Part 6 of the series: Neonatal Vascular Access: A Practical Guide to PICCs and Midlines
Introduction
Considerable attention is rightly given to device selection, insertion and maintenance, yet timely catheter removal is equally important. A vascular access device that is no longer clinically required should not simply remain in situ because it is functioning well. Every additional day exposes the infant to potential risks, including infection, thrombosis, migration and accidental dislodgement.
The challenge for clinicians is balancing the risks of keeping a device against the possibility that vascular access may soon be required again. Effective decision-making relies on daily assessment, multidisciplinary communication and a clear understanding of the infant’s treatment plan.
Why Removal Decisions Matter
Removing a PICC or Midline too early may lead to additional cannulation procedures if intravenous therapy is restarted. Conversely, leaving a device in place without a clear indication may expose the infant to avoidable complications.1,3
The objective should be simple:
Maintain vascular access only for as long as the benefits outweigh the risks.
This principle supports both patient safety and vessel preservation.
Daily Necessity Assessment
Every PICC and Midline should undergo a daily review to determine whether it remains clinically indicated.
Daily Line Necessity Checklist
Ask:
✅ Is intravenous therapy still required?
✅ Is parenteral nutrition still being administered?
✅ Can medications be transitioned to an enteral route?
✅ Is future IV therapy genuinely anticipated?
✅ Does the benefit of the device still outweigh the associated risks?
✅ If this device were not present today, would we insert it?
The final question is often the most revealing.
If the answer is no, removal should be considered.
Common Indications for Planned Removal
Therapy Completion
The most common reason for elective removal is completion of therapy.
Examples include:
- Completion of intravenous antibiotics
- Discontinuation of parenteral nutrition
- Resolution of hydration requirements
- Transition to enteral feeding and medication administration
Change in Clinical Condition
Improvements in clinical status may remove the need for ongoing vascular access.
Examples include:
- Feeding tolerance established
- Respiratory stability achieved
- Reduced monitoring requirements
- Preparation for discharge
Transition to Alternative Access
Occasionally, removal is appropriate because an alternative device better suits the patient’s needs.
When Removal Should Be Delayed
Although unnecessary devices should not remain in situ, premature removal is also problematic.
Clinicians should consider:
Is additional therapy likely?
For example:
- Blood cultures pending
- Further antibiotic decisions expected
- Potential feeding intolerance
- Anticipated clinical deterioration
How difficult would replacement be?
In some extremely preterm infants with limited vascular access, re-establishing access may be particularly challenging.
The decision should therefore consider both current and predicted treatment needs.
Planned vs Unplanned Removals
Monitoring removal patterns can provide valuable insight into vascular access quality.
Planned Removals
Examples include:
- Therapy completed
- Clinical goals achieved
- Device no longer necessary
Planned removals generally indicate successful vascular access management.
Unplanned Removals
Examples include:
- Occlusion
- Dislodgement
- Migration
- Suspected infection
- Catheter damage
High rates of unplanned removals may highlight opportunities for improvement in insertion, maintenance or securement practices.
What Removal Data Can Teach Us
Every catheter removal provides an opportunity to learn.
High Occlusion-Related Removal Rates May Indicate:
- Inconsistent flushing practices
- Delayed recognition of dysfunction
- Patency management challenges
High Dislodgement Rates May Indicate:
- Securement issues
- Dressing failures
- Inadequate handling procedures
High Infection-Related Removals May Indicate:
- Bundle compliance concerns
- Increased catheter manipulation
- Maintenance practice variation
High Migration Rates May Indicate:
- Inadequate monitoring
- Securement challenges
- Documentation inconsistencies
Reviewing these trends can support quality improvement initiatives across the NICU.
Clinical Scenario
Should This PICC Be Removed?
A 32-week infant has completed a 10-day antibiotic course.
Current status:
- Respiratory support discontinued
- Full enteral feeds established
- No intravenous medications prescribed
- PICC remains functional
The clinical team discusses whether the PICC should remain “just in case” further access becomes necessary.
Key Considerations
- Is there a current indication for IV access?
- Is further treatment anticipated?
- Does keeping the device reduce or increase risk?
In this scenario, if no further intravenous therapy is planned, removal would typically be appropriate because the risks of maintaining access may outweigh any potential benefit.
Safe Removal Principles
Prior to removal, clinicians should:
- Confirm the indication for removal
- Review local protocols
- Prepare all required equipment
- Communicate with the multidisciplinary team
- Inform and support parents or caregivers1
Following removal:
- Inspect the catheter to confirm it is intact
- Assess the insertion site
- Document findings
- Monitor the site according to local policy
Talking to Parents About Removal
Parents often view PICCs and Midlines as symbols of their baby’s illness.
Removal may therefore prompt a mixture of reassurance and anxiety.
Helpful discussions might include:
- Why the line is no longer required
- How treatment goals have changed
- What happens if access is needed again
- Signs clinicians will continue to monitor
These conversations help support family-centred care and reinforce clinical progress.
Key Practice Points
✅ Review catheter necessity every day.
✅ Remove devices as soon as they are no longer clinically indicated.
✅ Avoid “just in case” decision-making.
✅ Monitor planned versus unplanned removal rates.
✅ Use removal data to drive quality improvement.
✅ Remember that vessel preservation includes timely catheter removal.
Conclusion
Removal is not the end of the vascular access journey. It is an important clinical decision that should reflect the infant’s current and anticipated needs.
By incorporating daily necessity reviews, monitoring removal trends and using data to inform practice, neonatal teams can reduce unnecessary catheter exposure while preserving future vascular access options. Successful vascular access management depends not only on placing the right device, but also on recognising when it is no longer needed.
Next Article:
Building a Neonatal Vascular Access Pathway in the NICU
Supporting Materials
- Sharpe EL, Wyckoff MM, Pettit J, et al. Peripherally Inserted Central Catheters: Guideline for Practice. 4th ed. Chicago (IL): National Association of Neonatal Nurses; 2024.
- Sharpe EL, Pettit J. NANN neonatal peripherally inserted central catheters: clinical practice update. Adv Neonatal Care. 2024;24(4):e95-e107.
- Infusion Nurses Society. Infusion Therapy Standards of Practice. 9th ed. Norwood (MA): Infusion Nurses Society; 2024.
- Chen JW. Neonatal Vascular Access: Pearls, Proficiency and Innovation in Practice. Academy of Neonatal Nursing Annual Conference; 2018.
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