picc導(dǎo)管頭端定位與并發(fā)癥處理

1、PICC導(dǎo)管頭端定位與并發(fā)癥處理,楊正強(qiáng)江蘇省人民醫(yī)院 介入放射科,PICC導(dǎo)管的影像學(xué)評估內(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,PICC導(dǎo)管技術(shù)的相關(guān)解剖,前臂正中靜脈 頭靜脈 貴要靜脈 肱靜脈 腋靜脈 鎖骨下靜脈,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,右心房與右心耳,Right atrium

2、and Right atrial appendage,右心耳,下腔靜脈（ICV），下位峽部（CTI）室上嵴（SVC),主動脈（AO),以及右室流出道（ROVT）可見房室交界區(qū)水平的右心耳（RAA)和左右心房（RA and LA),右前斜位,左前斜位,Right atrial appendage,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

3、 Interv Radiol 2008; 19:359 –365,Cavoatrial 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 –365,奇靜脈,肺門上方匯入上腔靜脈,Azygos vein,在右膈腳處起于右腰升靜脈，沿食管的后方、胸主動脈的右側(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

4、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,正位胸片上的常用標(biāo)記,(1) 鎖骨(2) 肋骨(3) 主動脈球(4) 右心房(5) 右心室(6) 左心室(7) 左心房(8) 隆突(9) 右主支氣管(10) 左主支氣管(11) 橫膈(12) 氣管 (13) 肺,1) clavicle (2) rib, (3) aort

5、ic 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.,正位胸片上的心血管投射影像,中心靜脈導(dǎo)管頭端的理想位置,SVC,Cavoar

6、tial Junction ，略低于氣管隆突，高于心影輪廓？,British Journal of Anaesthesia,96 (3): 335–40 (2006),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,,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)該留有足夠的長度,,PICC導(dǎo)管頭端位置異常,左側(cè)置入的PICC,導(dǎo)管頭

7、端異位，進(jìn)入同側(cè)的頸內(nèi)靜脈,,PICC導(dǎo)管頭端位置異常,,左側(cè)置入的PICC導(dǎo)管，頭端進(jìn)入對側(cè)的鎖骨下靜脈,,PICC導(dǎo)管頭端位置異常,PICC導(dǎo)管頭端進(jìn)入內(nèi)乳靜脈,,文獻(xiàn)中外置中央型導(dǎo)管的頭端位置,CVC 導(dǎo)管頭端的位置,On a plain chest radiograph, a point two vertebral body units below the carina is a reliable estimate of the

8、 position of the anatomic cavoatrial junction in adolescents and young adults, irrespective of patient age, sex, height, weight, or body surface area. 在兒童和青年人群中，氣管隆突下方2個椎體是CAJ 的位置,－J Vasc Interv Radiol 2008; 19:359 –365

9、,PICC 經(jīng)左側(cè)入路，導(dǎo)管頭端位置偏高,PICC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,,,,熟悉心血管在胸片上的投射影像,胸片上SVC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,PICC 導(dǎo)管的頭端位置,氣管隆突做為標(biāo)記更方便,PICC的相關(guān)并發(fā)癥,穿刺部位的血腫右心房血栓與肺動脈栓塞導(dǎo)管斷裂，游離感染,PICC相關(guān)的靜脈

10、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.,基本資料,1994-1

11、996年，34個月期間，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

12、% of placements), and cytomegalovirus prophylaxis or viremia (for 8% of placements)注冊護(hù)士PICC team3-4Fr Bard 單腔 PICC導(dǎo)管嚴(yán)格的無菌操作和置入后胸片檢查確定導(dǎo)管頭端的位置,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：無名靜脈、鎖骨下靜脈、頸內(nèi)靜脈,治

13、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,Table 1. Sites of 52 venous thromboses associated with peripherally inserted central catheters in 51 patients,靜脈血栓形成的部位,PICC 導(dǎo)管置入后的間隔時間,Figure 1. Interval of time from t

14、he day of insertion of peripherally inserted central catheters to the day of diagnosis of upper extremity venous thrombosis for all case patients.,出現(xiàn)血栓后的處理,Table 2. Therapy administered to 51 patients with 52 peripherall

15、y inserted central catheter (PICC)–related venous thromboses,PICC靜脈血栓形成的相關(guān)因素,Table 3. Univariate logistic regression analysis of the demographic characteristics and risk factors of patients with peripherally inserted cen

16、tral catheter–related venous thromboses.,PICC 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600mOsm/L 高風(fēng)險A skilled-nursing facility（高級保健所）We speculate that these patients, who usua

17、lly required help with their daily activities and with antibiotic administration, had decreased mobility in their upper extremities, which predisposed them to develop VT,PICC 導(dǎo)管脫落至肺動脈,PICC 導(dǎo)管脫落至心臟，介入方法取出,,臨床研究,上肢的內(nèi)收和外展對P

18、ICC影響,目的：研究患者上肢由外展(abduction)變?yōu)閮?nèi)收(adduction)時，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?；颊咔靶胤胖靡桓煌竫線的標(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，測量導(dǎo)管頭端的移位情況,上肢的內(nèi)收和外展對PICC影響,結(jié)果：研究期間，61

19、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)上肢從外展位置回到內(nèi)收位置時候，43例向足側(cè)移動，7例向頭側(cè)移位，3例沒有發(fā)生移動。對于那些向足側(cè)移位的患者，平均移動的距離21mm（2－53mm)。右側(cè)上肢比左側(cè)上肢更傾向與移位。但是，沒有獲得統(tǒng)計學(xué)上的支持（p=0.29),上肢的內(nèi)收和外展對PICC影響,結(jié)論：在置入PICC導(dǎo)管時，當(dāng)上肢從外展到內(nèi)收時，導(dǎo)管頭端更容易向

20、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)管頭端定位時候考慮到,上肢的內(nèi)收和外展對PICC影響,PURPOSE This study examines whether the tip of peripherally inserted central catheters (PICCs) moves significantly with changes in arm position from abduc

21、tion to adduction.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

22、 wasthen placed on the anterior chest and digital images were obtained with the arm abducted and adducted in a similar phase of quiet respiration. Catheter tip movement was measured with use of the radiopaque ruler and f

23、ixed, bony anatomic landmarks.RESULTS Sixty-one consecutive PICCs were placed and evaluated during the study period (eight patients were excluded). Thirtythree catheters were placed from the right arm and 20 from the le

24、ft. 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, 2–53 mm). Rig

25、ht arm PICCs tended to move more than left arm 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 ab

26、duction to adduction; 58% of PICCs moved 20 mm or more. This change in position should be considered during final catheter tip positioning.,PICC 導(dǎo)管置入的導(dǎo)向方法,透視導(dǎo)引放置導(dǎo)管頭端能夠隨時調(diào)整到位性價比差,床邊PICC后胸片位置不正確，調(diào)整后（blindly)再胸片簡便,Which

27、 will be more advantageous,床邊PICC插管成功率,研究對象：兒童,平均6.9歲介入手術(shù)室完全沒有X線導(dǎo)引，模擬床邊放置PICC放置后，X線點(diǎn)片檢查觀察導(dǎo)管頭端在上腔靜脈的初始到位率,材料與方法,14-month period (2000–2001) 698例患者，843次PICC導(dǎo)管置入（男 463次，女 380次）682次靜脈抗生素給藥114 靜脈補(bǔ)液和抗高血壓藥物45例腸道外營養(yǎng)2例化療

28、,,PICC頭端位于上腔靜脈任何地方都為中心靜脈導(dǎo)管頭端位于上2/3者，也認(rèn)為是中心靜脈，但是需要調(diào)整到下1/3為理想,,SVC上界右側(cè)氣管支氣管角下界為心臟右側(cè)緣稍凹陷處,,上腔靜脈 14%右心房 26%頭臂干14%頸靜脈13%,鎖骨下靜脈 9%腋靜脈 8%貴要靜脈、頭靜脈、其他11%不成功 5%,Which is the Access Where is the Tip,Which is the Access W