complications in relation
to PICCs
A. MECHANICAL PHLEBITIS
Mechanical phlebitis is where the movement of a foreign object within a vein is the cause of the
inflammation and is the most frequent complication associated with PICCs.
Occurrence is normally evident within 10 days of insertion, therefore it is crucial to observe for
signs and symptoms in the early stages. Symptoms will be present around the bicep region,
above the PICC. As the PICC travels within the vein towards the superior vena cava the veins
become larger therefore accommodating the PICC without damage to the vein wall. The
symptoms include:
o Redness
o Swelling
o Pain
o Skin warm to touch
o Venous Cord (hard, palpable vein tracking up the arm)
Management
The PICC can still be used when symptoms of mechanical phlebitis are present. However, if
the symptoms become severe and there is no response to treatment, removal of the PICC may
be considered.
M.Hughes/IVAccess/CompPICCs/2006 2
Flow Chart
1
Redness, swelling and pain above PICC.
Tracking up the arm
Symptoms of Thrombosis:
Swelling of the arm, neck or shoulder
Pain in the shoulder No
Are there symptoms Bleeding at the exit site
of thrombosis Discolouration of the skin
Distension of the veins in the
Are there
No Yes symptoms
Treat for
Thrombosis as Yes of
per local policy thrombosis
Is the patient
pyrexial or are
there symptoms of Inform Dr. and consider
infection at the Yes Infection as the cause and
exit site treat with anti-biotics.
No
No. Moderate
to severe
Are the original symptoms of
mechanical phlebitis mild
M.Hughes/IVAccess/CompPICCs/2006 3
B. WITHDRAWAL OCCLUSION
Withdrawal Occlusion (WO) can be described as the inability to withdraw blood via the catheter
but it retains a capacity to infuse solutions without difficulty (Mayo 2001).
The main significance of WO is that the practitioner cannot be certain that the catheter is in the
vein when there is no free flowing blood return (Masoorli 2002). A satisfactory blood return is
the verification that the catheter is in a vein and that the catheter is functioning correctly prior to
any intravenous therapy.
The most serious, though rare consequence of WO is the leakage of vesicant or irritant drugs
into the surrounding tissues which can potentially cause extravasation injuries. This event is
extremely rare in PICCs. WO can result from a number of causes and can be classified as
non-thrombotic or thrombotic.
However, it is a thrombotic event that is the major cause of WO.
Thrombolytic agents.
Thrombolytic agents are a group of drugs which work by breaking down blood clots (clot lysis).
Urokinase is the most commonly used thrombolytic agent in catheter care. A bolus dose of
Urokinase may help to break down the fibrin formation at the tip of the catheter therefore
preventing withdrawal occlusion.
The recommended dose of Urokinase for use as a bolus lock for catheter clearance is 5,000
international units. The Urokinase needs to be prescribed by a Doctor.
Saline challenge
M.Hughes/IVAccess/CompPICCs/2006 4
Flow Chart
2 Unable to obtain a blood
sample from a PICC
Yes No
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C. COMPLETE CATHETER OCCLUSION
Complete catheter occlusion is when there is an inability to infuse any solution into the catheter
together with the inability to aspirate any blood from it. Complete occlusion can result from a
thrombotic or a non-thrombotic cause. In order to be able to diagnose and manage the
occlusion effectively, it is important to verify the source of the problem.
A thrombotic complete occlusion develops as a result of a build up of blood within the catheter
M.Hughes/IVAccess/CompPICCs/2006 6
Flow Chart
3 Unable to flush a PICC
Equipment required
Procedure:
M.Hughes/IVAccess/CompPICCs/2006 8
blood withdrawal is possible flush with 15-20 mls saline as per normal protocol. If
blood return is not possible repeat the injection of bolus urokinase.
11 Dispose of equipment according to hospital procedure, and document clearly in
patient’s notes.
(If procedure unsuccessful on first attempt, procedure may be repeated once after 1
hour)
(If the procedure is unsuccessful after two attempts, try again in 24hrs and leave the
urokinase lock insitu for 12 -24hrs)
M.Hughes/IVAccess/CompPICCs/2006 9
D. TORN/SPLIT PICC.
PICC lines are made of silicone, a very soft pliable material with a thick wall to enhance
durability. It is however possible for the PICC to develop tears, pinholes or leaks with time or
with improper handling. Tears and splits can occur at any site along the length of the PICC but
it is more common that damage takes place close to the exit site or on the external part of the
line.
If there has been leakage of chemotherapy around the split, the arm must be washed with
copious amounts of saline (maintaining sterility around exit site
M.Hughes/IVAccess/CompPICCs/2006 10
Flow Chart
4 Leaking at the site of the
PICC
No
This procedure should not be performed unless the practitioner has received specific
training in PICC repair.
Equipment needed
Procedure
(N.B. If connected to chemotherapy pump, this should first be disconnected and capped
off in the appropriate chemotherapy area where cytotoxic safe handling equipment is
easily available)
2 Support patients arm on a pillow ensuring arm is horizontal at 90 degrees to the body.
4 Open dressing pack, tip PICC repair kit, syringe, needle/s, stitch cutter, steri strips,
occlusive dressing and bionnector onto sterile field
5 Open 10ml 0.9% Sodium Chloride and place on trolley outside sterile field
6 Carefully remove old dressing and steri strips except the steri strip closest to where
the PICC exits the patients skin.
8 Using the green needle and 10ml syringe, draw up 10ml 0.9% Sodium Chloride using
swab from pack to hold ampule
9 Prime PICC repair kit sections. Place sterile dressing towel or bag from pack onto
patients arm under PICC line
M.Hughes/IVAccess/CompPICCs/2006 12
10 Clean needle-free connector with sterile alcohol wipe and allow to dry. Flush 2mls
0.9% sodium chloride into PICC line to identify precise ruptured area.
11 Using a sterile swab hold PICC line firmly and cut above rupture with stitch cutter.
Attach PICC repair kit by
a Inserting blue cuffed repair piece over PICC line (blue to blue)
b Hold PICC catheter push steel pin on grey piece of repair kit into blue catheter
up to hilt.
c Finally line up the grooves in each piece and click firmly together.
12 Attach new bionector and flush well under positive pressure using a pulsating turbulent
flush. Establish no further leak
13 Remove old steri strip and apply new steri strips and dressing
15 Document in medical notes and record in PICC diary, stating reason for repair.
M.Hughes/IVAccess/CompPICCs/2006 13
E. DEEP VENOUS THROMBOSIS
Deep venous thrombosis (DVT) is a condition which may present in the deep veins of the upper
or lower extremities. Catheter-related DVT involves the veins of the upper extremity, usually
the subclavian vein, the axillary vein and the Superior Vena Cava. This condition is referred to
as Upper Extremity Deep Vein Thrombosis (UEDVT).
It is important that if the PICC remains in situ, careful and frequent assessment of the patient
and the PICC should take place to detect any deterioration in symptoms or function.
When a clinical decision is made to remove the PICC, care must be taken when removing the
device due to the risk of a pulmonary embolus. The catheter should be removed in a suitable
area with access to oxygen and suction and the nurse should be aware of the correct
management of a patient in respiratory distress (Hadaway 2002).
M.Hughes/IVAccess/CompPICCs/2006 14
The patient has a swollen arm, hand
Flow Chart or neck
5
Consider Thrombosis
Explore the possibility of internal Follow Flow Trust Policy for the
catheter fracture. Dr. to request management of a suspected Thrombosis
linogram. Inform PICC placer or • Chest X-ray to verify tip
relevant specialist practitioner placement
• Doppler Ultrasound
• Review catheter function
• Ensure line is giving blood
Do not use line
The optimal position for the tip of a Central Venous Catheter (CVC) is the lower third of the
Superior Vena Cava (SVC) (Vesley 2002).
When the tip of the catheter moves from the desired position, the movement is referred to as
catheter tip malposition (Wise, Richardson and Lum 2001).
It important to remember that malposition of a CVC can be symptom free. There are however
some symptoms to observe which may require investigating:
o Sensation in the neck during flushing ‘ear gurgling’
o Chest pain
o Difficulty aspirating blood
o Inability or difficulty infusing fluids via the catheter
o Visible reflux into the catheter (blood within the catheter)
o Visible movement of the external portion of the PICC
If there is a suspicion that the external measurement of the PICC is longer than at the time of
placement, follow the guidelines below:
• Observe for any damage to the catheter
• Review the post insertion measurement if available and compare
If a patient is receiving therapy that is not toxic to the vein, for example
Normal Saline infusions, it is possible that a PICC that has migrated out of
the SVC can be used. The PICC can be used as a mid-line or a mid-
clavicular line. Advice from pharmacy or a PICC placer should be sought in
this instance.
M.Hughes/IVAccess/CompPICCs/2006 16
Flow Chart
6 Symptoms of Catheter
Malpositioning are present
M.Hughes/IVAccess/CompPICCs/2006 17
G. EXIT SITE INFECTION
Yes No
Yes No
Consider Granuloma or
infection Consider - allergy to
the dressing
Review the
Review the Patient patient within 5
within 4 days days. Consider
changing the
dressing to an
alternative if
symptoms
persist
M.Hughes/IVAccess/CompPICCs/2006 19
I. PAIN
Flow Chart
9
Pain in the shoulder, neck
or chest
Consider
Thrombosis
Migration of the tip Extravasation Damaged PICC
of the catheter into a
location other than
the SVC
Review patient
Flush the PICC for other
with Saline and symptoms of
observe for any thrombosis
Dr. to order a chest X-ray to symptoms flow chart 5
determine tip position
If in doubt Dr.
to order a
lineogram
M.Hughes/IVAccess/CompPICCs/2006 20
M.Hughes/IVAccess/CompPICCs/2006 21