A PICC line — peripherally inserted central catheter — is a long, flexible catheter inserted through an upper arm vein and advanced until its tip rests in the superior vena cava. Once placed, the PICC belongs to the nurses who maintain it. Every shift, that means flushing each lumen to preserve patency, assessing the insertion site for early infection signs, confirming the external catheter length hasn’t changed, and managing any infusions safely. When dressing changes and blood draws are due, those require their own disciplined technique.
This guide covers day-to-day PICC care: the SASH flushing protocol, dressing change steps, blood draw technique, complication recognition, documentation, and patient education. For placement, tip verification, and device selection, see the PICC line nursing overview.
What ongoing PICC care involves
After a PICC is placed and tip position confirmed by chest X-ray, ongoing nursing responsibilities are the same whether the patient is in the ICU, a step-down unit, or home health: keep the lumen patent, keep the site clean and dry, and catch complications early.
The three core maintenance tasks are:
- Flushing — before and after every infusion, medication, and blood draw; at minimum once per shift for each lumen not in active use
- Site assessment — every shift, every dressing change: inspect, measure, document
- Dressing care — change the transparent dressing every seven days (or sooner if compromised); change gauze every 48 hours
The two clinical events that require specific technique are blood draws via PICC and dressing changes. Both are described step by step below.
The SASH flushing protocol
SASH is the mnemonic for flushing a heparin-locked PICC lumen:
- S — Saline (10 mL normal saline, push-pause technique, before use)
- A — Administer the medication or infusion
- S — Saline (10 mL normal saline, push-pause technique, after the medication)
- H — Heparin lock (typically 100 units/mL per facility policy)
For facilities that use a saline-only locking policy (no heparin), the H step is replaced by a final saline flush delivered with positive pressure on disconnection.
Push-pause technique
Every saline flush uses the push-pause (pulsatile) technique. Inject 1–2 mL, pause briefly, resume. Repeat until the full volume is delivered. The intermittent turbulence created by pulsatile delivery clears fibrin deposits from the lumen walls more effectively than a slow, continuous push. Never compress the plunger in one smooth stroke for a PICC flush.
Syringe size
Always use a 10 mL or larger syringe. Smaller syringes — 1 mL, 3 mL, 5 mL — generate pressure per milliliter of force that exceeds the rated burst pressure of the PICC catheter. A 1 mL syringe used to try to clear an occlusion is a safety violation, not a troubleshooting strategy. If resistance is present, stop. Do not increase force regardless of syringe size.
Flush volumes and frequency
| Situation | Flush volume | Notes |
|---|---|---|
| Before any infusion or medication (pre-use) | 10 mL NS — push-pause | Confirms patency before administering medication |
| After any infusion or medication (post-use) | 10 mL NS — push-pause | Clears medication residue from lumen; prevents precipitation if incompatible drugs follow |
| After blood draw via PICC | 20 mL NS — push-pause | Higher volume needed to clear residual blood and prevent fibrin formation |
| Idle lumen (not in active use) | 10 mL NS — push-pause, then heparin or NS lock per policy | Minimum once per shift; idle lumens that are never flushed will clot |
| Lock solution (heparin-lock policy) | Heparin 100 units/mL, volume per catheter dead space (per facility policy) | Instill after final saline flush; do not allow saline to flow before heparin is fully instilled |
Positive pressure on disconnection
When removing the flush syringe from a positive-displacement needleless connector, maintain gentle forward pressure on the plunger while withdrawing the syringe from the connector. This prevents blood from refluxing into the catheter tip — reflux is the initiating event for fibrin sheath formation and eventual thrombotic occlusion.
Scrub the hub
Before connecting any syringe or tubing to the needleless connector, scrub the hub for a minimum of 15 seconds with a chlorhexidine/isopropyl alcohol (CHG/IPA) swab. Allow to dry. Biofilm accumulates on connector surfaces between accesses; mechanical friction combined with the antimicrobial agent disrupts it. Touching the hub before or after scrubbing contaminate the access point — do not skip the dry time.
PICC dressing change
When to change
- Transparent semipermeable membrane (TSM) dressing with CHG disc: every 7 days, or immediately if wet, soiled, lifted, or no longer fully adherent at any edge
- Gauze-based dressing: every 48 hours; used when the site is actively oozing, the patient is diaphoretic, or when skin integrity prevents TSM adhesion
- Change either dressing type immediately at any sign of dressing compromise — a partially lifted edge is not a 7-day dressing
Supplies
Sterile gloves, face mask, dressing change kit (CHG/IPA swabs or applicator, CHG-impregnated disc such as Biopatch, transparent semipermeable membrane dressing, catheter stabilization device if due for replacement, date label, sterile gauze).
Step-by-step procedure
- Perform hand hygiene. Don mask and non-sterile gloves.
- Remove old dressing by peeling edges toward the insertion site — not away from it. Stabilize the external catheter with your non-dominant hand throughout removal to prevent accidental dislodgement or outward migration.
- Remove non-sterile gloves, perform hand hygiene, and don sterile gloves.
- Inspect the insertion site: look for erythema, swelling, warmth, induration, or discharge. Palpate gently over the site through the skin. Note any tenderness.
- Measure and record external catheter length. Compare to the baseline documented at insertion. A change of more than 2 cm indicates inward or outward migration and must be reported to the provider before proceeding. Do not use the PICC until tip position is re-verified.
- Cleanse the site with CHG/IPA. Apply using back-and-forth friction for 30 seconds, working from the insertion point outward in a circular pattern. Allow to dry fully — 30 to 60 seconds. CHG does not form its protective film until it is completely dry; premature dressing application eliminates the antimicrobial benefit.
- Apply CHG-impregnated disc (Biopatch or equivalent) directly over the insertion site with the CHG side facing the skin. If a disc was present during removal, replace it with a fresh one at every dressing change.
- Apply transparent dressing over the CHG disc and the external catheter. Smooth from center outward, eliminating air pockets. Ensure all edges are fully sealed — no lifted corners.
- Secure the catheter stabilization device (e.g., StatLock) under the transparent dressing if replacement is due. Never secure the catheter with tape across the catheter body — stabilization devices provide structured anchorage that resists in-and-out motion.
- Label the dressing with the date, time, and your initials.
- Perform hand hygiene. Document: date and time of change, site appearance, external catheter length compared to baseline, dressing type applied, CHG disc applied (yes/no), and patient tolerance.
Dressing type comparison
| Dressing type | Change frequency | Indications | Key limitation |
|---|---|---|---|
| Transparent semipermeable membrane (TSM) | Every 7 days, or sooner if compromised | Dry, intact skin; no active bleeding or oozing at site; standard first choice | Does not adhere well when site is moist or patient is diaphoretic; moisture trapped under TSM increases infection risk |
| Gauze with tape | Every 48 hours, or sooner if compromised | Active site bleeding or oozing; diaphoretic patient; TSM allergy or skin breakdown preventing adhesion | Blocks direct site visualization; more frequent changes required; less comfortable for long-term use |
| CHG-impregnated disc (Biopatch) | Replace at every dressing change | Placed under TSM or gauze at every change — not a standalone dressing | Must have CHG side facing skin; sustained antimicrobial coverage does not extend indefinitely — must be replaced |
Blood draw technique
Blood can be drawn from a PICC, but the technique differs from a standard peripheral draw. Follow these steps precisely to avoid sample contamination and lumen damage.
- Stop all infusions through the PICC for a minimum of 1–5 minutes before drawing. Some medications (particularly vasopressors, insulin, chemotherapy) require a longer hold time per facility policy. If the patient cannot safely tolerate stopping an infusion, draw from a peripheral site instead.
- Scrub the hub (15 seconds CHG/IPA, allow to dry) on the lumen to be used.
- Flush the lumen with 10 mL NS using push-pause technique to clear infusate residue.
- Discard 5–10 mL of blood (or per facility policy — some specify a volume equal to twice the catheter dead space). The discard volume clears medication residue, heparin from the lock solution, and stagnant blood from inside the lumen. Samples drawn without a discard will contain diluted, potentially contaminated blood that undermines lab accuracy.
- Draw the sample into the correct tubes in the required order per your facility’s tube order protocol.
- Flush the lumen with 20 mL NS immediately after the draw using push-pause technique. The post-draw flush volume is 20 mL — double the standard pre-use flush — because residual blood remaining in the catheter lumen after a draw forms fibrin and initiates thrombotic occlusion within hours.
- Re-lock the lumen with heparin or NS per facility policy using positive pressure technique on disconnection.
- Resume infusions. Document: time of draw, lumen used, any difficulty with blood return, discard volume used.
Labs that must NOT be drawn from a PICC
Do not draw coagulation studies (PT, aPTT, anti-Xa, anti-factor Xa, TEG, thromboelastography) from a heparin-locked PICC. Residual heparin from the lock solution contaminates the sample and produces falsely prolonged results, even after an adequate discard. Draw coagulation labs from a peripheral vein.
Complication recognition and response
CLABSI (catheter-related bloodstream infection)
CLABSI is the most serious preventable complication of PICC care. The majority of CLABSIs originate from skin organisms migrating along the catheter tract or introduced via hub contamination during access.
Signs: new fever (temperature above 38°C/100.4°F) or hypothermia, rigors, chills, tachycardia, hypotension — with no other identifiable infection source. The insertion site may show erythema, warmth, or purulent discharge, but site findings are absent in many CLABSIs (intraluminal source).
Nursing response: notify the provider immediately. Draw blood cultures — one set from the PICC and one set from a peripheral vein — before starting antibiotics. Anticipate catheter removal. Do not replace the catheter over a guidewire when CLABSI is suspected; this preserves the infected tract. For blood culture collection technique, see the blood culture collection guide.
Occlusion
| Occlusion type | Presentation | Cause | Management |
|---|---|---|---|
| Mechanical | Resistance to flush; catheter flushes freely when arm is repositioned or kink is released | Kinked external catheter; inadvertently closed clamp; PICC pinched between clavicle and first rib (pinch-off syndrome); positional occlusion from arm position | Inspect all external components; reposition the arm (raise overhead, lower to side, have patient open and close fist); if clears on repositioning, document and monitor. If pinch-off is suspected, obtain imaging and notify provider. |
| Thrombotic — fibrin sheath or clot | Cannot flush and/or cannot aspirate blood; or catheter flushes but will not draw (withdrawal occlusion — fibrin flap at tip acting as a one-way valve) | Blood stasis, inadequate flushing, failure to use positive pressure on disconnection; fibrin sheath forms around catheter tip over time | Do NOT force flush. Notify provider. Anticipate alteplase (Cathflo Activase) 2 mg instilled and dwelled 30–120 minutes; may repeat once. If still unresolved, catheter may require removal and replacement. |
| Precipitate | Sudden occlusion immediately after sequential infusion of two medications; catheter completely blocked, will not flush in any direction | Two incompatible medications infused sequentially without adequate flushing between them; chemical precipitate forms inside the lumen (e.g., calcium + phosphate; phenytoin in dextrose) | Do NOT force flush. Do NOT use alteplase — tPA treats clots, not chemical precipitates. Notify provider and pharmacy. Management involves identifying the incompatible agents and a specific solvent — this is a pharmacy decision. |
Upper extremity DVT
Signs: arm swelling, pain, warmth, erythema in the PICC arm; mid-upper arm circumference more than 2 cm greater than baseline measurement taken at insertion.
Nursing response: notify the provider. Do not remove the PICC without provider guidance — premature removal may dislodge a partially formed clot. Anticipate duplex ultrasound order. Anticoagulation may be initiated before or after removal depending on clot burden and clinical status.
Assessment: measure mid-upper arm circumference at PICC insertion and every shift. Document baseline measurement in the chart. An increase of more than 2 cm from baseline is a reportable clinical finding, not a normal variation.
Phlebitis
Signs: pain, erythema, warmth, and induration along the catheter tract or at the insertion site; a palpable venous cord may be present in severe cases. Phlebitis is graded on a 1–4 scale.
Nursing response: grade and document. Notify the provider for grade 3 or higher, for purulent drainage at any grade, or when fever accompanies local findings. Apply a warm moist compress for mechanical or chemical phlebitis. If bacterial phlebitis is suspected, treat as CLABSI until cultures exclude it.
Documentation requirements
Every PICC assessment and maintenance activity requires documentation. The minimum dataset per shift:
- Date and time of assessment
- External catheter length (cm) compared to the documented baseline
- Site appearance: intact skin, no erythema/swelling/warmth/drainage, or specific findings if present
- Dressing status: intact, no lifted edges, date last changed
- Lumen patency: flushed freely with no resistance; blood return present or absent
- Infusions running via PICC: drug, rate, lumen used
- Any blood draws performed: time, lumen, discard volume, any difficulty with blood return
- Any dressing changes: site findings, CHG disc applied, dressing type, external catheter length at time of change
- Any complications identified and provider notification
Patient education
Patients discharged with a PICC require thorough education before leaving the hospital. Cover every point below and document that teaching was completed.
Daily activities and restrictions
- No blood pressure measurements in the PICC arm — the cuff compresses the vessel and the catheter. Tell every nurse and phlebotomist before they approach the arm.
- No venipuncture or blood draws from the PICC arm — needlesticks near the catheter increase infection risk and can damage the vessel.
- Swimming is not permitted. Showering is permitted with a waterproof cover protecting the dressing site — do not get the dressing wet.
- Avoid heavy lifting, strenuous repetitive arm movements, or contact sports with the PICC arm. Normal light activity is allowed.
- Keep the external catheter secured against the arm. Do not allow the catheter to dangle or catch on clothing.
Dressing care at home
- Inspect the dressing every day. Call the home health nurse or PICC clinic immediately if:
- The dressing is wet, lifted at any edge, soiled, or no longer fully adhering
- The insertion site shows new redness, swelling, warmth, or discharge
- The dressing comes off entirely
Do not attempt to change the dressing without proper training. Do not use adhesive tape as a substitute for a proper dressing.
Signs to report immediately
- Fever above 38°C (100.4°F), chills, rigors — possible CLABSI
- Arm swelling, pain, or warmth, especially if the PICC arm appears visibly larger than the other arm — possible DVT
- Difficulty with infusion at home: infusion alarm, resistance, or leaking
- Any visible damage, cracking, or kinking in the external catheter
NCLEX high-yield points
These are the most commonly tested principles for PICC line care on NCLEX. Master each before exam day.
- Never force a flush against resistance. Stop, investigate (reposition, check for kinks, check clamps), notify the provider. Forced flushing can rupture the catheter or embolize a clot. This is a safety violation regardless of how much pressure you apply.
- SASH = Saline–Administer–Saline–Heparin. For NS-only locking policies, the H step is replaced by a final saline flush with positive pressure on disconnection.
- Flush volume after blood draw is 20 mL NS, not 10 mL. The extra volume clears residual blood that causes fibrin formation. This distinction appears directly in NCLEX questions.
- Always use a 10 mL or larger syringe. Smaller syringes generate pressure that exceeds the catheter’s rated burst limit. A 3 mL syringe used on a PICC is unsafe even if the nurse applies gentle force.
- Push-pause technique for every flush. The turbulence created by pulsatile delivery clears fibrin deposits more effectively than a continuous push. Slow continuous flushing is incorrect technique.
- Positive pressure on disconnection prevents blood reflux into the catheter tip. Blood reflux initiates fibrin formation and is the primary mechanism of thrombotic occlusion.
- Scrub the hub 15 seconds minimum before every access. Ten seconds is insufficient and appears as a distractor on NCLEX.
- TSM dressing changes every 7 days; gauze every 48 hours. Change either type immediately if wet, soiled, or compromised.
- Do not draw coagulation studies (PT, aPTT) from a heparin-locked PICC. Heparin contamination of the sample produces falsely prolonged results. Use a peripheral vein.
- Measure mid-upper arm circumference every shift in a PICC patient. An increase greater than 2 cm from baseline suggests catheter-associated DVT — report to the provider.
- Do not remove the PICC for suspected DVT without a provider order. Premature removal can dislodge a forming clot.
- Alteplase (Cathflo Activase) 2 mg treats thrombotic occlusion. It does not treat mechanical or precipitate occlusion. Identify the type before escalating to tPA.
- External catheter length change greater than 2 cm from baseline indicates catheter migration. Stop using the PICC and notify the provider for tip re-verification.
- CLABSI: blood cultures from PICC and peripheral site, before antibiotics, then notify provider. Do not start antibiotics before drawing cultures — culture yield drops significantly after even one antibiotic dose.
Related skills
PICC line care intersects with several clinical competencies covered elsewhere on the site:
- PICC line nursing overview — insertion, tip verification, device selection, power-injectable PICCs, and removal procedure
- Central line nursing — CVCs, tunneled catheters, implanted ports, CLABSI prevention bundle
- Central line dressing change — sterile dressing change procedure for CVCs and non-PICC central lines
- Infection control and isolation precautions — standard precautions, contact/droplet/airborne isolation, and the full CLABSI prevention framework
- Blood culture collection nursing — collection technique, bottle order, skin antisepsis, and contamination prevention
Clinical sources
- Gorski LA, et al. “Infusion Therapy Standards of Practice, 8th Edition.” Journal of Infusion Nursing. 2021;44(1S):S1–S224. (INS Standards — primary reference for flush volumes, dressing frequencies, and maintenance protocols)
- Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. 2011 (updated). Available at: https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html
- O’Grady NP, et al. “Guidelines for the Prevention of Intravascular Catheter-Related Infections.” Clinical Infectious Diseases. 2011;52(9):e162–e193.
- Bhatt M, et al. “Peripherally Inserted Central Catheters.” StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
- Hallam C, et al. “Use of chlorhexidine-impregnated dressings to prevent vascular and epidural catheter colonisation and infection.” Journal of Hospital Infection. 2016.
- Chopra V, et al. “The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).” Annals of Internal Medicine. 2015;163(6 Suppl):S1–S40.