PICC導(dǎo)管的影像學(xué)評(píng)估ppt課件(PPT 52頁)

1、PICC導(dǎo)管頭端定位與并發(fā)癥處理1第1頁，共52頁。PICC導(dǎo)管的影像學(xué)評(píng)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2第2頁，共52頁。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3第3頁，共52頁。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4第4頁，共52頁。右心房與右心耳Right atrium and Right atrial appendage5第5頁，共52頁。右心耳下腔靜脈（ICV），下位峽部（CTI）室上嵴（SVC),主動(dòng)脈（AO),以及右室流出道（ROVT）可見房室交界

2、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 appendage6第6頁，共52頁。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 3657第7頁，共52頁。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 3658第8頁，共52頁。奇靜脈肺門上方匯入上腔靜脈Azygos vein在右

3、膈腳處起于右腰升靜脈，沿食管的后方、胸主動(dòng)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一9第9頁，共52頁。正位胸片上的常用標(biāo)記(1) 鎖骨(2) 肋骨(3) 主動(dòng)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) aortic knuckle, (4) right atrium, (5) right ventricle

4、, (6) left ventricle, (7) left atrium, (8) carina, (9) right bronchus, (10) left bronchus, (11) diaphragm, (12) trachea, (13) lungs.10第10頁，共52頁。正位胸片上的心血管投射影像11第11頁，共52頁。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 Anaesthesia,96 (3): 33540 (2006)12第12頁，共52頁。右側(cè)入路PICC 導(dǎo)管的頭端位

5、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13第13頁，共52頁。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14第14頁，共52頁。PICC導(dǎo)管頭端位置異常左側(cè)置入的PICC,導(dǎo)管頭端異位，進(jìn)入同側(cè)的頸內(nèi)靜脈15第15頁，共52頁。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(duì)側(cè)的鎖骨下靜脈16第16頁，共52頁。PICC導(dǎo)管頭端位置異常PICC導(dǎo)管頭端進(jìn)入內(nèi)乳靜脈17第17頁，共52頁。文獻(xiàn)中外置中央型導(dǎo)管的頭端位置18第18頁，共52頁。CVC 導(dǎo)管頭端的位置On a plain ch

6、est 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, weight, or body surface area. 在兒童和青年人群中，氣管隆突下方2個(gè)椎體是CAJ 的位置J Vasc Interv Radiol 2008;

7、 19:359 36519第19頁，共52頁。PICC 經(jīng)左側(cè)入路，導(dǎo)管頭端位置偏高20第20頁，共52頁。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(dòng)21第21頁，共52頁。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22第22頁，共52頁。PICC 導(dǎo)管的頭端位置氣管隆突做為標(biāo)記更方便23第23頁，共52頁。PICC的相關(guān)并發(fā)癥穿刺部位的血腫右心房血栓與肺動(dòng)脈栓塞導(dǎo)管斷裂，游離感染24第24頁，共52頁。PICC相關(guān)的靜脈血栓Chemaly RF;de Parr

8、es 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 2002.25第25頁，共52頁?；举Y料1994-1996年，34個(gè)月期間，2063例PICC 置入Indications for PICC placement included soft-tissue and bone infect

9、ions (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)注冊(cè)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26第26頁，共52頁。上肢靜脈血栓( UEVT)上肢表淺靜脈血

10、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27第27頁，共52頁。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28第28頁，共52頁。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29第29頁，共52頁。PICC 導(dǎo)管置入后的間隔時(shí)間Figure 1. Interval of time from the

11、day of insertion of peripherally inserted central catheters to the day of diagnosis of upper extremity venous thrombosis for all case patients.30第30頁，共52頁。出現(xiàn)血栓后的處理Table 2. Therapy administered to 51 patients with 52 peripherally inserted central catheter (PICC)related venous thromboses31第31頁，共52頁。PI

12、CC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 venous thromboses.32第32頁，共52頁。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(xiǎn)600mOsm/L

13、高風(fēng)險(xiǎn)A skilled-nursing facility（高級(jí)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 VT33第33頁，共52頁。PICC 導(dǎo)管脫落至肺動(dòng)脈34第34頁，共52頁。PICC 導(dǎo)管脫落至心臟，介入方

14、法取出35第35頁，共52頁。36第36頁，共52頁。臨床研究37第37頁，共52頁。上肢的內(nèi)收和外展對(duì)PICC影響目的：研究患者上肢由外展(abduction)變?yōu)閮?nèi)收(adduction)時(shí)，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38第38頁，共52頁。上肢的內(nèi)收和外展對(duì)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

15、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(shí)候，43例向足側(cè)移動(dòng)，7例向頭側(cè)移位，3例沒有發(fā)生移動(dòng)。對(duì)于那些向足側(cè)移位的患者，平均移動(dòng)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(jì)學(xué)上的支持（p=0.29)39第39頁，共52頁。上肢的內(nèi)收和外展對(duì)PICC影響結(jié)論：在置入PICC導(dǎo)管時(shí)，當(dāng)上肢從外展到內(nèi)收時(shí)，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(shí)候考慮到40第40頁，共52頁。上肢的內(nèi)收和外展對(duì)PICC影響PURPOSE This stu

16、dy examines whether the tip of peripherally inserted central catheters (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

17、 90 abducted position. A flexible, radiopaque ruler 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 fixed, bony anatomic landmarks

18、.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 left. Overall, 43 moved caudally, seven moved cephalad, and three did not move with movement of the arm from abd

19、uction 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 did not attain significance (P = .29).CONCLUSIONS There is a tendency for the PICC tip to move in a caudal direction with the cha

20、nge 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.41第41頁，共52頁。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(shí)調(diào)整到位性價(jià)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 advantageous42第42頁，共52頁。床邊PICC插管成功率研究對(duì)象：兒