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,PICC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,PICC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,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,右心房与右心耳,Right atrium and Right atrial appendage,下腔静脉（ICV），下位峡部（CTI）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
2、),右前斜位,左前斜位,Right atrial appendage,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; 19:359 365,Cavoatrial 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; 19:359 365,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
3、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,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) aortic knuckle, (4) right atrium, (5) right ventricle, (6) left ventricle, (7) left atrium, (8) carina,
4、 (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 Anaesthesia,96 (3): 33540 (2006),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,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
5、以，应该留有足够的长度,PICC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,PICC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,PICC导管头端位置异常,PICC导管头端进入内乳静脉,文献中外置中央型导管的头端位置,CVC 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
6、in adolescents and young adults, irrespective of patient age, sex, height, weight, 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; 19:359 365,PICC 经左侧入路，导管头端位置偏高,PICC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,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
7、气管隆突,PICC 导管的头端位置,气管隆突做为标记更方便,PICC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,PICC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.,基本资料,1994-199
8、6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 placements)
9、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,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,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,Table 1. Sites of 52 venous thromboses associated with peripherally inserted central catheters in 51 patients,静脉血栓形成的部位,PIC
10、C 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.,出现血栓后的处理,Table 2. Therapy administered to 51 patients with 52 peripherally inserted central catheter (PICC)
11、related venous thromboses,PICC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 venous thromboses.,PICC 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
12、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 mobility in their upper extremities, which predisposed them to develop VT,PICC 导管脱落至肺动脉,PICC 导管脱落至心脏，介入方法取出
13、,临床研究,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,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
14、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),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,上肢的内收和外展对PICC影响,PURPOSE This study examines whether the tip of peripherally inserted central cathe
15、ters (PICCs) moves significantly with changes in arm position from abduction 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 wasthen placed
16、 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 fixed, bony anatomic landmarks.RESULTS Sixty-one consecutive PICCs were placed and evaluated dur
17、ing the study period (eight patients were excluded). Thirtythree catheters were placed from 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
18、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 tendency for the PICC tip to move in a caudal direction with the change in arm position from abduction to adduction; 58% of PICCs move
19、d 20 mm or more. This change in position should be considered during final catheter tip positioning.,PICC 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 advantageous,床边PICC插管成功率,研究对象：儿童,平均6.9岁介入手术室完全没有X线导引，模拟床边放置PICC放置后，X线点片检查观察导管头端在上腔静脉的初始到位率,材料与方法,14-month per
20、iod (20002001) 698例患者，843次PICC导管置入（男 463次，女 380次）682次静脉抗生素给药114 静脉补液和抗高血压药物45例肠道外营养2例化疗,PICC头端位于上腔静脉任何地方都为中心静脉导管头端位于上2/3者，也认为是中心静脉，但是需要调整到下1/3为理想,SVC上界右侧气管支气管角下界为心脏右侧缘稍凹陷处,上腔静脉 14%右心房 26%头臂干14%颈静脉13%,锁骨下静脉 9%腋静脉 8%贵要静脉、头静脉、其他11%不成功 5%,Which is the Access Where is the Tip,Which is the Access Where is the Tip,结果,儿童的PICC导管放置，采用床边置管方式，85.8%(753/843)需要进行重新调整在间断透视导引，PICC导管到位率更高,讨论,文献报道成人中，床边方式，PICC导管到位率44% to 99%儿童的静脉管径小文章对中心静脉的严格定义,Smile for a Better LifeThank you for your attention,
