PICC导管头端定位与并发症处理PPT课件.ppt

PICC导管头端定位与并发症处理,杨正强江苏省人民医院介入放射科,12/15/2019,1,PICC导管的影像学评估内容,PICC导管技术的相关解剖上腔静脉气管隆突右心房静脉投影与X线骨性标记导管走行导管头端位置,12/15/2019,2,PICC导管技术的相关解剖,前臂正中静脉头静脉贵要静脉肱静脉腋静脉锁骨下静脉,12/15/2019,3,中心静脉解剖示意图,颈内静脉颈外静脉右侧头臂干上腔静脉,12/15/2019,4,右心房与右心耳,RightatriumandRightatrialappendage,12/15/2019,5,右心耳,下腔静脉（ICV），下位峡部（CTI）室上嵴（SVC),主动脉（AO),以及右室流出道（ROVT）可见房室交界区水平的右心耳（RAA)和左右心房（RAandLA),右前斜位,左前斜位,Rightatrialappendage,12/15/2019,6,右心耳,界嵴（TC）把上腔静脉（SCV）与右心耳(RAA）分开界嵴还把右心房分为后方的平滑壁和前方的梳状肌部,JVascIntervRadiol2008;19:359365,12/15/2019,7,CavoatrialJunction,腔静脉与心房交界（CAJ),SVC的起源气管隆突右心缘右侧主支气管腔静脉心房交界,JVascIntervRadiol2008;19:359365,12/15/2019,8,奇静脉,肺门上方汇入上腔静脉,Azygosvein,在右膈脚处起于右腰升静脉，沿食管的后方、胸主动脉的右侧上行，至第4胸椎体高度，向前勾绕右肺根上方，注入上腔静脉。主要属支：右肋间后静脉食管静脉支气管静脉半奇静脉副半奇静脉奇静脉是沟通上、下腔静脉系的重要途径之一,12/15/2019,9,正位胸片上的常用标记,(1)锁骨(2)肋骨(3)主动脉球(4)右心房(5)右心室(6)左心室(7)左心房(8)隆突(9)右主支气管(10)左主支气管(11)横膈(12)气管(13)肺,1)clavicle(2)rib,(3)aorticknuckle,(4)rightatrium,(5)rightventricle,(6)leftventricle,(7)leftatrium,(8)carina,(9)rightbronchus,(10)leftbronchus,(11)diaphragm,(12)trachea,(13)lungs.,12/15/2019,10,正位胸片上的心血管投射影像,12/15/2019,11,中心静脉导管头端的理想位置,SVC,CavoartialJunction，略低于气管隆突，高于心影轮廓？,BritishJournalofAnaesthesia,96(3):33540(2006),12/15/2019,12,右侧入路PICC导管的头端位置,经右侧置入的PICC导管，导管容易达到与上腔静脉平行,12/15/2019,13,左侧入路PICC导管的头端位置,经左侧置入的PICC导管，如果导管太短，头端容易抵着SVC的外侧壁，所以，应该留有足够的长度,12/15/2019,14,PICC导管头端位置异常,左侧置入的PICC,导管头端异位，进入同侧的颈内静脉,12/15/2019,15,PICC导管头端位置异常,左侧置入的PICC导管，头端进入对侧的锁骨下静脉,12/15/2019,16,PICC导管头端位置异常,PICC导管头端进入内乳静脉,12/15/2019,17,文献中外置中央型导管的头端位置,12/15/2019,18,CVC导管头端的位置,Onaplainchestradiograph,apointtwovertebralbodyunitsbelowthecarinaisareliableestimateofthepositionoftheanatomiccavoatrialjunctioninadolescentsandyoungadults,irrespectiveofpatientage,sex,height,weight,orbodysurfacearea.在儿童和青年人群中，气管隆突下方2个椎体是CAJ的位置,JVascIntervRadiol2008;19:359365,12/15/2019,19,PICC经左侧入路，导管头端位置偏高,12/15/2019,20,PICC导管头端位置位于RA,肝癌患者，PICC导管头端位于RA内，随血流钟摆运动,12/15/2019,21,熟悉心血管在胸片上的投射影像,胸片上SVC的边界不易明确骨性标记第5和6胸椎锁骨下界第3、4肋骨、肋间隙气道标记右侧气管主支气管角气管隆突,12/15/2019,22,PICC导管的头端位置,气管隆突做为标记更方便,12/15/2019,23,PICC的相关并发症,穿刺部位的血肿右心房血栓与肺动脉栓塞导管断裂，游离感染,12/15/2019,24,PICC相关的静脉血栓,ChemalyRF;deParresJB;RehmSJ;AdalKA;etal.VenousThrombosisAssociatedwithPeripherallyInsertedCentralCatheters:ARetrospectiveAnalysisoftheClevelandClinicExperience.ClinInfectDis2002.,12/15/2019,25,基本资料,1994-1996年，34个月期间，2063例PICC置入IndicationsforPICCplacementincludedsoft-tissueandboneinfections(for35%ofplacements),endocarditisandbloodstreaminfections(for15%ofplacements),intra-abdominalinfections(for9%ofplacements),andcytomegalovirusprophylaxisorviremia(for8%ofplacements)注册护士PICCteam3-4FrBard单腔PICC导管严格的无菌操作和置入后胸片检查确定导管头端的位置,12/15/2019,26,上肢静脉血栓(UEVT),上肢表浅静脉血栓血栓累及：头静脉、贵要静脉、颈外静脉和腋静脉上肢深静脉血栓血栓累及：无名静脉、锁骨下静脉、颈内静脉,12/15/2019,27,治疗措施,肝素静脉输注，继而口服华法林口服华法林皮下注射肝素溶栓或血栓切除腔静脉滤器植入观察,12/15/2019,28,Table1.Sitesof52venousthrombosesassociatedwithperipherallyinsertedcentralcathetersin51patients,静脉血栓形成的部位,12/15/2019,29,PICC导管置入后的间隔时间,Figure1.Intervaloftimefromthedayofinsertionofperipherallyinsertedcentralcatheterstothedayofdiagnosisofupperextremityvenousthrombosisforallcasepatients.,12/15/2019,30,出现血栓后的处理,Table2.Therapyadministeredto51patientswith52peripherallyinsertedcentralcatheter(PICC)relatedvenousthromboses,12/15/2019,31,PICC静脉血栓形成的相关因素,Table3.Univariatelogisticregressionanalysisofthedemographiccharacteristicsandriskfactorsofpatientswithperipherallyinsertedcentralcatheterrelatedvenousthromboses.,12/15/2019,32,PICC静脉血栓形成低相关因素,导管头端的位置高渗和偏酸性溶液损伤血管内皮细胞静脉炎（手术操作、化疗药物）两性霉素B在5%的葡萄糖溶液中，偏酸性渗透压与静脉炎的风险600mOsm/L高风险Askilled-nursingfacility（高级保健所）Wespeculatethatthesepatients,whousuallyrequiredhelpwiththeirdailyactivitiesandwithantibioticadministration,haddecreasedmobilityintheirupperextremities,whichpredisposedthemtodevelopVT,12/15/2019,33,PICC导管脱落至肺动脉,12/15/2019,34,PICC导管脱落至心脏，介入方法取出,12/15/2019,35,12/15/2019,36,临床研究,12/15/2019,37,上肢的内收和外展对PICC影响,目的：研究患者上肢由外展(abduction)变为内收(adduction)时，PICC导管头端的位置是否发生显著的移位材料与方法：患者上肢成90度外展，在超声导引下，PICC导管从肱静脉或贵要静脉置入。患者前胸放置一根不透x线的标尺，患者在平静呼吸下，摄取数字式正位胸片，患者上肢从外展到内收后，拍摄另一张胸片。利用不透x线标尺和固定的骨性标志，测量导管头端的移位情况,12/15/2019,38,上肢的内收和外展对PICC影响,结果：研究期间，61例患者接受了PICC导管置入，8例不包括在最终的研究之列。33例从右侧上肢，20例从左侧上肢置入PICC。最后，当上肢从外展位置回到内收位置时候，43例向足侧移动，7例向头侧移位，3例没有发生移动。对于那些向足侧移位的患者，平均移动的距离21mm（253mm)。右侧上肢比左侧上肢更倾向与移位。但是，没有获得统计学上的支持（p=0.29),12/15/2019,39,上肢的内收和外展对PICC影响,结论：在置入PICC导管时，当上肢从外展到内收时，导管头端更容易向足侧移位。58以上的患者PICC导管移位20mm以上，这种改变需要在最终导管头端定位时候考虑到,12/15/2019,40,上肢的内收和外展对PICC影响,PURPOSEThisstudyexamineswhetherthetipofperipherallyinsertedcentralcatheters(PICCs)movessignificantlywithchangesinarmpositionfromabductiontoadduction.MATERIALSANDMETHODSThecatheterswereinsertedinthebrachialorbasilicveinsunderultrasonographicguidancewiththeupperextremityina90abductedposition.Aflexible,radiopaquerulerwasthenplacedontheanteriorchestanddigitalimageswereobtainedwiththearmabductedandadductedinasimilarphaseofquietrespiration.Cathetertipmovementwasmeasuredwithuseoftheradiopaquerulerandfixed,bonyanatomiclandmarks.RESULTSSixty-oneconsecutivePICCswereplacedandevaluatedduringthestudyperiod(eightpatientswereexcluded).Thirtythreecatheterswereplacedfromtherightarmand20fromtheleft.Overall,43movedcaudally,sevenmovedcephalad,andthreedidnotmovewithmovementofthearmfromabductiontoadduction.Ofthosethatmovedcaudal,themeandistanceofmovementwas21mm(range,253mm).RightarmPICCstendedtomovemorethanleftarmPICCs,butthisdidnotattainsignificance(P=.29).CONCLUSIONSThereisatendencyforthePICCtiptomoveinacaudaldirectionwiththechangeinarmpositionfromabductiontoadduction;58%ofPICCsmoved20mmormore.Thischangeinpositionshouldbeconsideredduringfinalcathetertippositioning.,12/15/2019,41,PICC导管置入的导向方法,透视导引放置导管头端能够随时调整到位性价比差,床边PICC后胸片位置不正确，调整后（blindly)再胸片简便,Whichwillbemoreadvantageous,12/15/2019,42,床边PICC插管成功率,研究对象：儿童,平均6.9岁介入手术室完全没有X线导引，模拟床边放置PICC放置后，X线点片检查观察导管头端在上腔静脉的初始到位率,12/15/2019,43,材料与方法,14-monthperiod(20002001)698例患者，843次PICC导管置入（男463次，女380次）682次静脉抗生素给药114静脉补液和抗高血压药物45例肠道外营养2例化疗,12/15/2019,44,PICC头端位