PICC Line Care and Maintenance: Dressing Changes, Flushing, and Removal

Once a PICC is placed, maintenance is where infection prevention happens. Studies consistently show that CLABSI events are driven more by maintenance practice failures than by insertion technique failures. Every dressing change, every hub access, and every flush is an opportunity to either maintain sterility or introduce pathogens.

This guide covers INS 2021-compliant PICC maintenance protocols: dressing changes, flushing and locking, daily assessment, patient education, and safe removal.

Parent guide: PICC Lines: Complete Clinical Reference

Daily Assessment Requirements

Every nursing shift must include PICC assessment. Required documentation elements per INS 2021 (Standard 44: Assessment and Monitoring):

Site assessment:

Insertion site: erythema, swelling, tenderness, drainage (type, amount, color)
Dressing integrity: dry, occlusive, intact — or requires change
Securement device condition: intact, secure, not impeding circulation

Catheter assessment:

External catheter length (in cm from insertion site to first hub): compare to documented insertion length; document any change
Patency: flushed easily; blood return present or absent (document if absent)
Lumens used and functional

Necessity assessment:

Daily documentation that PICC is still clinically indicated: “PICC still required for [specific indication]”
Do not passively continue a PICC because it is present — every day requires active re-assessment

External length monitoring is the primary bedside tool for detecting catheter migration. If external length has decreased (catheter advanced in), tip may now be in RA — requires imaging. If external length increased (catheter withdrawn out), tip may be too proximal for central infusions.

Dressing Change Protocol

Frequency

Per INS 2021 Standard 40:

Gauze dressing: Change every 2 days (gauze dressings are not occlusive and require more frequent change)
TSM (transparent semi-permeable membrane) dressing: Change every 5–7 days or per institutional policy
CHG-impregnated dressing (gel patch): Change with TSM dressing change, or per product instructions (typically 7 days)
Any dressing: Change immediately if wet, soiled, loose, or non-intact

Most institutions use the TSM + CHG gel patch combination with a 7-day change interval as the standard protocol.

Equipment

Sterile gloves and non-sterile gloves
Mask for patient and clinician
CHG-impregnated gel patch (Biopatch equivalent or CHG-impregnated sponge)
TSM dressing (Tegaderm or equivalent, appropriate size to cover insertion site and leave catheter hub accessible)
Securement device (StatLock or equivalent)
CHG/alcohol antiseptic swabs (2% CHG/70% IPA, or per institutional supply)
Adhesive remover (non-alcohol-based if patient has sensitive skin)
Tape measure

Step-by-Step Dressing Change

1. Preparation:

Perform hand hygiene
Don non-sterile gloves
Apply mask; ask patient to turn face away from insertion site (or provide surgical mask to patient)
Position patient with arm extended, insertion site accessible

2. Old dressing removal:

Loosen edges of TSM dressing by lifting edges parallel to skin (horizontal stretch, not vertical peel — reduces MARSI risk)
Gently remove old CHG gel patch
Remove old securement device — note catheter external length before removal
Use adhesive remover as needed for stubborn adhesive
Inspect old dressing: note any discharge, odor, or sign of infection
Remove non-sterile gloves; perform hand hygiene; don sterile gloves

3. Site inspection:

Inspect insertion site for: erythema, swelling, tenderness, drainage, intact skin
Measure external catheter length
If signs of infection are present: notify provider before proceeding; do not complete dressing change until provider determines whether PICC should be removed

4. Skin antisepsis:

Apply CHG-based antiseptic (2% CHG/IPA) to insertion site and surrounding skin using back-and-forth friction for 30 seconds
Allow complete dry time before applying new dressing — CHG-alcohol requires full dry (approximately 30–60 seconds); do not fan or blot
Apply to an area at least as large as the new dressing will cover

5. New dressing application:

Place CHG gel patch (Biopatch equivalent) centered over insertion site, blue side down (toward skin per product instructions)
Apply new securement device (StatLock): thread catheter through securement device stabilizer; confirm catheter is secured without kinking
Apply TSM dressing, centered over insertion site and CHG gel patch; smooth from center outward to eliminate wrinkles
Ensure dressing edges are sealed; no tunneling under edges
Apply date, time, inserter initials to dressing label; apply to dressing edge (not over insertion site)

6. Documentation:

Old dressing appearance
Insertion site assessment findings
External catheter length measured and compared to insertion documentation
New dressing type applied
Antiseptic used; dry time confirmed
Patient tolerance

Flushing and Locking Protocol (SASH)

The SASH Protocol

SASH (Saline-Administer-Saline-Heparin) or SASSaline-only variant (SAS) is the standard PICC flushing protocol:

Before each use:

Flush with 10 mL normal saline using pulsatile (push-pause) technique

After each medication or infusion:

Flush with 10 mL normal saline using pulsatile technique

Lock between uses:

Saline flush (pulsatile), then heparin lock (10 units/mL) per institutional policy, OR
Saline-only lock (some institutions; confirm policy)
Apply positive pressure technique when ending flush: maintain thumb pressure on plunger as connector is clamped or disconnected

Pulsatile Flushing Technique

Continuous slow flushing does not clear the catheter lumen as effectively as pulsatile (turbulent) flushing. The push-pause technique:

Push 1–2 mL, pause 0.5 seconds, push 1–2 mL, pause — repeat for full flush volume
Creates oscillating turbulence in catheter lumen, reducing fibrin adherence

Scrub-the-Hub

Before every needleless connector access:

Scrub connector with 70% IPA pad using friction for minimum 15 seconds
Allow 15–30 seconds dry time before accessing
This step is non-negotiable — do not bypass it for urgency

Needle-Free Connector Management

Per INS 2021:

Change needleless connectors with tubing change (typically every 96 hours for continuous infusions) or per institutional policy
Do not change routinely before this interval without clinical indication (excessive changes increase manipulation and infection risk)
Replace immediately if blood is visible in connector, if damaged, or if integrity is compromised
Do not soak needleless connectors in antiseptic — this does not sterilize the internal pathway

Administration Set Management

Per INS 2021 Standard 37:

Continuous infusions (non-lipid, non-blood): Change administration set every 96 hours
Lipid-containing PN (3-in-1 admixture): Change every 24 hours
Lipid emulsion alone: Change every 12 hours
Blood and blood products: Change within 4 hours of transfusion completion; one set per unit
Intermittent infusions: Per institutional policy; typically single-use or 24-hour maximum

Label administration set with date and time of change.

Patient and Family Education

For patients being discharged with a PICC (home infusion, OPAT, home TPN), education must cover:

What to observe (emergency signs):

Fever >38°C (100.4°F) — call provider immediately
Shaking chills during infusion — call immediately
Redness, swelling, warmth, pain, or drainage at insertion site
Arm swelling (possible DVT)
Shortness of breath or chest pain (rare PICC-associated complication)
Dressing loosening, getting wet, or showing blood under dressing

Daily self-care:

Keep dressing dry: cover arm during shower (waterproof sleeve or wrap)
Do not submerge arm in bathtub, pool, or any water
Check dressing daily; call provider if loose, wet, or soiled before scheduled change date
Document PICC external length and call if catheter appears to have moved

Activity restrictions:

Avoid heavy lifting with the PICC arm (>10 lbs)
Avoid repetitive arm motion that could dislodge or kink catheter
Swimming is contraindicated with an external PICC
Most other normal daily activities are permitted

When to go to the emergency room:

Signs of air embolism (sudden chest pain, dyspnea, altered consciousness) — especially during dressing change or at any time PICC hub is exposed to air
Catheter appears to be broken, cracked, or leaking
Entire catheter appears to have come out

PICC Removal Protocol

Indications for Removal

Therapy complete
PICC no longer clinically indicated (daily necessity review)
Complication requiring removal (CLABSI, UEDVT when removing, phlebitis grade ≥2)
Scheduled replacement (device failure, malposition)
Patient discharge from service where PICC can no longer be maintained

Air Embolism Prevention During Removal

Air embolism is a specific risk during PICC removal if air enters the catheter track while the patient is upright or breathing deeply. Prevention:

Position patient supine or Trendelenburg (head down) — elevates venous pressure at the insertion site, reducing air entry risk
Ask patient to perform Valsalva maneuver (bear down, hold breath, or hum) during the moment of catheter removal — increases intrathoracic venous pressure
Alternatively: instruct patient to exhale and hold breath at the moment of withdrawal
Avoid removal during patient inspiration

Removal Procedure

Gather supplies: gloves, gauze, TSM or occlusive dressing, adhesive remover
Perform hand hygiene; don gloves
Position patient supine; explain Valsalva instruction
Remove securement device and dressing; expose full external catheter length
Withdraw catheter smoothly in one continuous motion — do not jerk or pull rapidly
At the moment of catheter tip exiting the skin: patient performs Valsalva (or exhales and holds)
Immediately apply firm pressure with gauze at insertion site
Hold pressure for ≥30 seconds (longer if on anticoagulation)
Apply occlusive dressing (TSM or petroleum gauze equivalent) to insertion site — maintain for at least 30–60 minutes to allow fibrin track to seal
Inspect catheter: Measure entire removed catheter length against documented insertion length (should match); confirm catheter is intact with no visible break, fraying, or missing segment

Post-Removal Documentation

Date and time of removal
Reason for removal
Catheter length on removal (matches insertion length: yes/no)
Catheter integrity: intact
Site appearance at removal
Dressing applied
Patient tolerance
Any difficulty during removal (resistance, etc.)

Troubleshooting: Difficult Removal

If catheter does not withdraw smoothly:

Do not force. Resistance can indicate catheter kinking, fibrin sheath, or catheter adherence to the vein wall.
Apply warm compress to the arm for 15–20 minutes; reattempt withdrawal gently
Reposition arm (abduction, extension, rotation) before reattempting
If catheter remains firmly fixed after warm compress and repositioning: notify provider; do not continue attempts; arrange fluoroscopic-assisted removal via interventional radiology

Never cut a PICC catheter — this risks catheter embolism. If catheter is damaged or cannot be withdrawn, escalate immediately.

Related guides:

Related policies:

Patient education:

Living with a PICC Line: Home Care Guide

References

Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standards 34–45). J Infus Nurs, 44(Suppl 1).
O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
Buetti N, et al. (2022). Strategies to prevent CLABSI in acute care hospitals: 2022 update. Infect Control Hosp Epidemiol, 43(5):553–569.
Moureau NL & Trick N. (2012). Evidence-based assessment and care of CVAD patients. J Infus Nurs, 35(3).
Hallam C, et al. (2016). Developing the evidence base for PICC maintenance. Br J Nurs, 25(Sup8):S4–S12.