What are the management options for a patient with a Peripherally Inserted Central Catheter (PICC) that flushes with slight resistance and has blood return?

Management of PICC Line with Slight Resistance on Flushing and Blood Return

A PICC line that flushes with slight resistance but maintains blood return should be assessed for partial occlusion and managed with proper flushing technique, catheter patency evaluation, and consideration of thrombolytic therapy if dysfunction progresses. 1

Immediate Assessment

Evaluate catheter patency by attempting gentle aspiration and flushing with 10 mL of normal saline using proper technique with a 10 mL or larger syringe. 1 Smaller syringes generate excessive pressure that can damage the catheter or dislodge thrombus. 1

Verify PICC tip position through chest radiograph if resistance persists, as malposition in the upper or middle superior vena cava (rather than the caudal SVC or cavoatrial junction) increases complication rates and can cause turbulent flow during flushing. 2, 1

Assess for early thrombotic complications, which occur in 4-8% of PICC cases and manifest initially as increased resistance before complete occlusion develops. 1, 3 The presence of slight resistance with maintained blood return suggests partial rather than complete occlusion. 2

Proper Flushing Technique

Use the turbulent push-pause flushing method with a 10 mL or larger syringe to maintain patency without causing catheter damage. 1 This technique creates turbulent flow that helps clear fibrin deposits more effectively than continuous pressure.

Flush with normal saline rather than heparin, as saline is equally effective for routine catheter maintenance and avoids unnecessary anticoagulant exposure. 1

Monitor prepump arterial pressure if using the PICC for dialysis or high-flow applications, as the ratio of blood flow to prepump pressure (conductance) should exceed 1.2 to indicate adequate function. 2

Management of Partial Occlusion

If resistance increases or blood aspiration becomes difficult, the catheter meets criteria for dysfunction requiring intervention. 2 Catheter dysfunction is defined as inability to achieve blood flow rates >300 mL/min (for dialysis) or inability to withdraw at least 3 mL of blood. 2, 4

Consider thrombolytic therapy with alteplase (Cathflo Activase) for documented catheter dysfunction:

• Dose: 2 mg in 2 mL for patients ≥30 kg, or 110% of internal lumen volume (not exceeding 2 mg) for patients <30 kg 4
• Administration: Instill into the occluded lumen and assess function after 30 minutes, then again at 120 minutes 4
• Second dose: May administer if function not restored after first dose 4
• Success rate: 67% after one dose, 88% after up to two doses in clinical trials 4

Evaluation for Underlying Causes

Assess for fibrin sheath formation, the most common cause of partial PICC occlusion, which develops around the catheter and causes one-way valve effect (can flush but difficult to aspirate). 2 This occurs in up to 25% of central venous catheters. 2

Evaluate for catheter malposition including:

• High SVC placement 2
• Tip angled against vessel wall 2
• Coiling or kinking of the catheter 1

Consider venous ultrasound if arm swelling, pain, or discoloration develops, as these suggest catheter-associated thrombosis requiring anticoagulation. 2

Risk Factors Requiring Heightened Surveillance

Monitor more closely if patient has:

• Age >65 years (4-fold increased risk of occlusion) 3
• Multilumen PICC (increased thrombosis risk) 2, 5
• Left-sided placement (higher DVT incidence than right-sided) 2
• Hematological malignancy or active chemotherapy 5
• Total parenteral nutrition through the PICC 5

Prevention of Progression

Maintain strict aseptic technique during all catheter manipulations to prevent infectious complications, which occur in 1.6-6.3% of PICCs. 3

Avoid using the catheter for blood sampling if possible, as frequent blood draws (>2 per week) are associated with shorter catheter duration and increased complications. 6

Position the catheter tip in the caudal SVC rather than upper SVC or subclavian/innominate veins, as proper positioning reduces thrombotic complications. 2, 1

When to Remove or Replace the PICC

Remove the catheter if:

• Function cannot be restored after two doses of thrombolytic therapy 4
• Signs of catheter-related bloodstream infection develop (fever, chills, positive blood cultures) 2
• Symptomatic venous thrombosis occurs with arm swelling despite anticoagulation 2

Consider alternative access (tunneled catheter or port) for patients requiring long-term therapy, as these have lower complication rates than PICCs for extended use. 7

Common Pitfalls to Avoid

Never force flush against significant resistance, as this can rupture the catheter, dislodge thrombus causing embolization, or cause vessel injury. 1

Do not delay intervention when resistance progresses, as early dysfunction is easier to salvage than complete occlusion, preventing inadequate therapy delivery and need for replacement. 2

Avoid placing new PICCs in veins with recent thrombosis (within 30 days), as this significantly increases risk of recurrent complications. 7

Do not use syringes smaller than 10 mL for flushing, as they generate excessive pressure (>40 psi) that can damage the catheter or cause complications. 1