PICC and midline
A long catheter in an arm vein, usually for antibiotics or chemo. Fever means think line infection; a swollen arm means think line thrombosis. Don't pull it reflexively.
Also called: PICC, peripherally inserted central catheter, PICC line, midline, long line, OPAT line
What it is
A PICC is a fine catheter inserted into an upper-arm vein and threaded so its tip sits in a central vein near the heart - a central line placed through the arm. A midline looks similar but is shorter and its tip stays in the arm (it is not central). Both are used when a patient needs weeks of IV treatment - outpatient antibiotics (OPAT), chemotherapy, or difficult access. The UK epic3 guideline frames the PICC as the device for patients in whom medium-term intermittent access is required
.
The patient arrives at the ED with the line already in. The three things that bring them in are infection, thrombosis and mechanical problems. PICCs are used in both adults and children (paediatric oncology and OPAT especially); the principles here are the same, with paediatric dosing and line care directed by the child's specialist team.
How to recognise it
- A catheter exiting the upper inner arm, secured with a dressing and often a securement device, with one, two or three lumens and a measured external length recorded.
- A patient on OPAT, chemotherapy or long-term IV therapy, often carrying a line-care passport with the insertion date, tip position and external length.
- A midline ends in the arm (not central), so it is not used for irritant drugs, vasopressors, TPN or large-volume central measurement - check the documentation for which device it is.
What it gets confused with
A tunnelled central line (Hickman) exits the chest and is tunnelled under the skin for long-term use; a PICC exits the arm. Both are central, but the tunnelled line is the longer-term, chest-sited device. A midline, unlike either, is not central at all.
What goes wrong
Catheter-related bloodstream infection
Fever or rigors, classically soon after the line is flushed or used; the patient may be systemically well or septic. The exit site may look normal.
Red flag
Take blood cultures - ideally paired, from the line and a peripheral vein - before antibiotics, treat sepsis on its merits, and involve the team that owns the line. Do not assume the line must come out: removal is a considered decision made with the owning team once cultures and the clinical picture are in, not a reflex response to fever - many catheter infections are treated with the line in situ.
Line-associated thrombosis
Swelling, aching or dilated surface veins in the arm, shoulder or neck on the side of the line; sometimes facial swelling with a more proximal clot.
Red flag
Upper-limb DVT around a PICC needs imaging (Doppler) and anticoagulation discussion; the line is often kept if still needed and functioning. Do not ignore a swollen arm on the PICC side.
Occlusion, dislodgement or breakage
The line will not flush or aspirate (occlusion), has partly pulled out (changed external length), or is split/leaking.
Red flag
A split or open central line risks air embolism and infection: clamp it between the break and the patient, stop using it, and refer. If the patient becomes acutely breathless or shocked, suspect air embolism - lie them head-down on the left side and give high-flow oxygen. Do not force a blocked lumen.
The first ten minutes
- Treat the clinical problem first - sepsis, the arm, the breathlessness - as you would in any patient; the line is one input, not the whole picture.
- For suspected line sepsis, take cultures (line + peripheral) before antibiotics and start sepsis treatment. Access the line only with strict asepsis: epic3 directs that you
Use the aseptic technique for the insertion and care of an intravascular access device
and decontaminate the hub -The hub should be cleaned for a minimum of 15 s and allowed to dry
. - For a swollen arm, arrange Doppler ultrasound and discuss anticoagulation; keep the line unless it is the problem.
- For a split or dislodged line, clamp it, stop using it, and refer to the owning team. A blocked lumen is flushed gently with sterile saline - never forced.
- Call the team that owns the line (OPAT, oncology, nutrition or the vascular access service) before deciding on removal.
Do not
Who owns it
The team that placed or uses the line - OPAT/microbiology, oncology, nutrition, or the vascular access / IV therapy team. Tell them the device type (PICC vs midline), number of lumens, insertion date, external length, whether it flushes and aspirates, and the culture results.
Who to call
The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.
- Say the device name first
- Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
- Say what you have already established
- Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
- Ask who owns it out of hours
- Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
- The patient's own team is a resource, not an afterthought
- Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.
When the device is not the problem
A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.
- The NTSP says it out loud
- The project's own manual warns that
patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.
The same sentence applies to every device in this tool. - Clear the device, then leave it
- Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
- The anchoring runs both ways
- The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.
- NTSP manual — Red flags · read in full
What the patient will be carrying
Patients on OPAT or chemotherapy usually carry a line-care passport recording the device, insertion date, tip position and external length, and the contact for their line team. Ask for it.
Scope of this page
This page covers recognising a PICC or midline and the first ED response to line infection, thrombosis and mechanical problems: culture, treat, access aseptically, refer. It does not teach line insertion, tip confirmation, thrombolytic line unblocking or the decision to remove - those belong to the vascular access and owning teams. PICCs are used in adults and children; paediatric line care and dosing are directed by the child's specialist team.