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PICC Complication
Management
Velindre Cancer Centre
A guide for healthcare professionals in the care and management of
PICC-related complications bases on presenting symptoms.
Meinir Hughes IV Access Specialist Nurse
Updated Jan 2107
Reference will be provided at the end of the document for
ease of use
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Complication management
Index
Page
3
Unable to obtain a blood sample from a PICC
Administration of bolus urokinase into a PICC without a blood return
4
Bleeding at the exit site
5
6
Signs of dressing allergy
7
Redness, swelling or pain of the arm above the PICC
8
Thrombosis assessment form
Unable to flush a PICC – complete occlusion
9
Administration of bolus urokinase into a blocked PICC using 3 way tap
10
Migrated PICC
12
Leaking PICC
13
Pain in the chest neck or shoulder
14
Signs of exit site infection
15
Stuck PICC – unable to remove the PICC
16
Complete migration of a severed PICC
17
Patient with signs of systemic infection – catheter-related blood stream inf
18
References
19
PICC Complication Management May 2016
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Unable to obtain a blood
sample from a PICC
Flush the PICC with 5-10 mls of
N. Saline 0.9% using a positive
pressure technique
Still no blood return: Ask pt to take deep
breaths. Change the patients position, lie
patient flat or sit up/ask to lie on their side.
Still no blood return: Remove the dressing and check
for any signs of catheter kinking. Change the needlefree connector. Carefully remove the upper portion
of the securacath to separate the two portions and
observe for kinks. Replace the upper portion of the
securacath and attempt to withdraw blood.
Still no blood return: Chest X-ray to determine tip location of the catheter.
Nb: If no X-ray facilities available i.e outreach/out of hrs, proceed with urokinase.
If the catheter tip is in the correct
location administer a bolus dose of
urokinase 10,000 units - follow
instructions page 4. Repeat
urokinase if unsuccessful.
If catheter tip is NOT in the correct location, DO NOT
use and contact PICC placer/ANP/Dr.
If no blood return after 3 x doses of
urokinase, consult PICC placer/ANP.
Consider lineogram to determine
prescence of a fibrin sheath
PICC Complication Management May 2016
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Administration of bolus Urokinase into a PICC without a blood return
You do NOT need to use a 3 way tap for the bolus administration of urokinase when there is only a
partial occlution – i.e unable to get a blood return but can flush.
Equipment required: Procedure incorporating ANTT
Plastic tray
Non-sterile gloves
1 x 10ml syringe
Blunt needle
Urokinase 10,000units - Urokinase can be given by a named individual using a Patient Group
Direction
I x 5ml vial diluents (water or saline – see urokinase data (box))
2 x green clinell wipe
Needle free connector
Procedure:
1. Wash hands.
2. Clean the tray with clinell antiseptic wipes and leave to dry.
3. Place unopened equipment into the tray: syringe, blunt needle, urokinase vial, non-sterile
gloves, diluents vial, needle-free connector and 2 x clinell wipes.
4. Put on non-sterile gloves.
5. Remove the cap from the urokinase vial and clean the bung with the clinell. Make sure to use a
part of the clinell not touched by the gloves.
6. Open the syringe & needle taking care not to contaminate key parts and draw up 1.5ml of the
diluent.
7. Reconstitute the Urokinase with 1.5ml of diluent. Draw up 1.5ml of Urokinase solution into
syringe.
8. Place the syringe filled with urokinase back into the syringe packaging or place a red end on the
tip of the syringe to protect the key part.
9. Remove the needle free connector from end of the PICC, clean the very end of the PICC with a
clinell – clean with a part of the clinell you have not touched – leave to dry.
10. Attach the syringe containing the Urokinase to the line and infuse 0.5ml into the PICC at 10
minute intervals until all 1.5mls administered. Label the line to inform that there is a urokinase
lock in situ.
11. Apply a new needle free connector to end of PICC and leave the Urokinase insitu for one hour
12. Withdraw the Urokinase lock. If blood withdrawal is possible flush with 15-20 mls of saline.
13. If the procedure is unsuccessful on the first attempt, flush the catheter and then repeat the
procedure again without delay – it is safe to flush the PICC after 1hr.
PICC Complication Management May 2016
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Bleeding at the exit site
of a PICC
A biopatch soiled with blood must
ALWAYS be changed.
Has the bleeding occurred previously
or is the bleeding significant?
Yes
Re- dress the PICC, cleanse
the site with chloraprepp and
place gauze at the exit site under AND above the
securacath! If there is a
biopatch at the site you may
need to consider removing it
and placing a gauze dressing
until bleeding has resolved.




No
Re-dress the PICC. Cleanse with
chlorhexidine.
Assess the patient for symptoms of thrombosis:
Swelling of the arm, neck or shoulder;
Discolouration of the arm
Swollen veins in the neck or upper arm
Pain in the arm or shoulder
If symptoms are
present, follow the
algorithm for
Thrombosis:
Page 7
If symptoms are not
present, ensure that
patient has a follow up
appointment for a
review.
PICC Complication Management May 2016
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Redness and tenderness or
blistering beneath the PICC
dressing:
Allergy to dressing
Are the symptoms severe
with redness + + open
wounds or blistering?
Yes
No
Apply cavilon beneath
all the dressing.
Review patient in 2-4
days.
Apply a Duoderm dressing
beneath
the PICC. DO NOT use cavilon
and duoderm! Refer to guidelines:
PICC care and management.
Has the allergy
improved?
Symptoms are
much worse –
blistering etc
No
Yes
Review patient in 2-4 days to
assess and consider
prescribing piriton if
experiencing severe itching.
Is there an
improvement when
patient is reviewed?
No
If slightly worse, change
the dressing to a
different one: IV 3000/
hydrofilm/Mepitel
dressing. DO NOT USE
CAVILON. Review in 2-4
days
Yes
Dress with biotain or mefix – both
dressings must be removed before IV
therapy to examine PICC site. If allergy
remains and securacath present, cover
loosely with gauze and bandage.
Continue to apply
cavilon beneath all the
dressing. Review in 2-4
days.
Re-dress using duoderm and
assess patient every 4-5 days. If
symptoms clear up, attempt to
dress without duoderm with a
different dressing from the
original.
If allergy persists – remove the line.
PICC Complication Management May 2016
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The patient has a swollen, inflamed,
red or painful arm, hand or neck:
Consider Thrombosis.
Asses the patient for the following
symptoms:
 Bleeding at exit site
 Discolouration of the arm
(cyanosis/redness)
 Pain in arm shoulder or neck
 Protruding veins in the chest,
arm or neck
 Difficulty moving the arm
You will need to do the following:



Chest X-ray to verify tip
placement
Doppler Ultrasound
If Doppler US not available and
symptoms are significant – give
LMWH whilst awaiting Doppler
Contact an appropriate
practitioner: IV Access Nurse;
ANP or PICC placer





Positive result:
Complete thrombosis assessment form.
Page 8
Review X-ray result for tip tocation and
verify that PICC is functioning – flushing
and blood withdrawal present.
Take bloods: Fbc; Rlb; Coag screen
Prescribe anticoagulant therapy – currently
low molecular weight heparin
Make an appointment for re-assessment
according to thrombosis assessment form.
 If the patient is on LMWH when
thrombosis is diagnosed, registrar to
review case with Haematologist.
Yes if:
 The PICC is not in the correct
position on X-ray
 There is evidence of
severe/extensive thrombosis i.e
peripheral vein; axilla and
subclavian.
 Symptoms do not improve or get
worse after 24-48 hrs
 Symptoms of infection are present.
However, medical guidance will be
required.
It is recommended that removal takes
place after 48hrs of anticoagulation.

As a general rule, the PICC can be used
when there is a DVT present unless the
patient condition determines otherwise.
Should the PICC be
removed?
No if:
Symptoms are mild or improve when re-assessed
The Doppler shows less extensive thrombosis.
This has to correspond with the PICC tip being in
correct location and the PICC is functioning i.e
giving blood and flushing.
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PICC-related Thrombosis assessment form: Suspected or diagnosed UEDVT
Name of patient: ……………………………… Hospital Number: …………………………… Date: .....................
Assess each patient’s symptoms: A. On presentation – day 1 B. Day 3 C. Day 6 D. Day 10
Perform PICC X-ray. Is the tip of the PICC correctly positioned in lower SVC?: yes 
Is the catheter functioning: Patent to flushing and blood withdrawal present?:
no 
yes  no 
Blood samples taken: Fbc:  Coag screen:  Renal and liver profile: 
Treatment given: ………………………………………………………………………………...
Symptoms Present (please circle)
a. Pain in: neck, arm or shoulder
0
1
2
no
pain
mild
pain
moderate
pain
1
No
swelling
minimal
swelling
 no
3
b. Swelling of: the neck, arm or
shoulder
0
 yes
severe
pain
 yes
 no
State yes or no
e. Limb discolouration
State yes or no
f. Headaches
State yes or no
g. Poor movement of the arm
 yes
100%
movement
75%
movement
50%
movement
If swelling of the arm exists please
measure at each assessment date.
Please state measurement from the exit
site to area of swelling: ………… cms
……..
Score
……....
Score
……...
Score
……..
Score
Score
Score
Score
Score
Score
Score
Score
Score
……cm
……cm
……cm
…….cm
extensive
swelling
d. Bleeding at the exit site
2
Date
3
State yes or no
1
Date
very
severe
c. Dilated collateral veins
0
Date
4
2
significant
swelling
Date
 no
3
< 25%
movement
Measurement of
arm circumference
at measuring site:
Signature:
PICC Complication Management May 2016
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Unable to flush a
PICC
Change end connector. Remove the dressing - check for any external kinks or any
damage to the line. Carefully remove the PICC from the securacath and manipulate
gently between finger and thumb. Ask pt to change position.
Attempt to flush but do
not use excessive
force
Yes: Use the
PICC
Can you flush the line?
Use the 3 way tap method to infuse
10,000 units (re-constituted as
instructed) into the PICC. See
instructions page 10.
There is NO need to X-ray the PICC
at this stage unless symptoms of
migration are present.
Are you able to
withdraw blood from the
PICC and flush it?
Yes
Use the PICC
Probable cause is
blood within the
lumen of the line.
No
X-ray to determine tip location.
Repeat the infusion of Urokinase
using the 3 way tap a further 2
times if required.
Are you able to
withdraw blood from the
PICC and flush it?
No
Determine probable
cause of the occlusion.
Has TPN been
infusing or has there
been a drug
incompatibility leading
to precipitate? If Yes:
Contact pharmacy
for advice.
No
Seek advice from
PICC placer or
ANP
PICC Complication Management May 2016
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Administration of bolus urokinase into a blocked PICC using a 3 way tap
Equipment required
Plastic tray
Pair of non-sterile gloves
2 x luer lock 10ml syringes
Blunt needle
3 way tap
Urokinase 10,000units - Urokinase can be given by a named individual using a Patient Group
Direction
1 x 5mls vial of diluents (saline or water) (usually written on the urokinase box)
Green clinell wipe x 2
Needle free connector
Sharps bin
Procedure: Using ANTT principles:
1. Wash hands.
2. Check Urokinase details in usual way, e.g., Name; Dose; Expiry Date; Route of administration.
3. Clean plastic tray with clinell antiseptic wipes and leave to dry.
4. Place unopened equipment into the tray: 2 x syringes, blunt needle, 3 way tap, urokinase vial,
non-sterile gloves, diluent and 2 x clinell.
5. Put on non-sterile gloves.
6. Remove the cap from the urokinase vial and clean the bung with the clinell. Make sure to use a
part of the clinell not touched by the gloves.
7. Open one syringe and the blunt needle and draw up 1.5mls of the diluents.
8. Reconstitute the Urokinase with 1.5mls of diluent. Draw up 1.5mls of Urokinase solution into
syringe.
9. Open the 3 way tap and carefully prime with the Urokinase solution.
10. Make sure to protect all the key parts of the 3 way tap prior to placing back on the tray.
11. Remove the needle free connector from end of the PICC, clean the very end of the PICC with a
clinell – clean with a part of the clinell you have not touched. Attach 3-way tap to the end of the
lumen.
12. Close the 3 way tap to the patient: attach the syringe containing the urokinase onto the three
way tap at 3 o’clock and an empty syringe onto 6 o’clock (see picture – next page)
PICC Complication Management May 2016
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13. Turn the tap OFF to the Urokinase syringe (3 o’clock – picture below left), pull back on the
empty syringe (6 o’clock) to create vacuum in catheter to approximately 8-9mls and hold the
plunger at aprox 8mls whilst at the same time slowly turning the closed position onto the
empty syringe (picture below right). Stop turning once you see a small amount of Urokinase
enter the PICC.
14. Repeat the procedure from point number 12 another 3 times every 5 minutes until all the
urokinase has been infused. Occasionally, urokinase will leak into the empty syringe – when
this happens turn the 3 way tap off to the patient to infuse the urokinase into the original syringe
and perform the procedure again from point 12.
15. Apply a new needle free connector to the end of PICC and leave the Urokinase insitu for one
hour.
16. After one hour, attempt to withdraw the Urokinase lock and establish a blood return. If blood
withdrawal is possible flush with 15-20 mls of saline. If blood return is not present, flush the PICC
with 10mls of Normal Saline 0.9% and attempt to establish a blood return again – this is safe to do
after one hour.
17. If no blood return present repeat the whole process without delay – this can be done up to another
2 times. It is recommended although NOT necessary (i.e if this occurs when X-ray is closed) to
perform a chest X-ray after the first attempt fails.
18. Decontaminate tray and dispose of equipment according to hospital procedure, and document
clearly in patient’s notes.
PICC Complication Management May 2016
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Moved PICC – PICC looks longer or
shorter at the external portion.
Measure the external part of
the PICC.
Compare the external measurement with
original one at placement - in the notes or
on Canisc. Ensure that there have not
been any other alterations i.e previous
movement.
Yes
Chest X-ray to review
tip location
Is the PICC longer or
shorter than the
original measurement
at placement?
No.
Use the
PICC
Tip of the PICC in the
right atrium
Carefully remove the PICC
from the securacath and
withdraw the PICC to the
desired length.
The tip of the line is
within the SVC
Use the PICC as normal.
The tip of the PICC is
out of the SVC – in the
brachiocephalic,
subclavian, axillary or
peripheral vein.
The tip of the PICC is
in upper SVC or just
tipping into SVC
DO NOT USE LINE: Refer to
PICC placer to consider
exchange over a wire if no signs
of thrombosis or infection.
PICC can stay in situ for 2 or 3
days awaiting this procedure.
Assess need for the PICC. If last
treatment – use the PICC and remove.
If for further treatments refer to PICC
placer to consider exchange over a
wire if no signs of infection. PICC
PICC Complication Management May 2016
can stay in
situ for 2 or 3 days awaiting
procedure.
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Leaking at the site of the PICC
or a leak from a split in the
PICC
If the PICC is leaking from the exit site or
from a split in the line, DO NOT use the
PICC.
If the PICC is no longer
required for therapy, remove
the PICC. Keep the PICC for
the IV Access Specialist to
examine.
If the PICC is still required,
refer to a PICC placer or
ANP. PICC replacement
will be necessary.
PICC Complication Management May 2016
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Pain in the shoulder,
neck or chest
Consider
Migration of the tip
of the catheter into
a location other
than the SVC
Extravasation
Damaged PICC
Examine arm and chest
for signs of extravasation
Flush the PICC
with Saline and
observe for any
symptoms
Thrombosis
Review patient for
other symptoms of
thrombosis.
See page: 7
Ensure PICC is giving a blood
sample.
If in doubt request
lineogram
Request chest X-ray to
determine tip position.
PICC Complication Management May 2016
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Redness or pain at the exit site of the
PICC
Is the redness associated with
swelling or exudate at the site?
Yes
Collect swab from site.
Please make sure all relevant
information and diagnosis is
clearly written on the form.
No
Consider early
signs of infection
Evaluate symptoms. If there is redness, exudate,
swelling or pain at the exit site within 2 cm of exit
site – treat as infection. Also: Consider reaction to
the securacth:
Treat as exit site infection
Cleanse the site with chlorhexidine
in alcohol and allow to dry for 2
mins. Prescribe oral anti biotics.
If symptoms are fairly significant,
consider removal of the PICC.
Send tip for C&S. Prior to removal,
cleanse the exit site thoroughly in
order to prevent contamination of
the tip as it passes through the skin.
–.
Is there clear straw colour
watery exudate without
redness, pyrexia?
Consider lymph drainage
Cleanse the exit site with
chlorhexidine 2% in
alcohol and leave to dry
Advise patient to report
any exacerbation of the
redness or any other
symptoms: pain,
swelling or exudate
Assess for symptoms of systemic
infection:
Rigors and pyrexia or general deteoriation.
If present – follow guidelines for suspected
systemic infection promptly. See page 18.
NB: Biopatches are not to be used as
treatment of infections once diagnosed.
PICC Complication Management May 2016
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Stuck PICC. Unable to remove a PICC
NEVER forcefully remove a PICC.
Place a dressing securely over the PICC and
X-ray the patient: Request a chest, arm and
shoulder X-ray.
Observe the X-ray closely
for any knots in the line.
No Knots.
Apply heat along the length of the
vein for 10 mins then attempt to
remove. If still no success:
A Knot is visable
on X-ray
No
success
No risks: Is it within normal working hrs; is there a
radiologist on site?
Refer to
interventional
radiologist in the
nearest teaching
hospital
Assess the patient for any risks
associated with a stuck PICC. If no risk,
patient can be discharged and to attend
VCC for another attempt in 1-3 days.
Still no success.
If risks
Yes
No success
With a radiologist present, attempt to place a wire into
the PICC under fluoroscopy and attempt to remove
the PICC – great care must be taken when using a
wire and ONLY experienced practitioner such as a
Doctor, ANP or PICC placer should attempt.
Clamp the external part of the
line which has been cut !!
Replace the securacath! Refer
to vascular surgeon.
Refer to vascular surgeons in the nearest
teaching hospital. Remove both parts of the
securacath! (This is to ensure that the Surgeons
don’t have this as an obstacle).
PICC Complication Management May 2016
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Complete migration of a severed
portion of a PICC into the venous
system
Is the patient at home and there is clear
indication that the PICC has completely
migrated (you may ask the patient to take a
picture and email to VCC to establish for
certain)
Yes; patient is at home and there is clear
indication that a portion of the PICC has
completely migrated:
 Advise patient to lay flat.
 Assess patients condition: If
difficulty breathing or other acute
symptoms, 999 ambulance to be
On admission to the unit
contacted
to attend local acute
Establish that there is no
hospital
external part of the PICC that
 If asymptomatic,
advise pt to lie flat
can be located
and arrange for direct referral to an
interventional radiologist or surgeon
in patients local acute hospital.
No: Patient is in Velindre:
 Lie patient flat
 Monitor patient closely
 Record observations, NEWS
 Contact IV Access specialist
bleep 157 or ANP
 Assess patient’s condition: If
difficulty breathing or other acute
symptoms, give oxygen and dial
999 ambulance. Place patient in
steep left lateral position if it is
suspected that PICC is
obstructing the pulmonary valve.
If patient asymptomatic; On call Medical
Registrar to refer to the Vascular suite
in the X-ray department at UHW If out
of hours patient will need to be
admitted under the care of the surgical
team.
Contact the Vascular room to request
that all parts of the PICC (external and
internal) are saved to send for analysis
PICC Complication Management May 2016
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Patient presenting with symptoms of systemic infection and has a CVC (Central
Venous Catheter) in situ. Please use along with full guidelines on the intranet.
Yes
Follow the neutropenic
sepsis policy
Yes
Yes
Is the patient pyrexial?
Is the patient neutropenic?
Is or has the patient been
experiencing rigors
associated with flushing of
the line on admission or at
home?
Highly suspicious of a CVC related infection. Inform
Registrar/Consultant and observe patient closely.
No
No
Is or has the patient been
experiencing rigors
associated with flushing of
the line on admission or at
home?
No
No
Take blood cultures from CVC and
peripheral vein. Observe patient for
symptoms of infection
Check observations ½ hourly; observe for signs of septic shock.
Observe urinary output closely – start a fluid balance chart
Blood sampling:
 Fbc, Emergency U + E
 Blood cultures - from BOTH CVC (all lumens) AND peripheral vein. When taking blood
cultures from a CVC, take separate samples from each lumen and do not discard the first
blood. If there is a high suspicion of line infection i.e significant history of rigors post flush and
or patient unwell – take blood cultures from the line BUT DON’T flush but remove the line!
CVC to be left in
situ
Assess the criteria for immediate
removal – see section 3 of CVC
infection guidelines
Give broad spectrum antibiotics through the line.
(according to neutropenic sepsis policy)
IV ANTIBIOTICS MUST BE GIVEN AS SOON AS POSSIBLE
Continue to monitor patient closely.
If blood culture is positive,
seek microbiology advice
(see table 1) Line may
need to be removed.
CVC to be removed
Treat with antibiotics peripherally.
According to neutropenic sepsis
policy if neutropenic or seek
microbiology advice
If the CVC is to remain in situ, treat with antibiotics according
to organism specific guidelines and seek microbiology advice
(see table 2) If the patient continues to have signs of infection
after 48hrs or is deteriorating clinically– remove the line.
Send line tip to microbiology for culture & inform
infection control nurse
PICC Complication Management May 2016
Page 19 of 19
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indwelling central venous catheters. Lancet 374 (9684) 159
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O’Grady et al. (2011). Guidelines for the prevention of intravascular catheter-related infection.
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Pettit J. (2007) Technological advances for PICC placement and management. Advances in
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RCN (2003/Nov 2005) Standards for infusion therapy
Richardson D, Bruso P (1993) Vascular access devices – management of common
complications. Journal of Intravenous Nursing 16 (1) 44-49.
Rowley S. (2009) Improving standards of aseptic practice through an ANTT trust wide
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(1) sup18-23
Savage K, et al (1999) Outpatient use of low molecular wright heparin (Dalteparin) for the
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Simcock. L. (2001) Managing occlusions in central venous catheters. 197 (21) 36
The Royal Marsden Hospital (1993) Care of patients with central venous lines. Manual of
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Todd J (Feb 1998) Peripherally inserted catheters. Professional Nurse. 13 (5).
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.
PICC Complication Management May 2016