23.1 PICC Lines, Implanted Ports, Tunneled Catheters & Vascular Device Troubleshooting
Key Takeaways
Choose access by therapy, duration, vessel anatomy and patient risk. Confirm the tip before routine use. Avoid intracardiac neonatal PICC placement.
Paired blood cultures can identify a clinical catheter-related bloodstream infection. CDC/NHSN CLABSI surveillance uses separate event and line eligibility rules.
Suspected Candida line infection generally warrants prompt removal and systemic therapy. Balance source control and access with the treating team, especially in neutropenia or when alternative access is unavailable.
Check mechanical causes before treating a suspected lumen clot. Use labeled lumen-based or weight-based Cathflo dosing and avoid forceful flushing. Stop using a catheter with suspected pinch-off.
For suspected gas embolism, stop further air entry and give 100% oxygen for life-threatening events. For extravasation, stop the infusion, avoid flushing and use the agent-specific protocol.
Choose a vascular device by the child's anatomy, the therapy and its expected duration. When a device malfunctions, first decide whether the child has an emergency, such as infection, gas embolism or tamponade, or a problem limited to the catheter.
Device selection, insertion and tip confirmation
| Device | Practical use | Care considerations |
|---|---|---|
| PICC | Central access through an arm vein or, when appropriate, a lower-extremity vein. Useful for prolonged IV antibiotics or nonperipherally compatible infusions such as concentrated parenteral nutrition. | External hub and dressing need ongoing care. Match catheter size and lumens to vein size and therapy. |
| Tunneled cuffed catheter | Long-term, frequent access for therapies such as home parenteral nutrition. | The cuff helps secure the catheter. Plan removal with an appropriately trained team and follow the device-specific flushing and locking protocol. |
| Implanted port | Intermittent long-term treatment, such as chemotherapy. | Access the reservoir with a sterile noncoring needle. Follow the port's maintenance and flush instructions when deaccessed. |
| Nontunneled CVC | Short-term access for acute resuscitation, concurrent incompatible infusions or hemodynamic monitoring. Use a suitable dedicated catheter when dialysis is needed. | Review necessity daily and remove when safe alternative access is available or central access is no longer needed. |
Consider the drug or solution, concentration, osmolarity, vesicant risk, duration and local route policy. The ASPEN 900 mOsm/L recommendation concerns peripheral parenteral nutrition. Use drug-specific compatibility and administration guidance for other infusions. In shock, carefully monitored peripheral vasoactive therapy can begin while central access is arranged. Waiting for the central line can delay resuscitation. miniMAGIC · ASPEN parenteral nutrition guidance · 2026 pediatric sepsis guideline
Use ultrasound to assess vein patency and caliber and guide insertion when appropriate. Choose the smallest device and fewest lumens that meet the need. MiniMAGIC rated an outer catheter diameter to inner vein diameter ratio ≤45% appropriate for PICCs in its pediatric population. Consider a smaller device or larger suitable vein when the ratio is high. Neonatal intensive care patients and other specialized groups require their own access guidance. Use hand hygiene, maximal sterile barriers and age-appropriate skin antisepsis, then verify the guidewire is in the vein before dilation. During PICC insertion with a peel-away introducer, advance the catheter through the sheath without force. Document the external length after securing the line, and confirm the final tip. Use aseptic hub access and replace a loose, damp or visibly soiled dressing. Use the age- and device-specific dressing schedule. ASA central venous access guideline · SHEA acute-care prevention bundle · CDC NICU recommendations
For an upper-body PICC or standard infusion CVC, the distal SVC near the superior cavoatrial junction is a typical target. For a neonatal lower-extremity PICC, verify that the tip is in the IVC near the diaphragm and outside the heart according to the neonatal protocol. Neonatal PICCs should avoid intracardiac positioning. Targets differ for certain devices, such as dedicated dialysis catheters. Use a validated confirmation method appropriate to the line, such as radiography, ultrasound or intracavitary ECG, before routine use. Limb position can change a neonatal PICC tip location. Reassess migration if external length changes or new dysfunction develops. Sudden unexplained collapse in a neonate with a central line warrants stopping the infusion, urgent bedside evaluation for tamponade and preparation for emergency drainage if tamponade is found. AAP neonatal ultrasonography report · Infusion Nurses Society tip standards · UNC neonatal PICC protocol · Pediatric parenteral nutrition vascular-access guideline
Suspected catheter-related bloodstream infection
With fever, rigors during infusion or unexplained instability, obtain labeled paired catheter and peripheral blood cultures with comparable volumes at approximately the same time before antimicrobials when feasible. Avoid delaying treatment of shock. If peripheral collection is infeasible, sample at least two different lumens when available and interpret with the treating team. Paired growth of the same organism with the catheter sample turning positive at least two hours earlier supports clinical catheter-related bloodstream infection (CRBSI). Recovery of the same organism from a peripheral blood culture and a properly cultured removed tip is another criterion. Consider culture volume, prior antibiotics, organism and other sources when interpreting the result.
Central line-associated bloodstream infection (CLABSI) is also a CDC/NHSN surveillance term. Under the 2026 protocol, a laboratory-confirmed primary bloodstream infection with an eligible central line on the event date or the preceding day may meet CLABSI criteria. Line eligibility begins on central-line day 3. For a new count, day 1 is inpatient insertion or first inpatient access of a line present on admission. After replacement, restart the count if a full calendar day passed without a central line. For the surveillance denominator, count line-days from the first day the line is present according to the reporting protocol. Surveillance attribution does not require differential time to positivity or identification of the responsible line. IDSA catheter infection guideline · CDC/NHSN 2026 bloodstream infection protocol
| Clinical situation | Source-control decision |
|---|---|
| Shock from suspected line infection, tunnel or pocket infection, endocarditis, suppurative thrombophlebitis or persistent bloodstream infection | Arrange urgent source control and systemic treatment. With a retained line, repeat cultures and pursue removal if cultures remain positive at about 72 hours on active therapy, or earlier if clinical deterioration demands it. |
| CRBSI due to Candida, S. aureus, P. aeruginosa or mycobacteria | Prompt removal is generally indicated. For a child with no alternative access, urgently weigh the risks and plan source control with ID and vascular access specialists. In neonatal candidemia, removal is strongly recommended. In neutropenic candidemia, the GI tract may be the source and the decision is individualized. |
| Selected uncomplicated infection of a long-term line, such as susceptible coagulase-negative staphylococci in a stable patient with difficult access | After confirming true infection, discuss salvage with systemic therapy plus an organism-specific antibiotic lock if feasible and there is no tunnel or pocket infection. Use a compatible pharmacy-prepared lock and repeat cultures. Ethanol is not a routine CRBSI treatment. |
For a nonneutropenic child with an alternative access plan and Candida in both Broviac and peripheral cultures, rigors during flushing and earlier catheter growth favor a line source. Remove the catheter promptly when safe and treat candidemia systemically. Follow repeat cultures to document clearance. IDSA catheter infection recommendations · IDSA candidiasis recommendations · Differential positivity study in candidemia
Occlusion, device damage and gas embolism
- Check for a mechanical or chemical problem first. Inspect clamps, tubing, dressing and noncoring needle position. Review recent infusions for possible precipitation and consult pharmacy for a solution-specific plan. Never force a flush. Infusion without blood return can reflect a fibrin sheath or a tip against the vessel wall. Persistent dysfunction warrants vascular access evaluation. Limb or neck swelling raises concern for venous thrombosis and calls for imaging and a separate anticoagulation decision.
- Treat suspected intraluminal clot with a catheter-specific protocol. Cathflo alteplase is instilled at 1 mg/mL. The U.S. label specifies 2 mg in 2 mL at ≥30 kg, or 110% of internal lumen volume below 30 kg, capped at 2 mg in 2 mL. A child below 30 kg with a 0.50-mL lumen would receive 0.55 mL, or 0.55 mg. Check function after 30 minutes and again at 120 minutes if needed. A second dose may be used if the first fails at 120 minutes. Once patent, aspirate residual drug and clot before flushing according to the label and pediatric protocol. Review bleeding risk and possible line infection before use.
- Recognize pinch-off syndrome. A subclavian catheter can be compressed between the clavicle and first rib. Positional difficulty infusing or withdrawing blood plus focal narrowing at that site is a clue. Stop using the device and arrange prompt specialist removal because repeated compression can fracture it. If fracture or fragment embolization is suspected, obtain imaging and urgent interventional consultation.
- Recognize suspected gas embolism. Sudden hypoxemia, dyspnea, hypotension or a drop in end-tidal CO₂ after an open or damaged line raises concern. Stop further air entry by closing or clamping the line. Activate emergency response, give 100% oxygen for life-threatening gas embolism and support circulation. The 2025 AHA guidance supports supine or recovery positioning on a level surface and hyperbaric oxygen consultation for life-threatening pediatric events. Use standard CPR when needed.
- Prevent air entry during removal. Use the device-specific removal protocol. For relevant neck or chest lines, use supine positioning if tolerated and time withdrawal with a cooperative Valsalva or expiration according to protocol. Apply pressure and an air-occlusive dressing after removal and check that the catheter is intact.
Cathflo U.S. label · ASH/ISTH pediatric thrombosis guideline · Pinch-off clinical series · AHA 2025 gas embolism guidance · UC San Diego catheter removal protocol
Infiltration and extravasation
Infiltration is leakage of a nonvesicant into surrounding tissue. Extravasation of a vesicant can injure tissue. Stop the infusion immediately. Keep the access temporarily for gentle aspiration of residual drug when appropriate and avoid flushing. Assess perfusion and injury extent, elevate when appropriate, and notify pharmacy and the treating team. Rapidly worsening pain, ischemia, sensory changes or tense swelling requires urgent assessment for limb injury or compartment syndrome. Restore essential infusions through separate suitable access.
| Infusate | Targeted response |
|---|---|
| Dopamine or another adrenergic vasopressor | Blanching and cool skin suggest vasoconstriction. Use prompt local phentolamine per the pediatric protocol and a warm compress as indicated. A U.S. dopamine label gives phentolamine 0.1–0.2 mg/kg, maximum 10 mg, for local infiltration. |
| Selected hyperosmolar or irritant infusates | Review the exact agent and severity. A pediatric pathway may use hyaluronidase for a severe injury from a selected infusate. Contrast media extravasation has its own radiology protocol and does not routinely use hyaluronidase. |
| Vinca alkaloids | Contact oncology pharmacy promptly. Use the pediatric oncology protocol. Pediatric guidance includes hyaluronidase and warmth for vinca extravasation. |
| Anthracyclines | Contact oncology immediately for cooling and possible dexrazoxane. The U.S. extravasation label starts the first dose within six hours and repeats at about 24 and 48 hours. Remove cooling at least 15 minutes before infusion when dexrazoxane is used. Pediatric safety and effectiveness are unestablished in that label, so use the pediatric oncology protocol and specialist dosing. |
Dopamine U.S. label · Pediatric extravasation pathway · ACR contrast manual · Pediatric antineoplastic extravasation guideline · ONS/ASCO adult antineoplastic extravasation guideline · Totect U.S. label
A nonneutropenic 12-year-old receives home parenteral nutrition through a tunneled Broviac. He develops fever and rigors during flushing. Paired catheter and peripheral cultures drawn simultaneously with comparable volumes grow Candida albicans. The catheter culture signals positive 3.5 hours earlier. No other source is identified, and alternative vascular access is available. What is the best catheter management?
Retain the catheter and administer systemic fluconazole plus daily 70% ethanol lock therapy
Retain the catheter and administer an amphotericin B antifungal lock for 14 days
Observe on systemic micafungin and repeat paired blood cultures in 48 hours before deciding on removal
Remove the tunneled Broviac catheter promptly and treat with systemic antifungal therapy
A 3-year-old girl in septic shock is receiving a peripheral dopamine infusion while awaiting central venous access when the nurse notes a pale, cool, indurated 3-cm area of blanching around the dorsal hand IV hub. After immediately stopping the infusion and gently aspirating from the catheter hub, which targeted intervention is indicated?
Administer subcutaneous phentolamine infiltration around the blanched perimeter and apply a warm compress
Administer intravenous dexrazoxane within 6 hours and apply a cold compress
Inject subcutaneous hyaluronidase around the site and pack the hand in ice
Flush the peripheral IV with 10 mL of 0.9% normal saline to dilute the dopamine locally
A 9-year-old boy with acute lymphoblastic leukemia has a right subclavian implanted port that intermittently fails to aspirate blood or infuse unless he abducts and raises his right arm overhead. A chest radiograph demonstrates focal luminal scalloping of the catheter between the clavicle and the first rib. What is the underlying complication and required next step?
Fibrin sheath formation; instill alteplase 2 mg for 60 minutes and resume normal port access
Pinch-off syndrome; discontinue port use and arrange prompt catheter removal to prevent fracture and embolization
Venous gas embolism; begin 100% oxygen and obtain emergency resuscitation support.
Right atrial tip malposition; arrange repositioning of the catheter tip.
Sections you finish are checked off in the contents.