1、PICC導(dǎo)管頭端定位與并發(fā)癥處理楊正強江蘇省人民醫(yī)院 介入放射科2021/7/16 星期五1PICC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線骨性標記導(dǎo)管走行導(dǎo)管頭端位置2021/7/16 星期五2PICC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2021/7/16 星期五3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2021/7/16 星期五4右心房與右心耳Right atrium and Right atrial appendage2021/7/16 星期五5右心耳下腔靜脈（ICV），下位峽部（CTI）

2、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 appendage2021/7/16 星期五6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 3652021/7/16 星期五7Cavoatrial 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

3、:359 3652021/7/16 星期五8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一2021/7/16 星期五9正位胸片上的常用標記(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) 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 A

5、naesthesia,96 (3): 33540 (2006)2021/7/16 星期五12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)管容易達到與上腔靜脈平行2021/7/16 星期五13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2021/7/16 星期五14PICC導(dǎo)管頭端位置異常左側(cè)置入的PICC,導(dǎo)管頭端異位，進入同側(cè)的頸內(nèi)靜脈2021/7/16 星期五15PICC導(dǎo)管頭端位置異常左側(cè)置入的PICC導(dǎo)管，頭端進入對側(cè)的鎖骨下靜脈2021/7/16 星期五16PICC導(dǎo)管頭端位置異常PICC

6、導(dǎo)管頭端進入內(nèi)乳靜脈2021/7/16 星期五17文獻中外置中央型導(dǎo)管的頭端位置2021/7/16 星期五18CVC 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 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 3652021/7/16 星期五19PICC 經(jīng)左側(cè)入路，導(dǎo)管頭端位置偏高2021/7/16 星期五20PICC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)，隨血流鐘擺運動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、肋間隙氣道標記右側(cè)氣管主支氣管角氣管隆突2021/7/16 星期五22PICC 導(dǎo)管的頭端位置氣管隆突做為標記更方

8、便2021/7/16 星期五23PICC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2021/7/16 星期五24PICC相關(guān)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 Cleveland Clinic Experience. Clin Infect Dis 2002.2021/7/16 星期五25基

9、本資料1994-1996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% of placements), and cytomegalovirus prophylaxis or viremia (for 8% of

10、placements)注冊護士PICC team3-4Fr Bard 單腔 PICC導(dǎo)管嚴格的無菌操作和置入后胸片檢查確定導(dǎo)管頭端的位置2021/7/16 星期五26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2021/7/16 星期五27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2021/7/16 星期五28Table 1. Sites of 52 venous thromboses associated with peripherally inse

11、rted central catheters in 51 patients靜脈血栓形成的部位2021/7/16 星期五29PICC 導(dǎo)管置入后的間隔時間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出現(xiàn)血栓后的處理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 central catheterrelated venou

13、s thromboses.2021/7/16 星期五32PICC 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 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 導(dǎo)管脫落至肺動脈2021/7/16 星期五34PICC 導(dǎo)管脫落至心臟，介入方法取出2021/7/16 星期五352021/7/16 星期五36臨床研究2021/7/16 星期五37上肢的內(nèi)收和外展對PICC影響目的：研究患者上肢由外展(abduction)變?yōu)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。患者前胸

15、放置一根不透x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(dǎo)管頭端的移位情況2021/7/16 星期五38上肢的內(nèi)收和外展對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(xué)上的支持（p=0.29)2021/7/16 星期

16、五39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2021/7/16 星期五40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 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 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 will be more advantageous2021/7/16 星期五42床邊PICC插管成功率研究對象：兒童,平均6.9歲介入手術(shù)