医学资料PICC导管头端定位与并发症处理

1、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2021/7/16 星期五1PICC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2021/7/16 星期五2PICC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2021/7/16 星期五3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2021/7/16 星期五4右心房与右心耳Right atrium and Right atrial appendage2021/7/16 星期五5右心耳下腔静脉（ICV），下位峡部（CTI）

2、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（RA and LA)右前斜位左前斜位Right atrial appendage2021/7/16 星期五6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J Vasc Interv Radiol 2008; 19:359 3652021/7/16 星期五7Cavoatrial Junction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J Vasc Interv Radiol 2008; 19

3、:359 3652021/7/16 星期五8奇静脉肺门上方汇入上腔静脉Azygos vein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一2021/7/16 星期五9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) a

4、ortic knuckle, (4) right atrium, (5) right ventricle, (6) left ventricle, (7) left atrium, (8) carina, (9) right bronchus, (10) left bronchus, (11) diaphragm, (12) trachea, (13) lungs.2021/7/16 星期五10正位胸片上的心血管投射影像2021/7/16 星期五11中心静脉导管头端的理想位置SVC,Cavoartial Junction ，略低于气管隆突，高于心影轮廓？British Journal of A

5、naesthesia,96 (3): 33540 (2006)2021/7/16 星期五12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2021/7/16 星期五13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2021/7/16 星期五14PICC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2021/7/16 星期五15PICC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2021/7/16 星期五16PICC导管头端位置异常PICC

6、导管头端进入内乳静脉2021/7/16 星期五17文献中外置中央型导管的头端位置2021/7/16 星期五18CVC 导管头端的位置On a plain chest radiograph, a point two vertebral body units below the carina is a reliable estimate of the position of the anatomic cavoatrial junction in adolescents and young adults, irrespective of patient age, sex, height, weigh

7、t, or body surface area. 在儿童和青年人群中，气管隆突下方2个椎体是CAJ 的位置J Vasc Interv Radiol 2008; 19:359 3652021/7/16 星期五19PICC 经左侧入路，导管头端位置偏高2021/7/16 星期五20PICC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2021/7/16 星期五21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2021/7/16 星期五22PICC 导管的头端位置气管隆突做为标记更方

8、便2021/7/16 星期五23PICC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2021/7/16 星期五24PICC相关的静脉血栓Chemaly RF;de Parres JB;Rehm SJ;Adal KA; et al. Venous Thrombosis Associated with Peripherally Inserted Central Catheters: A Retrospective Analysis of the Cleveland Clinic Experience. Clin Infect Dis 2002.2021/7/16 星期五25基

9、本资料1994-1996年，34个月期间，2063例PICC 置入Indications for PICC placement included soft-tissue and bone infections (for 35% of placements), endocarditis and bloodstream infections (for 15% of placements), intra-abdominal infections (for 9% of placements), and cytomegalovirus prophylaxis or viremia (for 8% of

10、placements)注册护士PICC team3-4Fr Bard 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2021/7/16 星期五26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2021/7/16 星期五27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2021/7/16 星期五28Table 1. Sites of 52 venous thromboses associated with peripherally inse

11、rted central catheters in 51 patients静脉血栓形成的部位2021/7/16 星期五29PICC 导管置入后的间隔时间Figure 1. Interval of time from the day of insertion of peripherally inserted central catheters to the day of diagnosis of upper extremity venous thrombosis for all case patients.2021/7/16 星期五30出现血栓后的处理Table 2. Therapy admin

12、istered to 51 patients with 52 peripherally inserted central catheter (PICC)related venous thromboses2021/7/16 星期五31PICC静脉血栓形成的相关因素Table 3. Univariate logistic regression analysis of the demographic characteristics and risk factors of patients with peripherally inserted central catheterrelated venou

13、s thromboses.2021/7/16 星期五32PICC 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A skilled-nursing facility（高级保健所）We speculate that these patients, who usually required help with their daily activities and with antibiotic administration, had decreased mobil

14、ity in their upper extremities, which predisposed them to develop VT2021/7/16 星期五33PICC 导管脱落至肺动脉2021/7/16 星期五34PICC 导管脱落至心脏，介入方法取出2021/7/16 星期五352021/7/16 星期五36临床研究2021/7/16 星期五37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

15、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2021/7/16 星期五38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)2021/7/16 星期

16、五39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20 mm以上，这种改变需要在最终导管头端定位时候考虑到2021/7/16 星期五40上肢的内收和外展对PICC影响PURPOSE This study examines whether the tip of peripherally inserted central catheters (PICCs) moves significantly with changes in arm position from abduction to adduction

17、.MATERIALS AND METHODS The catheters were inserted in the brachial or basilic veins under ultrasonographic guidance with the upper extremity in a 90 abducted position. A flexible, radiopaque ruler wasthen placed on the anterior chest and digital images were obtained with the arm abducted and adducte

18、d in a similar phase of quiet respiration. Catheter tip movement was measured with use of the radiopaque ruler and fixed, bony anatomic landmarks.RESULTS Sixty-one consecutive PICCs were placed and evaluated during the study period (eight patients were excluded). Thirtythree catheters were placed fr

19、om the right arm and 20 from the left. Overall, 43 moved caudally, seven moved cephalad, and three did not move with movement of the arm from abduction toadduction. Of those that moved caudal, the mean distance of movement was 21 mm (range, 253 mm). Right arm PICCs tended to move more than left arm

20、PICCs, but this did not attain significance (P = .29).CONCLUSIONS There is a tendency for the PICC tip to move in a caudal direction with the change in arm position from abduction to adduction; 58% of PICCs moved 20 mm or more. This change in position should be considered during final catheter tip positioning.2021/7/16 星期五41PICC 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Which will be more advantageous2021/7/16 星期五42床边PICC插管成功率研究对象：儿童,平均6.9岁介入手术