethanol 1
• For blood clots: Use urokinase or recombinant tissue plasminogen activator (rTPA) 1
• For drug precipitates: Use NaOH or HCl 1
• For contrast medium: Use NaHCO3 1

When Pharmacological Clearance is Appropriate

• Attempt pharmacological clearance for PICCs or long-term venous access devices where preservation of the line is important. 1
• This approach is preferred over removal when the PICC remains clinically necessary and there are no signs of infection. 1

When to Remove or Exchange the PICC

Exchange Over Guidewire

• For non-tunneled short-term catheters with obstruction, exchange over a guidewire or removal is the most appropriate action. 1
• Guidewire exchange is appropriate when the PICC is no longer functional but an indication for continued PICC use remains present. 1
• Never advance a migrated PICC—perform guidewire exchange instead if there are no signs of local or systemic infection. 1, 3

Absolute Contraindications to Continued Use

Do not attempt to use or clear a PICC with resistance if: 1

• Signs of catheter-related bloodstream infection are present
• There is evidence of catheter damage or rupture
• The external portion of the catheter shows visible damage

Prevention of Future Occlusions

Proper Flushing Technique

• Use normal saline exclusively for maintaining catheter patency—heparin is not recommended for routine PICC maintenance. 1, 2, 3
• Employ a turbulent push-pause flushing technique for optimal lumen clearance. 2, 3
• Flush the PICC after each use and follow appropriate protocols when the catheter is not in active use. 1, 2

Avoid High-Risk Practices

• Avoid routine use of the PICC for blood product infusion, blood withdrawal, or contrast medium injection. 1, 2, 3
• Do not allow direct contact between lipid parenteral nutrition and heparin solutions. 1
• Use infusion pumps for continuous parenteral nutrition to prevent intraluminal obstruction. 1, 2, 3

Common Pitfalls to Avoid

• Never use syringes smaller than 10 mL for flushing or clearance attempts—this is the most common cause of iatrogenic catheter damage. 1, 2, 3
• Do not ignore early signs of resistance; address partial occlusions before they become complete. 1
• Do not attempt to "power through" resistance with forceful flushing—this causes catheter rupture. 1
• Avoid using the PICC for high-pressure contrast injection unless it is specifically certified as "power injectable." 1

Clinical Decision Algorithm

1. Encounter resistance during flushing → Stop immediately 1
2. Assess for infection signs → If present, do not attempt clearance; remove PICC 1
3. Determine obstruction type → Select appropriate clearing agent 1
4. Attempt pharmacological clearance → Use ≥10 mL syringe only 1, 2, 3
5. If clearance fails → Exchange over guidewire (if no infection) or remove 1
6. If PICC no longer needed → Remove rather than attempting salvage 1