Complicações do PICC em adultos: prevenção e estratégias de enfermagem baseadas em evidências

Authors

  • Luciana Cristina Tavares Caetano
  • Isaac Cardoso Vieira
  • Fernanda Cristina Guassu Almeida

DOI:

https://doi.org/10.33159/25959484.repen.2026v37a04

Keywords:

PICC, Complicações, Enfermagem, Trombose, Infecção

Abstract

Objective: To analyze the main complications related to the use of Peripherally Inserted Central Catheters (PICC) in adults, with emphasis on bloodstream infections, venous thrombosis, and lumen occlusion, and to identify prevention strategies focused on nursing care. Methods: An integrative literature review was conducted, including studies from the past ten years that addressed clinical, technical, and organizational factors associated with PICC use. The selected studies focused on nursing practices, care protocols, and the use of technologies such as ultrasound guidance. Results: The analysis showed that adopting evidence-based practices, continuous nursing education, and standardized protocols significantly contribute to the prevention of complications. Proper insertion, maintenance, and monitoring of PICCs were linked to a substantial reduction in infection, thrombosis, and occlusion risks, enhancing both patient safety and treatment effectiveness. Conclusion: It is concluded that PICCs are a safe and effective option for long-term venous access in adult patients, provided they are appropriately indicated and managed. Nursing care plays a vital role in minimizing risks and ensuring quality care, especially in complex clinical contexts where personalized care and the use of technology are central to positive outcomes.
Descriptors: PICC; Complications; Nursing; Thrombosis; Infection.

References

1. Waitt C, Waitt P, Pirmohamed M. Intravenous therapy. Postgrad Med J. 2004;80(939):1–6. https://doi.org/10.1136/pmj.2003.010421

2. Merrell SW, Peatross BG, Grossman MD, Sullivan JJ, Harker WG. Peripherally inserted central venous catheters: Low-risk alternatives for ongoing venous access. West J Med [Internet]. 1994[cited 2025 Jun 30];160(1):25–30. Available from: https://pubmed.ncbi.nlm.nih.gov/8128698/

3. Sharp R, Grech C, Fielder A, Mikocka Walus A, Esterman A. Vein diameter for peripherally inserted catheter insertion: a scoping review. J Assoc Vasc Access. 2016;21(3):166–75. https://doi.org/10.1016/j.java.2016.02.002

4. Johansson E, Hammarskjöld F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: A systematic review of the literature. Acta Oncol. 2013;52(5):886–92. https://doi.org/10.3109/0284186X.2013.773072

5. Moureau N. Vascular safety: it’s all about PICCs. Nurs Manage. 2006;37(5):22–27. https://doi.org/10.1097/00006247-200605000-00007

6. Nicholson J. Development of an ultrasound-guided PICC insertion service. Br J Nurs. 2010;19(10):S9–17. https://doi.org/10.12968/bjon.2010.19.Sup3.48212

7. Von Eiff C, Jansen B, Kohnen W, Becker K. Infections associated with medical devices: Pathogenesis, management, and prophylaxis. Drugs. 2005;65(2):179–214. https://doi.org/10.2165/00003495-200565020-00003

8. Pelling H, Nzakizwanayo J, Milo S, Denham EL, Macfarlane WM, Bock LJ, et al. Bacterial biofilm formation on indwelling urethral catheters. Lett Appl Microbiol. 2019;68(4):277–93. https://doi.org/10.1111/lam.13144

9. Busch LM, Kadri SS. Antimicrobial treatment duration in sepsis and serious infections. J Infect Dis. 2020;222(Suppl 2):S142–55. https://doi.org/10.1093/infdis/jiaa247

10. Ahmed SS, McCaskey MS, Bringman S, Eigen H. Catheter-associated bloodstream infection in the pediatric intensive care unit: a multidisciplinary approach. Pediatr Crit Care Med. 2012;13(2):e69–72. https://doi.org/10.1097/PCC.0b013e31820ac2e1

11. Zochios V, Umar I, Simpson N, Jones N. Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients. J Vasc Access. 2014;15(5):329–37. https://doi.org/10.5301/jva.5000239

12. Dougherty L. Frequency, diagnosis, and management of occlusive and mechanical PICC complications. In: Peripherally inserted central venous catheters. Milano: Springer Milan; 2014. p. 85–94. https://doi.org/10.1007/978-88-470-5665-7_8

13. Pina TV, Cunha NC, Ferreira EB, Rocha PRS. Complications of peripherally inserted central catheter: integrative review. Rev Enferm UFPE. 2023;17(1). https://doi.org/10.5205/1981-8963.2023.253981

14. Oliveira RM, Leitão IMTA, Silva LMSD, Figueiredo SV, Sampaio RL, Gondim MM. Strategies for promoting patient safety: from the identification of the risks to evidence-based practices. Esc Anna Nery. 2014;18:122–9. https://doi.org/10.5935/1414-8145.20140018

15. Xu B, Zhang J, Hou J, Ma M, Gong Z, Tang S. Nurses’ attitudes and knowledge of peripherally inserted central catheter maintenance in primary hospitals in China: a cross-sectional survey. Risk Manag Healthc Policy. 2020;13:903–13. https://doi.org/10.2147/RMHP.S250741

16. Aljanabi HM, Mousa O, Al Zawad MA, Sindi FR, Asalem RA, Alqasim AA, et al. Evaluating the knowledge and attitudes of nurses toward PICC care before and after specialized training in Dammam Health Network (DHN) in the KSA. Gland Surg. 2024;9(2):481–516. https://doi.org/10.13140/RG.2.2.23971.57129

17. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med. 2006;31(4):311–23. https://doi.org/10.1016/j.rapm.2006.04.004

18. Mendes KDS, Silveira RCDCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17:758-64. https://doi.org/10.1590/S0104-07072008000400018

19. Oliveira JLR, Beccaria LM, Pereira GAA, Poletti NA, Gabriel CS. Cateter central de inserção periférica em adultos hospitalizados: competências necessárias à sua inserção. Rev Bras Enferm. 2020;73(Supl. 4):e20190240. https://doi.org/10.1590/0034-7167-2019-0240

20. Pereira FG, Oliveira AC, Paula AO, Souza RM. (). Infraestrutura hospitalar e segurança do paciente: uma análise a partir das boas práticas em terapia intravenosa. Rev Bras Enferm. 2019;72(6):1562–8. https://doi.org/10.1590/0034-7167-2018-0680

21. Walters B, Price C. Quality improvement initiative reduces the occurrence of complications in peripherally inserted central catheters. J Infus Nurs. 2019;42(1):29–36. https://doi.org/10.1097/NAN.0000000000000310

22. Meyer BM. Understanding the patient experience of peripherally inserted central catheter-related deep vein thrombosis using interpretive phenomenology. J Infus Nurs. 2017;40(5):287-96. https://doi.org/10.1097/nan.0000000000000238

23. Sharp R, Cummings M, Fielder A, Mikocka-Walus A, Grech C, Esterman A. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study. Int J Nurs Stud. 2015;52(3):677–85. https://doi.org/10.1016/j.ijnurstu.2014.12.002

24. Chang C, Zhang H, Wang Y, Liu F, Li Y. Prognostic factors for catheter-related thrombosis in hematological patients with peripherally inserted central catheters. Thromb Res. 2025;223:105507. https://doi.org/10.1097/MD.0000000000041181

25. Santacruz Cerdá E, Arcano K, Arrieta Blanco F, Ortiz Flores A, Mateo Lobo R, Botella Carretero JI, et al. Eficacia de la nutrición parenteral domiciliaria de larga evolución con catéter de acceso periférico: a propósito de un caso. Nutr Hosp. 2016;33(1):185–7. https://doi.org/10.20960/nh.31

26. Alsaleh K, Alosaimi D, Almousawi A, Alshaikh M, Omar H. Effectiveness of a nurse-led peripherally inserted central catheter service: a retrospective cohort study. J Vasc Access. 2024;26(4). https://doi.org/10.1177/11297298241263886

27. Assis GLC, Mota ANB, Cesar VF, Turrini RNT, Ferreira LM. Custo direto da inserção do cateter central de inserção periférica por enfermeiros em adultos hospitalizados. Rev Bras Enferm. 2021;74:e20190663. https://doi.org/10.1590/0034-7167-2019-0663

28. Mitelmão FCR, Mangini Filho S, Chaud MV, Vila MMDC, Balcão VMCF, Oliveira Junior JMD. Caracterização física de cateteres centrais de inserção periférica (CCIP). Matéria (Rio J). 2020;25:e-12545. https://doi.org/10.1590/S1517-707620200001.0870

29. Lv L, Wang H, Zhang X, Zhang M. Cluster nursing in the prevention of PICC related venous thrombosis and its influence on tumor patients' coagulation functions. Int J Clin Exp Med [Internet]. 2020[cited 2025 Jun 30];13(12):10005–11. Available from: https://e-century.us/files/ijcem/13/12/ijcem0120598.pdf

30. Huang R, Jiang Y, Le X. [Retracted] Prevention and nursing research of PICC catheter related complications in patients with digestive system malignant tumors based on smart medical blockchain. J Healthc Eng. 2021;2021(1):5519722. https://doi.org/10.1155/2021/5519722

31. McDiarmid S, Scrivens N, Carrier M, Sabri E, Toye B, Huebsch L, et al. Outcomes in a nurse led peripherally inserted central catheter program: a retrospective cohort study. CMAJ Open. 2017;5(3):E535–9. https://doi.org/10.9778/cmajo.20170010

32. Mielke D, Wittig A, Teichgräber U. Peripherally inserted central venous catheter (PICC) in outpatient and inpatient oncological treatment. Support Care Cancer. 2020;28:4753–60. https://doi.org/10.1007/s00520-019-05276-0

33. Grau D, Clarivet B, Lotthé A, Bommart S, Parer S. Complications with peripherally inserted central catheters (PICC) used in hospitalized patients and outpatients: a prospective cohort study. Antimicrob Resist Infect Control. 2017;6:1–8. https://doi.org/10.1186/s13756-016-0161-0

34. Curto García N, García Suárez J, Callejas Chavarria M, Gil Fernández JJ, Martín Guerrero Y, Magro Mazo E, et al. A team based multidisciplinary approach to managing peripherally inserted central catheter complications in high risk haematological patients: a prospective study. Support Care Cancer. 2015;24:93–101. https://doi.org/10.1007/s00520-015-2754-1

35. Ullman AJ, August D, Kleidon T, Walker R, Marsh NM, Bulmer A, et al. Peripherally Inserted Central catheter iNnovation to reduce Infections and Clots (the PICNIC trial): a randomized controlled trial protocol. BMJ Open. 2021;11(4):e042475. https://doi.org/10.1136/bmjopen-2020-042475

36. Zheng LY, Peng Y, Yuan H, Liu SX, Xue H, Zhang XY. Nurses’ knowledge of the management of drug induced peripherally inserted central catheter obstruction: a descriptive phenomenological study. J Vasc Access. 2020;21(5):680–6. https://doi.org/10.1177/1129729819900864

37. Morano SG, Latagliata R, Girmenia C, Massaro F, Berneschi P, Guerriero A, et al. Catheter associated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer. 2015;23:3289–95. https://doi.org/10.1007/s00520-015-2740-7

38. Tolera BD, Hui F. Exploring individual and organizational factors influencing registered nurses in preventing peripherally inserted central catheter-related complications. J Nurs Pract. 2025;4(4). https://doi.org/10.5281/zenodo.546199

1. Waitt C, Waitt P, Pirmohamed M. Intravenous therapy. Postgrad Med J. 2004;80(939):1–6. https://doi.org/10.1136/pmj.2003.010421 DOI: https://doi.org/10.1136/pmj.2003.010421

2. Merrell SW, Peatross BG, Grossman MD, Sullivan JJ, Harker WG. Peripherally inserted central venous catheters: Low-risk alternatives for ongoing venous access. West J Med [Internet]. 1994[cited 2025 Jun 30];160(1):25–30. Available from: https://pubmed.ncbi.nlm.nih.gov/8128698/

3. Sharp R, Grech C, Fielder A, Mikocka Walus A, Esterman A. Vein diameter for peripherally inserted catheter insertion: a scoping review. J Assoc Vasc Access. 2016;21(3):166–75. https://doi.org/10.1016/j.java.2016.02.002 DOI: https://doi.org/10.1016/j.java.2016.02.002

4. Johansson E, Hammarskjöld F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: A systematic review of the literature. Acta Oncol. 2013;52(5):886–92. https://doi.org/10.3109/0284186X.2013.773072 DOI: https://doi.org/10.3109/0284186X.2013.773072

5. Moureau N. Vascular safety: it’s all about PICCs. Nurs Manage. 2006;37(5):22–27. https://doi.org/10.1097/00006247-200605000-00007 DOI: https://doi.org/10.1097/00006247-200605000-00007

6. Nicholson J. Development of an ultrasound-guided PICC insertion service. Br J Nurs. 2010;19(10):S9–17. https://doi.org/10.12968/bjon.2010.19.Sup3.48212 DOI: https://doi.org/10.12968/bjon.2010.19.Sup3.48212

7. Von Eiff C, Jansen B, Kohnen W, Becker K. Infections associated with medical devices: Pathogenesis, management, and prophylaxis. Drugs. 2005;65(2):179–214. https://doi.org/10.2165/00003495-200565020-00003 DOI: https://doi.org/10.2165/00003495-200565020-00003

8. Pelling H, Nzakizwanayo J, Milo S, Denham EL, Macfarlane WM, Bock LJ, et al. Bacterial biofilm formation on indwelling urethral catheters. Lett Appl Microbiol. 2019;68(4):277–93. https://doi.org/10.1111/lam.13144 DOI: https://doi.org/10.1111/lam.13144

9. Busch LM, Kadri SS. Antimicrobial treatment duration in sepsis and serious infections. J Infect Dis. 2020;222(Suppl 2):S142–55. https://doi.org/10.1093/infdis/jiaa247 DOI: https://doi.org/10.1093/infdis/jiaa247

10. Ahmed SS, McCaskey MS, Bringman S, Eigen H. Catheter-associated bloodstream infection in the pediatric intensive care unit: a multidisciplinary approach. Pediatr Crit Care Med. 2012;13(2):e69–72. https://doi.org/10.1097/PCC.0b013e31820ac2e1 DOI: https://doi.org/10.1097/PCC.0b013e31820ac2e1

11. Zochios V, Umar I, Simpson N, Jones N. Peripherally inserted central catheter (PICC)-related thrombosis in critically ill patients. J Vasc Access. 2014;15(5):329–37. https://doi.org/10.5301/jva.5000239 DOI: https://doi.org/10.5301/jva.5000239

12. Dougherty L. Frequency, diagnosis, and management of occlusive and mechanical PICC complications. In: Peripherally inserted central venous catheters. Milano: Springer Milan; 2014. p. 85–94. https://doi.org/10.1007/978-88-470-5665-7_8 DOI: https://doi.org/10.1007/978-88-470-5665-7_8

13. Pina TV, Cunha NC, Ferreira EB, Rocha PRS. Complications of peripherally inserted central catheter: integrative review. Rev Enferm UFPE. 2023;17(1). https://doi.org/10.5205/1981-8963.2023.253981 DOI: https://doi.org/10.5205/1981-8963.2023.253981

14. Oliveira RM, Leitão IMTA, Silva LMSD, Figueiredo SV, Sampaio RL, Gondim MM. Strategies for promoting patient safety: from the identification of the risks to evidence-based practices. Esc Anna Nery. 2014;18:122–9. https://doi.org/10.5935/1414-8145.20140018 DOI: https://doi.org/10.5935/1414-8145.20140018

15. Xu B, Zhang J, Hou J, Ma M, Gong Z, Tang S. Nurses’ attitudes and knowledge of peripherally inserted central catheter maintenance in primary hospitals in China: a cross-sectional survey. Risk Manag Healthc Policy. 2020;13:903–13. https://doi.org/10.2147/RMHP.S250741 DOI: https://doi.org/10.2147/RMHP.S250741

16. Aljanabi HM, Mousa O, Al Zawad MA, Sindi FR, Asalem RA, Alqasim AA, et al. Evaluating the knowledge and attitudes of nurses toward PICC care before and after specialized training in Dammam Health Network (DHN) in the KSA. Gland Surg. 2024;9(2):481–516. https://doi.org/10.13140/RG.2.2.23971.57129

17. Hebl JR. The importance and implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med. 2006;31(4):311–23. https://doi.org/10.1016/j.rapm.2006.04.004 DOI: https://doi.org/10.1016/j.rapm.2006.04.004

18. Mendes KDS, Silveira RCDCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17:758-64. https://doi.org/10.1590/S0104-07072008000400018 DOI: https://doi.org/10.1590/S0104-07072008000400018

19. Oliveira JLR, Beccaria LM, Pereira GAA, Poletti NA, Gabriel CS. Cateter central de inserção periférica em adultos hospitalizados: competências necessárias à sua inserção. Rev Bras Enferm. 2020;73(Supl. 4):e20190240. https://doi.org/10.1590/0034-7167-2019-0240

20. Pereira FG, Oliveira AC, Paula AO, Souza RM. (). Infraestrutura hospitalar e segurança do paciente: uma análise a partir das boas práticas em terapia intravenosa. Rev Bras Enferm. 2019;72(6):1562–8. https://doi.org/10.1590/0034-7167-2018-0680 DOI: https://doi.org/10.1590/0034-7167-2018-0680

21. Walters B, Price C. Quality improvement initiative reduces the occurrence of complications in peripherally inserted central catheters. J Infus Nurs. 2019;42(1):29–36. https://doi.org/10.1097/NAN.0000000000000310 DOI: https://doi.org/10.1097/NAN.0000000000000310

22. Meyer BM. Understanding the patient experience of peripherally inserted central catheter-related deep vein thrombosis using interpretive phenomenology. J Infus Nurs. 2017;40(5):287-96. https://doi.org/10.1097/nan.0000000000000238 DOI: https://doi.org/10.1097/NAN.0000000000000238

23. Sharp R, Cummings M, Fielder A, Mikocka-Walus A, Grech C, Esterman A. The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): a prospective cohort study. Int J Nurs Stud. 2015;52(3):677–85. https://doi.org/10.1016/j.ijnurstu.2014.12.002 DOI: https://doi.org/10.1016/j.ijnurstu.2014.12.002

24. Chang C, Zhang H, Wang Y, Liu F, Li Y. Prognostic factors for catheter-related thrombosis in hematological patients with peripherally inserted central catheters. Thromb Res. 2025;223:105507. https://doi.org/10.1097/MD.0000000000041181 DOI: https://doi.org/10.1097/MD.0000000000041181

25. Santacruz Cerdá E, Arcano K, Arrieta Blanco F, Ortiz Flores A, Mateo Lobo R, Botella Carretero JI, et al. Eficacia de la nutrición parenteral domiciliaria de larga evolución con catéter de acceso periférico: a propósito de un caso. Nutr Hosp. 2016;33(1):185–7. https://doi.org/10.20960/nh.31 DOI: https://doi.org/10.20960/nh.31

26. Alsaleh K, Alosaimi D, Almousawi A, Alshaikh M, Omar H. Effectiveness of a nurse-led peripherally inserted central catheter service: a retrospective cohort study. J Vasc Access. 2024;26(4). https://doi.org/10.1177/11297298241263886 DOI: https://doi.org/10.1177/11297298241263886

27. Assis GLC, Mota ANB, Cesar VF, Turrini RNT, Ferreira LM. Custo direto da inserção do cateter central de inserção periférica por enfermeiros em adultos hospitalizados. Rev Bras Enferm. 2021;74:e20190663. https://doi.org/10.1590/0034-7167-2019-0663 DOI: https://doi.org/10.1590/0034-7167-2019-0663

28. Mitelmão FCR, Mangini Filho S, Chaud MV, Vila MMDC, Balcão VMCF, Oliveira Junior JMD. Caracterização física de cateteres centrais de inserção periférica (CCIP). Matéria (Rio J). 2020;25:e-12545. https://doi.org/10.1590/S1517-707620200001.0870 DOI: https://doi.org/10.1590/s1517-707620200001.0870

29. Lv L, Wang H, Zhang X, Zhang M. Cluster nursing in the prevention of PICC related venous thrombosis and its influence on tumor patients' coagulation functions. Int J Clin Exp Med [Internet]. 2020[cited 2025 Jun 30];13(12):10005–11. Available from: https://e-century.us/files/ijcem/13/12/ijcem0120598.pdf

30. Huang R, Jiang Y, Le X. [Retracted] Prevention and nursing research of PICC catheter related complications in patients with digestive system malignant tumors based on smart medical blockchain. J Healthc Eng. 2021;2021(1):5519722. https://doi.org/10.1155/2021/5519722 DOI: https://doi.org/10.1155/2021/5519722

31. McDiarmid S, Scrivens N, Carrier M, Sabri E, Toye B, Huebsch L, et al. Outcomes in a nurse led peripherally inserted central catheter program: a retrospective cohort study. CMAJ Open. 2017;5(3):E535–9. https://doi.org/10.9778/cmajo.20170010 DOI: https://doi.org/10.9778/cmajo.20170010

32. Mielke D, Wittig A, Teichgräber U. Peripherally inserted central venous catheter (PICC) in outpatient and inpatient oncological treatment. Support Care Cancer. 2020;28:4753–60. https://doi.org/10.1007/s00520-019-05276-0 DOI: https://doi.org/10.1007/s00520-019-05276-0

33. Grau D, Clarivet B, Lotthé A, Bommart S, Parer S. Complications with peripherally inserted central catheters (PICC) used in hospitalized patients and outpatients: a prospective cohort study. Antimicrob Resist Infect Control. 2017;6:1–8. https://doi.org/10.1186/s13756-016-0161-0 DOI: https://doi.org/10.1186/s13756-016-0161-0

34. Curto García N, García Suárez J, Callejas Chavarria M, Gil Fernández JJ, Martín Guerrero Y, Magro Mazo E, et al. A team based multidisciplinary approach to managing peripherally inserted central catheter complications in high risk haematological patients: a prospective study. Support Care Cancer. 2015;24:93–101. https://doi.org/10.1007/s00520-015-2754-1 DOI: https://doi.org/10.1007/s00520-015-2754-1

35. Ullman AJ, August D, Kleidon T, Walker R, Marsh NM, Bulmer A, et al. Peripherally Inserted Central catheter iNnovation to reduce Infections and Clots (the PICNIC trial): a randomized controlled trial protocol. BMJ Open. 2021;11(4):e042475. https://doi.org/10.1136/bmjopen-2020-042475 DOI: https://doi.org/10.1136/bmjopen-2020-042475

36. Zheng LY, Peng Y, Yuan H, Liu SX, Xue H, Zhang XY. Nurses’ knowledge of the management of drug induced peripherally inserted central catheter obstruction: a descriptive phenomenological study. J Vasc Access. 2020;21(5):680–6. https://doi.org/10.1177/1129729819900864 DOI: https://doi.org/10.1177/1129729819900864

37. Morano SG, Latagliata R, Girmenia C, Massaro F, Berneschi P, Guerriero A, et al. Catheter associated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer. 2015;23:3289–95. https://doi.org/10.1007/s00520-015-2740-7 DOI: https://doi.org/10.1007/s00520-015-2740-7

38. Tolera BD, Hui F. Exploring individual and organizational factors influencing registered nurses in preventing peripherally inserted central catheter-related complications. J Nurs Pract. 2025;4(4). https://doi.org/10.5281/zenodo.546199

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2026-07-14

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Caetano LCT, Vieira IC, Almeida FCG. Complicações do PICC em adultos: prevenção e estratégias de enfermagem baseadas em evidências . Rev Paul Enferm [Internet]. 2026 Jul. 14 [cited 2026 Jul. 15];37. Available from: https://repen.com.br/repen/article/view/495

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Vol. 37 (2026): Revista Paulista de Enfermagem - 2026 - 37

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