Difficulty removing PICC line

[aging1]

I tried to remove a PICC line today that had been in for 6 months, site looks good, no issues with it. (I'm an infusion nurse but not recently). It pulled about halfway out with gentle intermittent traction, then stopped. I massaged the arm above, pulled again (gently) and something "gave", the pt felt something in his axilla, and it pulled maybe another inch, but then just stretched and retracted. Tried pausing for possible vasospasm, but no more give.

I didn't want to pull any harder, obviously, and risk breaking it. Never had this experience before - anyone? I cleaned the area with CHG and coiled most of it under a transparent dressing; I'm sending him for an xray tomorrow.

Any thoughts? I wonder if it migrated around a corner in the wrong direction. Could vasospasm cause complete lack of movement, or just resistance?

I greatly appreciate the expertise and helpful spirit of this site - thanks!

[iluvivt, BSN, RN]

You could have tried a few things in this situation. I would like to know which vein it was accessed from and if it was on the right or left side and did the patient have any history of chest surgery,have any rhythm devices (is the PICC on the same side) or any body habitus issues that may interfere with an easy removal. The Cephalic vein has a pathway that is not as direct as the Basilic and Brachial and may be tortuous. A PICC from the left side also often takes a very sharp turn into the SVC and malpositions are more common from the left side. A rhythm device or other VAD may interfere with the PICC advancing during insertion or may impede removal. Yes, venous spasm can be incredibly strong and can prevent removal and advancement during insertion. During PICC insertion you literally can tug on the PICC in the grip of a venous spasm and feel how strong it is and I would not believe it unless I had experienced it myself.

Place the patient in correct anatomical position as much as they physically do this and with their shoulders to the bed or surface. Have the patient then pull their arm out away from their body (abduct) at a 90 degree angle and then gently pull the PICC out using a hand over hand technique. You are just trying to straighten out the venous pathway that the PICC takes en route to the SVC. If the right angle arm positioning does not do the trick you can position the arm higher and higher with the shoulder joint rotated inward. Both of these tricks are used during insertion to advance a PICC into the Axillary vein during insertion.

Traction is no longer recommended as a technique to remove a resistant PICC. If repositioning the patient does not work then apply warm compress,keep the patient calm and try after 15 min of warmth application. I have seen Nitroglycerin paste recommended as an option as well but then you have to deal with the potential side effects of that and I have always been able to get a stuck PICC out with nursing interventions and I have had a it happen many times. There are some more adavnced techniques that an IV nurse can perform but I will not go into those.

If after heat and patient position changes you are still unsuccessful you do exactly what you did. You resecure it and call for an IV nurse or call the MD as they can look at it under fluoroscopy,insert a wire,inject some dye..all kinds of things to check on it and remove it. You absolutely do not want to fracture it and have it embolize. I have seen that happen as well and that can be very dangerous and even fatal especially in the neonate and pediatric populations. You did good!!!

[IVRUS, BSN, RN]

As Iluvivt said, "You did good!" I too would have halted any further attempts at removal if the steps that Iluvivt didn't work. You truly do NOT want an embolized IV catheter. Most of the time I find that the reason behind a resistant PICC removal is because of a Thrombus.

And pulling on the IV catheter when resistance is met can cause this embolism.