What is the appropriate evaluation and management for a non‑functional PICC line in the left upper arm?

Management of a Non-Functional PICC Line in the Left Upper Arm

For a non-functional PICC line that remains clinically necessary, guidewire exchange is the appropriate management strategy, provided there are no signs of local or systemic infection. 1

Initial Assessment

Determine the Nature of Dysfunction

Assess whether the catheter is occluded or mechanically compromised:

• Check for mechanical causes first: Examine for kinking of the external portion, clamps left in closed position, or patient positioning issues that may be compressing the catheter 2
• Assess ability to withdraw blood: Inability to withdraw at least 3 mL of blood defines catheter dysfunction 3
• Test infusion capability: Determine if you can still instill fluid through the catheter 3
• Never forcefully flush a catheter meeting resistance, as this can damage the catheter or cause complications 2

Evaluate for Complications

Screen for infection:

• Examine the exit site for redness, swelling, or purulent discharge 4
• Check for systemic signs including fever, chills, or hypotension 4
• If exudate is present, obtain a swab for culture and Gram staining 4

Assess for thrombosis:

• Evaluate for arm pain, swelling, or discoloration suggesting venous occlusion 4
• If symptoms are present, obtain ultrasound evaluation 4

Management Based on Clinical Scenario

If Catheter is Occluded but Otherwise Intact

For thrombotic occlusion with ability to instill fluid:

• Administer alteplase 2 mg/2 mL instilled into the catheter lumen for patients weighing ≥30 kg 3
• Assess for restoration of function at 30 minutes by attempting to withdraw 3 mL of blood and infuse 5 mL of saline 3
• If function is not restored at 30 minutes, reassess at 120 minutes 3
• A second dose may be administered if the first dose fails, with 85% of patients achieving restored function after up to two doses 3

If Catheter Requires Replacement

Guidewire exchange is appropriate when:

• The PICC is non-functional but clinically still necessary 1
• Changes to catheter characteristics are desired (number of lumens, power-injection compatibility) 1
• There are no signs of local or systemic infection 1

Guidewire exchange is inappropriate when:

• The PICC has migrated or been dislodged, regardless of distance 1
• Signs of infection are present at the exit site or systemically 1

For migrated PICCs:

• Do not advance the catheter back into position 1
• Guidewire exchange is the appropriate management if the PICC remains clinically necessary 1

If PICC is No Longer Needed

Remove the catheter when:

• The PICC has not been used for any clinical purpose for ≥48 hours 2
• The patient no longer has a clinical indication for central access 2
• Complications such as infection or thrombosis are present and the PICC is not essential 1

Special Considerations

Recent Thrombosis

If the patient had PICC-related DVT within the past 30 days:

• Strongly avoid placing a new PICC due to high risk of recurrent thrombosis 1
• If central access is absolutely necessary, use the smallest catheter gauge and fewest lumens possible 1
• Place in the contralateral arm only after at least 3 months of anticoagulation 1
• Consider alternative access such as midline catheter for antibiotics lasting <15 days 1

Catheter Selection for Replacement

If long-term access (>6 weeks) is still required:

• Consider tunneled catheters or implantable ports instead of another PICC, as these have lower complication rates for extended use 4, 2
• Prefer single-lumen catheters unless multiple ports are essential to reduce infection risk 5
• Prefer the right arm over the left to reduce thrombosis risk 5

Common Pitfalls to Avoid

• Never attempt to advance a migrated PICC back into position - this is rated as inappropriate regardless of how far it has dislodged 1
• Never perform guidewire exchange in the presence of infection - remove the catheter entirely in this scenario 1
• Do not use syringes smaller than 10 mL for flushing, as excessive pressure can damage the catheter 2
• Do not automatically replace a non-functional PICC without reassessing the indication for central access 4
• Avoid placing a new PICC in a vein with recent thrombosis (within 30 days) due to high recurrence risk 1