PICC導管頭端定位與并發(fā)癥處理課件

1、PICC導管頭端定位與并發(fā)癥處理PICC導管頭端定位(dngwi)與并發(fā)癥處理楊正強江蘇省人民(rnmn)醫(yī)院 介入放射科第一頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC導管(dogun)的影像學評估內(nèi)容PICC導管技術(shù)的相關(guān)(xinggun)解剖上腔靜脈氣管隆突右心房靜脈投影與X線骨性標記導管走行導管頭端位置第二頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC導管(dogun)技術(shù)的相關(guān)解剖前臂正中前臂正中(zhngzhng)(zhngzhng)靜脈靜脈 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 鎖骨下靜脈鎖骨下靜脈第三頁，共五十三頁。PICC導管頭端定

2、位與并發(fā)癥處理中心(zhngxn)靜脈解剖示意圖頸內(nèi)靜脈(jngmi) 頸外靜脈(jngmi) 右側(cè)頭臂干 上腔靜脈(jngmi)第四頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理右心房與右心耳(xn r)(xn r)Right atrium and Right atrial appendageRight atrium and Right atrial appendage第五頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理右心耳(xn r)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(fn sh)交界區(qū)水平的右心耳（RAA)和左右

3、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 appendage第六頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理右心耳(xn r)(xn r)界嵴（TC）把上腔靜脈(jngmi)（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; 19:359 365第七頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理Cavoatrial JunctionCavoatrial Junction腔靜脈與心房(xnfng)交界（CAJ)SVC 的起源氣

4、管隆突右心緣右側(cè)主支氣管腔靜脈心房(xnfng)交界J Vasc Interv Radiol 2008; 19:359 365第八頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理奇靜脈(jngmi)肺門上方肺門上方(shn fn)(shn fn)匯入上匯入上腔靜脈腔靜脈Azygos veinAzygos vein在右膈腳處起于右腰升靜脈，沿食管(shgun)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第九頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理

5、正位胸片上的常用(chn yn)標記(1) (1) 鎖骨鎖骨(2) (2) 肋骨肋骨(3) (3) 主動脈球主動脈球(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(xnfng)(xnfng)(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) le

6、ft ventricle, (7) left atrium, (8) carina, (9) right bronchus, (10) left bronchus, (11) diaphragm, (12) trachea, (13) lungs.第十頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理正位(zhn wi)胸片上的心血管投射影像第十一頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理中心靜脈導管頭端的理想(lxing)位置SVC,Cavoartial Junction ，略低于氣管隆突，高于心影(xn yn)輪廓？British Journal of Anaesthesia,96 (

7、3): 33540 (2006)第十二頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理右側(cè)(yu c)入路PICC 導管的頭端位置經(jīng)右側(cè)置入的PICC導管， 導管容易達到(d do)與上腔靜脈平行第十三頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理左側(cè)(zu c)入路PICC導管的頭端位置經(jīng)左側(cè)置入的PICC導管，如果導管太短，頭端容易(rngy)抵著SVC的外側(cè)壁，所以，應該留有足夠的長度第十四頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC導管(dogun)頭端位置異常左側(cè)置入的PICC,導管頭端異位(y wi)，進入同側(cè)的頸內(nèi)靜脈第十五頁，共五十三頁。PICC導管頭端定位與并發(fā)

8、癥處理PICC導管頭端位置(wi zhi)異常左側(cè)置入的PICC導管(dogun)，頭端進入對側(cè)的鎖骨下靜脈第十六頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC導管(dogun)頭端位置異常PICC導管(dogun)頭端進入內(nèi)乳靜脈第十七頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理文獻中外置中央型導管(dogun)的頭端位置第十八頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理CVC 導管(dogun)頭端的位置On a plain chest radiograph, a point two On a plain chest radiograph, a point two ver

9、tebral body units below the carina is vertebral body units below the carina is a reliable estimate of the position of a reliable estimate of the position of the anatomic cavoatrial junction in the anatomic cavoatrial junction in adolescents and young adults, adolescents and young adults, irrespectiv

10、e of patient age, sex, height, irrespective of patient age, sex, height, weight, or body surface area. weight, or body surface area. 在兒童和青年人群在兒童和青年人群(rnqn)(rnqn)中，氣管隆中，氣管隆突下方突下方2 2個椎體是個椎體是CAJ CAJ 的位置的位置J Vasc Interv Radiol 2008; 19:359 365第十九頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 經(jīng)左側(cè)(zu c)入路，導管頭端位置偏高第二十頁，共五十三

11、頁。PICC導管頭端定位與并發(fā)癥處理PICC導管(dogun)頭端位置位于RA肝癌患者，PICC導管頭端位于(wiy)RA內(nèi)，隨血流鐘擺運動第二十一頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理熟悉心血管在胸片上的投射(tush)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記第5和6 胸椎鎖骨下界第3、4肋骨(lig)、肋間隙氣道標記右側(cè)氣管主支氣管角氣管隆突第二十二頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 導管(dogun)的頭端位置氣管氣管(qgun)(qgun)隆突做為標記更方便隆突做為標記更方便第二十三頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理

12、PICC的相關(guān)(xinggun)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脈栓塞右心房血栓與肺動脈栓塞導管斷裂導管斷裂(dun li)(dun li)，游離，游離感染感染第二十四頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC相關(guān)(xinggun)的靜脈血栓Chemaly RF;de Parres JB;Rehm SJ;Adal KA; et al. Venous Thrombosis Associated with Peripherally Inserted Central Catheters: A Retrospective Analysis of the Clevelan

13、d Clinic Cleveland Clinic Experience. Clin Infect Dis 2002.第二十五頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理基本(jbn)資料1994-1996年，34個月期間(qjin)，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-

14、abdominal infections (for 9% of placements), and cytomegalovirus prophylaxis or viremia (for 8% of placements)注冊護士PICC team3-4Fr Bard 單腔 PICC導管嚴格的無菌操作和置入后胸片檢查確定導管頭端的位置第二十六頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理上肢靜脈(jngmi)血栓( UEVT)上肢表淺靜脈血栓血栓累及(lij)：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)靜脈第二十七頁，共五十三頁。PICC導管頭端定位與

15、并發(fā)癥處理治療(zhlio)措施肝素靜脈輸注，繼而口服(kuf)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第二十八頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理Table 1. Sites of 52 venous thromboses associated with peripherally inserted central catheters in 51 patients靜脈血栓(xushun)形成的部位第二十九頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 導管(dogun)置入后的間隔時間Figure 1. Interval of time from th

16、e day of insertion of peripherally inserted central catheters to the day of diagnosis of upper extremity venous thrombosis for all case patients.第三十頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理出現(xiàn)(chxin)血栓后的處理Table 2. Therapy administered to 51 patients with 52 peripherally inserted central catheter (PICC)related venous

17、thromboses第三十一頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC靜脈血栓形成的相關(guān)(xinggun)因素Table 3. Univariate logistic regression analysis of the demographic characteristics and risk factors of patients with peripherally inserted central catheterrelated venous thromboses.第三十二頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 靜脈血栓形成(xngchng)低相關(guān)因素導管頭

18、端的位置高滲和偏酸性溶液損傷血管內(nèi)皮細胞靜脈炎（手術(shù)操作(cozu)、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險600mOsm/L 高風險A skilled-nursing facility（高級保健所）We speculate that these patients, who usually required help with their daily activities and with antibiotic administration, had decreased mobility in their upper extremities, which pre

19、disposed them to develop VT第三十三頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 導管(dogun)脫落至肺動脈第三十四頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC PICC 導管導管(dogun)(dogun)脫落至心臟，介入方法取出脫落至心臟，介入方法取出第三十五頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理第三十六頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理臨床(ln chun)研究第三十七頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理上肢(shngzh)的內(nèi)收和外展對PICC影響目的：研究患者上肢由外展(abduction)變?yōu)?/p>

20、內(nèi)收(adduction)時，PICC導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(d wi)展，在超聲導引下，PICC導管從肱靜脈或貴要靜脈置入?；颊咔靶胤胖靡桓煌竫線的標尺，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線標尺和固定的骨性標志，測量導管頭端的移位情況第三十八頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理上肢(shngzh)的內(nèi)收和外展對PICC影響結(jié)果(ji gu)：研究期間，61例患者接受了PICC導管置入，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，當上肢從外展位置回到

21、內(nèi)收位置時候，當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（253mm)。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)計學上的支持（p=0.29)第三十九頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理上肢(shngzh)的內(nèi)收和外展對PICC影響結(jié)論：在置入PICC導管時，當上肢從外展到內(nèi)收時，導管頭端更容易向足側(cè)移位。58以上(yshng)的患者PICC導管移位20 mm以上(yshng)，這種改變需要在最終導管頭端定位時候考慮到第四十頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理上肢(shng

22、zh)的內(nèi)收和外展對PICC影響PURPOSE PURPOSE This study examines whether the tip of peripherally inserted central catheters (PICCs) This study examines whether the tip of peripherally inserted central catheters (PICCs) moves moves significantly with changes in arm position from abduction to adduction.MATERIALS A

23、ND METHODS The catheters were inserted in the brachial or basilic veins under 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 ante

24、rior 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 fixed, bony anatomic landmarks.RESULTS Sixty-one consecutive PICCs were placed and evaluated during the stud

25、y period (eight RESULTS Sixty-one consecutive PICCs were placed and evaluated during the study period (eight patients patients were excluded). Thirtythree catheters were placed from the right arm and 20 from the left. Overall, 43 moved 43 moved caudally, seven moved cephalad, caudally, seven moved c

26、ephalad, and three did not move with and three did not move with movement of the arm from abduction tomovement 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 PICCs, but this

27、 did not attain significance (P = .29).CONCLUSIONS There is a tendency for the PICC tip to move in a caudal direction with CONCLUSIONS There is a tendency for the PICC tip to move in a caudal direction with the change in the change in arm position from abduction to adduction; 58% of PICCs moved 20 m

28、m 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 or more. This change in position should be considered during final catheter tip positioning.positioning.第四十一頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理PICC 導管置入的導向(do xin

29、)方法透視導引放置導管(dogun)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(tiozhng)后（blindly)再胸片簡便Which will be more advantageous第四十二頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理床邊PICC插管成功率研究對象：兒童研究對象：兒童, ,平均平均6.96.9歲歲介入手術(shù)室介入手術(shù)室完全沒有完全沒有X X線導引線導引(do yn)(do yn)，模擬床邊放置，模擬床邊放置PICCPICC放置后，放置后，X X線點片檢查線點片檢查觀察導管頭端在上腔靜脈的初始到位率觀察導管頭端在上腔靜脈的初始到位率第四十三頁，共五十三頁。PICC導管頭端定位與并發(fā)癥處理材料(cilio)與方法14-month period (20002001) 698例患者(hunzh)，843次PICC導管置入（男 463次，女