Troubleshooting
Definition: Impairment of catheter function by the inability to withdraw blood or resistance with flushing the line.
The four common types of clots associated with PICC lines are depicted below (Genetech, 2007)
- Intraluminal thrombus. Forms within the catheter lumen and causes either a partial or complete occlusion.
- Fibrin Tail. The most common type of catheter occlusion forms when fibrin adheres to the catheter tip. It can act as a one-way valve, permitting infusion but not withdrawal of fluid or blood from the catheter.
- Mural Thrombus. Forms when the fibrin from a vessel-wall injury binds to the fibrin covering the catheter surface. A mural thrombus may lead to the formation of a venous thrombus.
- Fibrin Sheath. Forms when fibrin adheres to the external surface of the catheter, covering it like a sock
Solution:
For instructions on how to reconstitute, please refer to: Cathflo.com
Gather supplies
- Cathflo 2mg/2ml
- Chloraprep applicator
- 10ml Normal Saline flushes (2)
Step by Step:
- Scrub the junction between the catheter and the cap with Chloraprep prior to removing the cap.
- Remove the cap and scrub the injection port with Chloraprep using friction for 30 seconds.
- Directly attach Cathflo syringe to the injection port.
- Instill Cathflo for 120 minutes.
- After 120 minutes, use 10ml syringe to withdraw Cathflo. Continue withdrawing until you have aspirated 4 to 5ml of blood and discard.
- Flush the lumen with at least 20ml of normal saline.
- If functionality does not return, you can repeat this process x 1.
- If the PICC lumen remains occluded after 2 Cathflo doses, please contact our service. e time.
Definition: Unilateral arm swelling on the same side as the PICC could be indicative of a thrombus formation. A thrombus is a blood clot also known as a Deep Vein Thrombosis (DVT).
Solution:
- An observed unilateral arm swelling in the arm in which the PICC is placed. This type of asymmetry between the upper extremities may reflect DVT formation.
- Do not take blood pressure on swollen extremity.
- Raise the affected area to reduce swelling.
- Notify the medical team and recommend a Doppler ultrasound. If the Doppler ultrasound is positive for a DVT, the medical team may outline a treatment plan.
Definition: Vessel wall irritation with damage to endothelial cells. Symptoms associated with phlebitis may include edema, heat, and pain upon palpation.
Types of Phlebitis: Mechanical, chemical, and bacterial.
Solution:
- Apply warm compresses TID and PRN for 48 hours post placement. If discomfort continues after 48 hours, please contact our service for evaluation.
Pain / Discomfort in the Extremity
Definition: Pain can be experienced after PICC insertion. This could be associated with a difficult line placement causing an inflammatory response.
Solution:
- Apply warm compresses TID and PRN for 48 hours post placement. If discomfort continues after 48 hours, please contact our service for evaluation.
If electric-like sensations, numbness, or tingling is felt this could be suggestive of nerve stimulation.
Solution:
- Prompt catheter removal.
Definition: Where the tip of the catheter is no longer in the central vessel. All central lines (PICC is one of many central lines) must be placed in the central vessel. Most common cause of malposition is accidental pulling of catheter out of the central vessel. This can happen a multitude of ways. Any significant force on the catheter can dislodge or pull the catheter out of place. Besides direct pulling on the catheter, this can include vigorous arm movement, excessive coughing, mechanical ventilation, and vomiting.
External Signs of Catheter Malpositioning
- An increase in external length of the catheter outside of the insertion site.
- Inability to aspirate blood
Internal Signs of Catheter Malpositioning
- Migration of catheter tip to another anatomical site confirmed by chest x-ray
- Cardiac arrhythmias
- Pain or discomfort in the chest, neck, and back
- Gurgling or swishing sounds in the ear
Solution:
- Contact your provider or our team if you notice your PICC line is pulled out or malpositioned.
- A prompt order of a CXR needs to be done to see the location of the tip of the catheter. If the CXR shows that the tip is not in the correct location your provider will consult our team for further review and revision or replacement of the catheter.
Definition: When a PICC line removal is met with resistance. If a PICC is not retracting with ease during removal it could be related to a venous spasm, fibrin build up, an infectious process, or possible thrombus.
Solution:
- Please do not "pull" against resistance.
- Apply heat for 20 minutes and attempt again. Provide a slow steady continual retraction with removal.
- If unable to remove catheter, contact PICC Services for removal, possible venogram and fluoroscopy.
Significant Bleeding at the Insertion Site
Definition: Post insertion bleeding from a PICC placement is common. However, excessive bleeding can prompt continued PICC inspection and assessment. You may need further evaluation with your provider or with our PICC team to distinguish normal bleeding from excessive bleeding.
Symptoms
- Continuous bleeding at PICC insertion site
- Detachment of the occlusive transparent dressing secondary to excessive bleeding
- Hematoma expanding from entry site outward.
Solution:
- Contact your provider.
- Your provider will take a look at your most recent labs and may order new labs as needed.
- You may need to be evaluated to make sure no complications like accidentally puncture of an artery was not done. In addition, we may have to place a pressure dressing.
- Minimize any excessive body movements.
Catheter Related Blood Stream Infection (CRBSI)
Definition: A complication of catheter placement were a microbe (i.e. bacteria, fungus) grow from the catheter placement causing an infection.
Signs and symptoms of local PICC infection
- Limited infection at site of insertion
- Tenderness, erythema, and purulence at catheter-skin insertion site
Signs and symptoms of systemic PICC infection
- Positive blood cultures from PICC
- Persistent fevers
- Multi-organ involvement and failure
Solution:
- If signs and symptoms of local or systemic PICC infection are noted, contact the primary medical team immediately.
- Sterile dressing change and cap change should be performed regularly as indicated by your primary provider/team.
- Always make sure that prior to any accessing of your PICC line that the hub is cleaned with alcohol per policy.
Definition: Leakage of fluid from the PICC insertion site, external catheter itself, or the hub. This may be due to a thrombus or rupture or fracture of the catheter.
Solution:
- Stop all infusions.
- Identify the if the catheter is leaking/ballooning, clamp the catheter. If leaking is from insertion site, apply a sterile pressure dressing. Always contact your provider if any questions or concerns with catheter.
- Observe the arm for swelling/redness/pain. If yes to any contact your provider/team and Ultrasound of the arm may be needed to evaluate for a clot to the vein.
If the catheter breaks or is accidently cut...
Wash your hands, clamp the catheter and call your physician or home health nurse.
If the injection cap comes loose...
Wash your hands, clamp the catheter, remove the old cap, then clean the area with alcohol and place a new cap.
If the PICC site has redness, swelling, drainage, or tenderness, or you have a fever or other signs of infection...
Please contact your physician.
If there is fluid leaking at the insertion site...
Please contact your physician.
If the catheter is difficult to flush...
Please contact your physician or home health nurse.
If your PICC is accidentally pulled out...
DO NOT PANIC! Cover the site with gauze and apply pressure until all bleeding stops. Apply a bandage and call your doctor.
When in doubt...
Please contact your physician or home health nurse.
You may contact the UCLA PICC Office at 310-267-9793 if you have any questions or concerns. The hours of operation are Monday-Friday 8:00 am to 5:00 pm. You may leave a message and your call will be returned within the same day.