Can a Peripherally Inserted Central Catheter (PICC) line with slight resistance during flushing but still yielding blood return be used?

PICC Line with Slight Resistance During Flushing

Do not use a PICC line that demonstrates resistance during flushing, even if blood return is present, until the obstruction is properly evaluated and cleared using appropriate pharmacological agents. 1

Immediate Management Protocol

Stop flushing immediately when resistance is encountered. Resistance indicates intraluminal obstruction from lipid aggregates, drug precipitates, blood clots, or contrast medium, and forcing fluid through an obstructed catheter can cause catheter rupture, extravasation, or embolization of clot material. 1

Assessment Steps

• Assess for signs of infection at the insertion site and systemically before attempting any clearance procedures. 1

• Determine the likely obstruction type based on recent catheter use:

  • Blood clots from inadequate flushing or blood draws 1
  • Lipid aggregates from parenteral nutrition 1
  • Drug precipitates from incompatible medications 1
  • Contrast medium from imaging procedures 1

Pharmacological Clearance Protocol

Attempt pharmacological clearance only using a 10 mL or larger syringe to avoid excessive pressure that may damage or rupture the catheter. 1 Smaller syringes generate higher pressures and should never be used. 1

Agent Selection by Obstruction Type

• For blood clots: Use urokinase or recombinant tissue plasminogen activator (rTPA) 1

• For lipid aggregates: Use ethanol 1

• For drug precipitates: Use NaOH or HCl depending on the precipitate 1

• For contrast medium: Use NaHCO3 1

If Clearance Fails

• Exchange the catheter over a guidewire if there are no signs of infection 1

• Remove the PICC entirely if infection is suspected or guidewire exchange is not feasible 1

Critical Safety Points

Never force fluid through a resistant catheter. The presence of blood return does not guarantee safe catheter function—resistance itself is the critical warning sign requiring intervention. 1 Blood return simply confirms catheter tip position in the vein but does not exclude partial obstruction that could lead to complications if flushing is forced. 1

Use only 10 mL or larger syringes for any flushing or clearance attempts, as recommended by both the Society of Interventional Radiology and the American Society for Parenteral and Enteral Nutrition. 1

Prevention of Future Occlusions

• Employ turbulent push-pause flushing technique with normal saline after each use for optimal lumen clearance 1

• Avoid routine blood draws through the PICC when possible 1

• Avoid direct contact between lipid parenteral nutrition and heparin solutions 1

• Do not use the PICC for contrast medium injection unless absolutely necessary 1