1、Lines and tubes in Neonates,2018/7/23,1,From:Paediatric Radiology and Neonatology of the Emmas Children Hospital, Academical Medical Center, AmsterdamPublication date:November 5, 2013Translator:Ma Qiuhong,Contents,2018/7/23,2,Umbilical artery line（脐动脉线） Umbilical vein catheter （脐静脉管） Peripherally In
2、serted Central Catheter（中心静脉导管） Endotracheal tube（气管导管） Chest drainage tube （胸腔引流管） Gastric catheters （胃管） Reploggels suction catheter（抽吸导管） Extracorporeal membrane oxygenation （体外膜肺氧合）,In this review we will discuss the normal and abnormal position of tubes and lines on a neonatal chest x-ray.,1、Um
3、bilical artery line,Umbilical artery catheterization provides direct access to the arterial system and allows accurate measurement of arterial blood pressure, blood sampling and intravascular access for fluids and medication （脐动脉插管可直接进入动脉系统，可精确测量动脉血压、血液采集以及经血管内使用液体和药物）The catheter should be passed t
4、hrough the umbilic artery and enter the aorta via the internal iliac artery.It should demonstrate the typical loop from the umbilicus inferiorly into the internal iliac artery. （导管应通过脐动脉、经髂内动脉进入主动脉，从脐下至髂内动脉显示典型的环）,2018/7/23,3,2018/7/23,4,In order to avoid placement into aortic branches, the catheter
5、 should be either in a high position above the celiac, mesenteric and renal arteries or in a low position below the inferior mesenteric artery:（为了避免导管放置主动脉分支中，导管要么位于腹腔干，肠系膜上和肾动脉以上，要么位于肠系膜下动脉以下）high position: T6-T9（高位置管）low position: L3-L5（低位置管）The high position is advisable since it leads to less va
6、scular complications.（高位置管是合适的因为可以减少血管并发症）,Umbilical artery line (2)First study the images.Then continue reading.The findings are:Umbilical artery line in a good high position.Malposition of umbilical vein line in right portal vein. （异位的脐静脉位于门静脉右侧）,2018/7/23,5,2018/7/23,6,Umbilical artery line (3)Fi
7、rst study the images.Then continue reading.The findings are:Malposition of umbilical artery line, folded（折叠） in the abdominal aorta.,2018/7/23,7,Umbilical artery line (4)First study the images.Then continue reading.The findings are:Deep position of umbilical artery line, in aortic arch（主动脉弓）.Umbilic
8、al vein line with tip in right portal vein.（脐静脉尖端位于门静脉右支）,2018/7/23,8,Umbilical artery line (5)First study the images.Then continue reading.The findings are:Malposition of umbilical artery line in left iliac artery（左侧髂动脉）.Deep position of umbilical vein line in right atrium（右心房）.Good position of gas
9、tric tube.（胃管）,2、Umbilical vein catheter,An umbilical vein catheter should pass through the umbilic vein into the left portal vein.（脐静脉导管通过脐静脉进入左侧门静脉）Then through the ductus venosus into a hepatic vein and the inferior caval vein (IVC).（然后通过导管静脉入肝静脉和下腔静脉（IVC）The tip should be positioned in the IVC a
10、t the level of the diaphragm（尖端应位于横隔膜水平的下腔静脉内）Several line malpositions are possible：Low position in the umbilical vein.（脐静脉位置低）Not all medication can be administered through a line in this position.Intrahepatic into the portal venous system, both right and left, or even into the superior mesenteric
11、 or splenic vein（肝内门静脉系统，包括左右测，甚至到肠系膜上静脉或脾静脉）。This can cause thrombosis（血栓）.,2018/7/23,9,2018/7/23,10,Perforation of the portal vein can cause haemorrhage or abscess formation in the liver.（门静脉穿孔可导致肝内出血或脓肿形成）Position too deep in right atrium or in the left atrium through a patent foramen ovale or at
12、rial septal defect.This can lead to cardiac arrhythmias or perforation.（导管位置太深，位于右心房或左心房内，通过卵圆孔未闭或房间隔缺损，可导致心律失常或穿孔）,2018/7/23,11,Umbilical venous line (2)First study the images.Then continue reading.The findings are:Umbilical vein line positioned in the periphery of the liver through the right porta
13、l vein.（脐静脉经右侧门静脉位于肝脏边缘）Artery line in the left subclavian artery（左锁骨下动脉）.,2018/7/23,12,Umbilical venous line (3)First study the images.Then continue reading.The findings are:This is a lateral horizontal beam radiograph.(横向水平投照位)It illustrates the umbilical vein line following the traject of the umb
14、ilical vein into the liver (blue arrow).（显示脐静脉管沿着脐静脉进入肝脏）The line is not deep enough.The umbilical arterial line first passes caudally（尾部） and enters the iliac artery（髂动脉） (red arrow).,Umbilical venous line (4)Study the image.Then continue reading.The findings are:The umbilical vein line is position
15、ed （位于）in the umbilical vein and not deep enough.,2018/7/23,13,2018/7/23,14,Umbilical venous line (5)Study the image.Then continue reading.The findings are:The tip of the umbilical vein line is pointed downwards and probably situated in the mesenterical vein.（脐静脉管尖端朝下，可能位于小肠系膜静脉内）,2018/7/23,15,Umbil
16、ical venous line (6)Study the images.Then continue reading.The findings are:The umbilical venous line is too deep and positioned in the right atrium 右心房.The umbilical arterial line is at the level of T10 (preferrably at level T6-T9).最好The endotracheal tube is positioned too deep.It should be 1 cm ab
17、ove the trachea bifurcation.（气管插管）,2018/7/23,16,Umbilical venous line (7)Study the images.Then continue reading.The findings are:The umbilical venous line is too deep.The line probably went through a patent foramen ovale and through the left atrium into a pulmonary vein.（脐静脉管太深，可能会通过未必的卵圆孔进入左心房到肺静脉）
18、,2018/7/23,17,2018/7/23,18,2018/7/23,19,In this patient ultrasound detected a thrombus in the left portal vein after umbilical venous line (arrows).（脐静脉插管后作左侧门静脉血栓）Catheter malposition in the left portal vein increases the occurrence of portal venous thrombosis.（左侧门静脉导管移位增加静脉血栓形成）Clinically silent p
19、ortal venous thrombosis is frequently associated with catheterization of the umbilical vein in critically ill neonates, and spontaneous resolution without any treatment is expected in many cases.,临床上无症状的门静脉血栓常与危重新生儿的脐静脉插管有关，在许多情况下无需任何治疗就可自发消退。,2018/7/23,20,Umbilical venous line (8)Study the images.T
20、hen continue reading.The findings are:The umbilical venous line is too deepAfter repositioning the tip is in a good position.Notice that the endotracheal tube is too deep.,3、Peripherally Inserted Central Catheter（经外周穿刺中心静脉导管）,A peripheral inserted central catheter or PICC line is positioned in the g
21、reat vessels, preferably in the superior or inferior caval vein(上下腔静脉).It is important for the neonatologist（新生儿专家） to know if the line is in a superficial position, because then not all medication can be given.The left image shows a PICC line, that was placed in the left arm.It was hard to determin
22、e the exact location of the tip.The lumen（腔） of the line was filled with contrast, showing the tip of the line high in the superior caval vein.,2018/7/23,21,It is advised not to use more contrast than the volume of the line, in order to prevent hypothyroidism(甲状腺功能减退) in reaction to iodine containin
23、g contrast(碘对比剂), although the risk is low.,2018/7/23,22,2018/7/23,23,（PICC管尖端准确位置是在右心房之上约3-5cm处，或位于上腔静脉的中1/3至下1/3处）,血管造影显示上腔静脉由左右头臂静脉在左右侧第一肋软骨和胸骨柄交界水平汇合而成，宽1.52.0cm。正位时可见其沿纵隔右缘几乎垂直下行68cm进入右心房上部。,2018/7/23,24,PICC line (2)Study the image.Then continue reading.The findings are:Malpositioned PICC line
24、 in the right atrium.,2018/7/23,25,PICC line(3)Study the image.Then continue reading.The findings are:Malpositioned PICC line.Probably located in the coronary sinus (冠状窦)or in the left atrium (左心房)after passing through a patent foramen ovale（未闭的卵圆孔）.,PICC line(4)Study the image.Then continue reading
25、.The findings are:Malpositioned PICC line through a patent foramen ovale into the left atrium and subsequently into a pulmonary vein(肺静脉).,2018/7/23,26,4、Endotracheal tube（气管插管）,The tip of an endotracheal tube should be in between the thoracic aperture （胸廓口）and 1 cm above the carina（气管隆突）.The tip tr
26、avels downward if the neck is flexed or upward if the neck is extended.（如果颈部屈曲尖端下移，颈部伸展尖端上移）The most common malpositioning is in the right mainstem bronchus（右主支气管）, because of the shallower（浅、小） angle of the right main bronchus.,2018/7/23,27,Here a good positioned tube in a patient with a pneumothor
27、ax （气胸）on the left.,2018/7/23,28,Endotracheal tube (2)Study the image.Then continue reading.The findings are:Right mainstem bronchus intubation with atelectasis （肺不张）of the entire left lung.,2018/7/23,29,Endotracheal tube (3)Study the image.Then continue reading.The findings are:Endotracheal tube is
28、 positioned in the oesophagus（食道）.Chest radiograph shows dilatation of the esophagus and stomach, that are filled with air (arrows).,2018/7/23,30,Endotracheal tube (4)Study the image.Then continue reading.The findings are:Endotracheal tube is positioned in the right main bronchus.Atelectasis of left
29、 upper lobe of the lung（左肺上叶不张）.,2018/7/23,31,5、Chest drainage tube（胸腔引流管）,Chest drainage tube are placed in case of respiratory distress caused by pleural fluid or pneumothorax（胸腔积液或气胸引起的呼吸困难） in order to allow sufficient expansion of the lung for ventilation（使肺充分通气复张）.The tube should be positioned
30、 in the midaxillary line via the 4th - 6th intercostal space（腋中线第4-6肋间隙）.The position should be apical anterior（前上方） in patients with a pneumothorax（气胸）.,2018/7/23,32,Study the image.Then continue reading.The findings are:Endotracheal tube in good position.Straight chest drain tube in good position.
31、 Drainage however is not optimal(积气排放不是最佳).Mediastinal shift to the right（纵隔右移）. There is however no tension-pneumothorax（张力性气胸）, since the diaphragm has a normal convex upper border（横隔上缘正常向上凸）.,2018/7/23,33,8、Extracorporeal membrane oxygenation（体外膜肺氧合）,Extra corporal membrane oxygenation or ECMO is
32、 a extracorporeal technique to oxygenate the child when conventional circulatory and respiratory support fails.One sheet is placed in the superior caval vein and one in the brachiocephalic artery （体外膜肺氧合或ECMO是当常规的循环、呼吸支持失败时进行的体外循环技术。一端放置上腔静脉，一端放置头臂动脉）,2018/7/23,34,In this patient, who has a large pn
33、eumatocele（肺大疱）, a pigtail catheter （猪尾巴形导管）is placed in the pneumatocele.Complications of chest tubes are:Perforation of vessels or pericardium. This may cause hematothorax.（血管或心包穿孔，可能导致血胸）Subcutaneous or subpleural position.This will result in an aberrant position of the drain and dysfunction. （位于
34、皮下或胸膜下，这些异常位置将导致引流和功能障碍。）,2018/7/23,35,6、Gastric catheters（胃管）,Gastric catheters should be positioned with the tip in the stomach.,2018/7/23,36,7、Reploggels suction catheter（里普洛格尔抽吸管）,Replogles suction catheters are used in case of oesophageal atresia to remove saliva.（食道闭锁患儿吸取痰液）They are positioned
35、 in the blind ending oesophagus.（食管盲端）The markings of a Replogles suction catheter form a dashed line（虚线）.Here a preterm infant with oesophageal atresia with a fistula.（食道闭锁合并瘘的早产儿）There is a Reploggels drain in situ.（引流）Notice deep position of endotracheal tube and atelectasis of left upper lobe. （注意气管导管位置和左肺上叶不张）,2018/7/23,37,
