PICC導(dǎo)管頭端定位與并發(fā)癥處理

1、2021/8/21PICC導(dǎo)管頭端定位與并發(fā)癥處理?xiàng)钫龔?qiáng)江蘇省人民醫(yī)院 介入放射科2021/8/22PICC導(dǎo)管的影像學(xué)評(píng)估內(nèi)容PICC導(dǎo)管技術(shù)的相關(guān)解剖上腔靜脈氣管隆突右心房靜脈投影與X線骨性標(biāo)記導(dǎo)管走行導(dǎo)管頭端位置2021/8/23PICC導(dǎo)管技術(shù)的相關(guān)解剖前臂正中靜脈前臂正中靜脈 頭靜脈頭靜脈 貴要靜脈貴要靜脈 肱靜脈肱靜脈 腋靜脈腋靜脈 鎖骨鎖骨下靜脈下靜脈2021/8/24中心靜脈解剖示意圖頸內(nèi)靜脈 頸外靜脈 右側(cè)頭臂干 上腔靜脈2021/8/25右心房與右心耳Right atrium and Right atrial appendageRight atrium and Right

2、atrial appendage2021/8/26右心耳下腔靜脈（ICV），下位峽部（CTI）室上嵴（SVC),主動(dòng)脈（AO),以及右室流出道（ROVT）可見(jiàn)房室交界區(qū)水平的右心耳（RAA)和左右心房（RA and LA)右前斜位右前斜位左前斜位左前斜位Right atrial appendageRight atrial appendage2021/8/27右心耳界嵴（TC）把上腔靜脈（SCV）與右心耳(RAA）分開界嵴還把右心房分為后方的平滑壁和前方的梳狀肌部J Vasc Interv Radiol 2008; 19:359 3652021/8/28Cavoatrial JunctionCa

3、voatrial Junction腔靜脈與心房交界（CAJ)SVC 的起源氣管隆突右心緣右側(cè)主支氣管腔靜脈心房交界J Vasc Interv Radiol 2008; 19:359 3652021/8/29奇靜脈肺門上方匯入上腔靜脈肺門上方匯入上腔靜脈Azygos veinAzygos vein在右膈腳處起于右腰升靜脈，沿食管的后方、胸主動(dòng)脈的右側(cè)上行，至第4胸椎體高度，向前勾繞右肺根上方，注入上腔靜脈。主要屬支： 右肋間后靜脈 食管靜脈 支氣管靜脈 半奇靜脈 副半奇靜脈奇靜脈是溝通上、下腔靜脈系的重要途徑之一2021/8/210正位胸片上的常用標(biāo)記(1) (1) 鎖骨鎖骨(2) (2) 肋骨

4、肋骨(3) (3) 主動(dòng)脈球主動(dòng)脈球(4) (4) 右心房右心房(5) (5) 右心室右心室(6) (6) 左心室左心室(7) (7) 左心房左心房(8) (8) 隆突隆突(9) (9) 右主支氣管右主支氣管(10) (10) 左主支氣管左主支氣管(11) (11) 橫膈橫膈(12) (12) 氣管氣管 (13) 肺肺1) clavicle (2) rib, (3) aortic knuckle, (4) right atrium, (5) right ventricle, (6) left ventricle, (7) left atrium, (8) carina, (9) right b

5、ronchus, (10) left bronchus, (11) diaphragm, (12) trachea, (13) lungs.2021/8/211正位胸片上的心血管投射影像2021/8/212中心靜脈導(dǎo)管頭端的理想位置SVC,Cavoartial Junction ，略低于氣管隆突，高于心影輪廓？British Journal of Anaesthesia,96 (3): 33540 (2006)2021/8/213右側(cè)入路PICC 導(dǎo)管的頭端位置經(jīng)右側(cè)置入的PICC導(dǎo)管， 導(dǎo)管容易達(dá)到與上腔靜脈平行2021/8/214左側(cè)入路PICC導(dǎo)管的頭端位置經(jīng)左側(cè)置入的PICC導(dǎo)管，如果

6、導(dǎo)管太短，頭端容易抵著SVC的外側(cè)壁，所以，應(yīng)該留有足夠的長(zhǎng)度2021/8/215PICC導(dǎo)管頭端位置異常左側(cè)置入的PICC,導(dǎo)管頭端異位，進(jìn)入同側(cè)的頸內(nèi)靜脈2021/8/216PICC導(dǎo)管頭端位置異常左側(cè)置入的PICC導(dǎo)管，頭端進(jìn)入對(duì)側(cè)的鎖骨下靜脈2021/8/217PICC導(dǎo)管頭端位置異常PICC導(dǎo)管頭端進(jìn)入內(nèi)乳靜脈2021/8/218文獻(xiàn)中外置中央型導(dǎo)管的頭端位置2021/8/219CVC 導(dǎo)管頭端的位置On a plain chest radiograph, a On a plain chest radiograph, a point two vertebral body units

7、point two vertebral body units below the carina is a reliable below the carina is a reliable estimate of the position of the estimate of the position of the anatomic cavoatrial junction in anatomic cavoatrial junction in adolescents and young adults, adolescents and young adults, irrespective of pat

8、ient age, irrespective of patient age, sex, height, weight, or body sex, height, weight, or body surface area. surface area. 在兒童和青年人群中，氣管隆突在兒童和青年人群中，氣管隆突下方下方2 2個(gè)椎體是個(gè)椎體是CAJ CAJ 的位置的位置J Vasc Interv Radiol 2008; 19:359 3652021/8/220PICC 經(jīng)左側(cè)入路，導(dǎo)管頭端位置偏高2021/8/221PICC導(dǎo)管頭端位置位于RA肝癌患者，PICC導(dǎo)管頭端位于RA內(nèi)，隨血流鐘擺運(yùn)動(dòng)20

9、21/8/222熟悉心血管在胸片上的投射影像胸片上胸片上SVCSVC的邊界不易明確的邊界不易明確骨性標(biāo)記第5和6 胸椎鎖骨下界第3、4肋骨、肋間隙氣道標(biāo)記右側(cè)氣管主支氣管角氣管隆突2021/8/223PICC 導(dǎo)管的頭端位置氣管隆突做為標(biāo)記更方便氣管隆突做為標(biāo)記更方便2021/8/224PICC的相關(guān)并發(fā)癥穿刺部位的血腫穿刺部位的血腫右心房血栓與肺動(dòng)脈栓塞右心房血栓與肺動(dòng)脈栓塞導(dǎo)管斷裂，游離導(dǎo)管斷裂，游離感染感染2021/8/225PICC相關(guān)的靜脈血栓Chemaly RF;de Parres JB;Rehm SJ;Adal KA; et al. Venous Thrombosis Assoc

10、iated with Peripherally Inserted Central Catheters: A Retrospective Analysis of the Cleveland Clinic Cleveland Clinic Experience. Clin Infect Dis 2002.2021/8/226基本資料1994-1996年，34個(gè)月期間，2063例PICC 置入Indications for PICC placement included soft-tissue and bone infections (for 35% of placements), endocard

11、itis and bloodstream infections (for 15% of placements), intra-abdominal infections (for 9% of placements), and cytomegalovirus prophylaxis or viremia (for 8% of placements)注冊(cè)護(hù)士PICC team3-4Fr Bard 單腔 PICC導(dǎo)管嚴(yán)格的無(wú)菌操作和置入后胸片檢查確定導(dǎo)管頭端的位置2021/8/227上肢靜脈血栓( UEVT)上肢表淺靜脈血栓血栓累及：頭靜脈、貴要靜脈、頸外靜脈和腋靜脈上肢深靜脈血栓血栓累及：無(wú)名靜脈、

12、鎖骨下靜脈、頸內(nèi)靜脈2021/8/228治療措施肝素靜脈輸注，繼而口服華法林口服華法林皮下注射肝素溶栓或血栓切除腔靜脈濾器植入觀察2021/8/229Table 1. Sites of 52 venous thromboses associated with peripherally inserted central catheters in 51 patients靜脈血栓形成的部位2021/8/230PICC 導(dǎo)管置入后的間隔時(shí)間Figure 1. Interval of time from the day of insertion of peripherally inserted cent

13、ral catheters to the day of diagnosis of upper extremity venous thrombosis for all case patients.2021/8/231出現(xiàn)血栓后的處理Table 2. Therapy administered to 51 patients with 52 peripherally inserted central catheter (PICC)related venous thromboses2021/8/232PICC靜脈血栓形成的相關(guān)因素Table 3. Univariate logistic regressi

14、on analysis of the demographic characteristics and risk factors of patients with peripherally inserted central catheterrelated venous thromboses.2021/8/233PICC 靜脈血栓形成低相關(guān)因素導(dǎo)管頭端的位置高滲和偏酸性溶液損傷血管內(nèi)皮細(xì)胞靜脈炎（手術(shù)操作、化療藥物）兩性霉素B 在5%的葡萄糖溶液中，偏酸性滲透壓與靜脈炎的風(fēng)險(xiǎn)600mOsm/L 高風(fēng)險(xiǎn)A skilled-nursing facility（高級(jí)保健所）We speculate tha

15、t these patients, who usually required help with their daily activities and with antibiotic administration, had decreased mobility in their upper extremities, which predisposed them to develop VT2021/8/234PICC 導(dǎo)管脫落至肺動(dòng)脈2021/8/235PICC PICC 導(dǎo)管脫落至心臟，介入方法取出導(dǎo)管脫落至心臟，介入方法取出2021/8/2362021/8/237臨床研究2021/8/238

16、上肢的內(nèi)收和外展對(duì)PICC影響目的：研究患者上肢由外展(abduction)變?yōu)閮?nèi)收(adduction)時(shí)，PICC導(dǎo)管頭端的位置是否發(fā)生顯著的移位材料與方法：患者上肢成90度外展，在超聲導(dǎo)引下，PICC導(dǎo)管從肱靜脈或貴要靜脈置入。患者前胸放置一根不透x線的標(biāo)尺，患者在平靜呼吸下，攝取數(shù)字式正位胸片，患者上肢從外展到內(nèi)收后，拍攝另一張胸片。利用不透x線標(biāo)尺和固定的骨性標(biāo)志，測(cè)量導(dǎo)管頭端的移位情況2021/8/239上肢的內(nèi)收和外展對(duì)PICC影響結(jié)果：研究期間，61例患者接受了PICC導(dǎo)管置入，8例不包括在最終的研究之列。33例從右側(cè)上肢，20例從左側(cè)上肢置入PICC。最后，當(dāng)上肢從外展位置回

17、到內(nèi)收位置時(shí)候，當(dāng)上肢從外展位置回到內(nèi)收位置時(shí)候，43例向足側(cè)移動(dòng)，7例向頭側(cè)移位，3例沒(méi)有發(fā)生移動(dòng)。對(duì)于那些向足側(cè)移位的患者，平均移動(dòng)的距離21mm（253mm)。右側(cè)上肢比左側(cè)上肢更傾向與移位。但是，沒(méi)有獲得統(tǒng)計(jì)學(xué)上的支持（p=0.29)2021/8/240上肢的內(nèi)收和外展對(duì)PICC影響結(jié)論：在置入PICC導(dǎo)管時(shí)，當(dāng)上肢從外展到內(nèi)收時(shí)，導(dǎo)管頭端更容易向足側(cè)移位。58以上的患者PICC導(dǎo)管移位20 mm以上，這種改變需要在最終導(dǎo)管頭端定位時(shí)候考慮到2021/8/241上肢的內(nèi)收和外展對(duì)PICC影響PURPOSE PURPOSE This study examines whether the

18、tip of peripherally inserted central This study examines whether the tip of peripherally inserted central catheters (PICCs) moves catheters (PICCs) moves significantly with changes in arm position from abduction to adduction.MATERIALS AND METHODS The catheters were inserted in the brachial or basili

19、c MATERIALS AND METHODS The catheters were inserted in the brachial or basilic veins under 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 abducte

20、d and adducted 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 RESULTS Sixty-one consecutive PICCs were placed and evaluated

21、during the study period (eight patients period (eight patients were excluded). Thirtythree catheters were placed from the right arm and 20 from the left. Overall, 43 moved 43 moved caudally, seven caudally, seven moved cephalad, moved cephalad, and three did not move with movement of the arm from an

22、d three did not move with movement of the arm from abduction toabduction 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 PICCs, but this did not attain significance (P = .29).CONCLUSIONS There is a te

23、ndency for the PICC tip to move in a caudal direction CONCLUSIONS There is a tendency for the PICC tip to move in a caudal direction with the change in with the change in arm position from abduction to adduction; 58% of PICCs arm position from abduction to adduction; 58% of PICCs moved 20 mm or more. This change in position should be considered during moved 20 mm or more. This change in position should be considered during final catheter tip positioning.final catheter tip positioning.2021/8/242PICC 導(dǎo)管置入的導(dǎo)向方法透視導(dǎo)引放置導(dǎo)管頭端能夠隨時(shí)調(diào)整到位性價(jià)比差床邊PICC后胸片位置不正確，調(diào)整后（blindly)再胸片簡(jiǎn)便Wh