Radiological Insertion of PICC Dept of Diagnostic Radiology

Radiological Insertion of PICC Dept. of Diagnostic Radiology, Chang Gung Memorial Hospital, Chia-Yi Speaker: Chien-lin Liao Date: 2007. 04 11/5/2020 1

前言 n n 認識CVC(中心靜脈導管) Purpose of CVC Why PICC ？ How to do it？ 11/5/2020 2

中心靜脈導管的分類 Devises and insertion techniques 〉周邊靜脈置入-Peripherally Inserted Central Catheters(PICC Lines) 〉皮下植入-Subcutaneous Port、Hickman Catheter n 11/5/2020 4

靜脈導管種類 〉依導管末端開口 n Close end (Groshong) n Open end 〉依管腔分類 n Single lumen n Dual lumen n Triple lumen 11/5/2020 Groshong slit valve 7

CVC (Triple Lumen Central Venous Catheter) 11/5/2020 11

Tunneled Catheter ( Hickman) n 11/5/2020 13

Tunneled Catheter ( Hickman) 11/5/2020 14

Tunneled Catheter ( Hickman) 11/5/2020 15

Tunneled Catheter ( Hickman) 11/5/2020 16

SVAD (Subcutaneous Vascular Access Device): Port-A 11/5/2020 18

SVAD (Subcutaneous Vascular Access Device): Port-A 11/5/2020 19

11/5/2020 Single Lumen Port Double Lumen Port 20

PICC 的種類 依其導管末端之不同 -Open end -Close end (Groshong Catheter) n 依其導管管腔之不同 -Single lumen -Dual lumen n 11/5/2020 22

PICC (Peripherally Inserted Central Catheter) 11/5/2020 23

Structure of PICC 11/5/2020 24

Many brands of PICC Cook 11/5/2020 25

Many brands of PICC BD Arrow, Bard , BD, Cook , HDC 11/5/2020 26

Hickman and Port Site 11/5/2020 PICC Line Site 27

Why PICC? n Problems with traditional CVCs insertion: 1. Invasive, expensive 2. Pneumothorax: ～ 5% 3. Central vein traumatic occlusion 4. Infection rate: CVCs > PICC 5. Bleeding complication: CVCs > PICC 11/5/2020 28

Why PICC? Phlebitis Difficult iv access O 2, bleeding tendency, can’t lie flat purpura 11/5/2020 29

Why PICC? Port / Hickman catheters PICC does exactly the same job as CVCs 11/5/2020 30

PICC may be the initial line 1. Estimated iv use > 2 wks < 6 mo 2. Frequent iv access 3. Iv infusate is hypertonic, toxic phlebitis 4. Can’t lie flat or bleeding tendency 5. Preserve as much peripheral veins 11/5/2020 31

血管的選擇 依其解剖位置及特性依序為 n 貴要靜脈 (Basilic Vein) n 肘正中靜脈 (Median cubital Vein) n 頭靜脈 (Cephalic Vein) 11/5/2020 32

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Peel-away sheath 1 3 11/5/2020 2 4 37

Nurse insertion at bedside: as early as 1988 11/5/2020 39

Radiological insertion of PICC All access service provider: Image guidance No visible or palpable vein IJ Echoguide venipuncture 11/5/2020 40

Ultrasound-guided Insertion 11/5/2020 42

Post PICC 11/5/2020 43

The use of peripherally inserted central catheter (PICC) in adult with acute leukemia Sung-Yu Chu Kee-Min Yeow Chin J Radiol 2004； 29： 61 -66 n 1998. 6 to 2000. 9 CGMH n Total cases=41 newly diagnosed acute leukemia patients n Successful rate = 97. 7% (43/44) n Pneumothorac rate = 100% negative n No hemotoma was noted at puncture sits Difficult access sites basilic vein=14 Brachial vein=12 cephalic vein=13 antecubital vein=4 RT IJ=1 n The PICCs were used for total 3219 catheter-days (mean 73. 2 days ) n Thirty-three PICCs have been user for chemotherapy for average of 1. 9 courses (range 1~5) Concerns: n Infection-less than conventional central venous catheter. 11/5/2020 44

PICC material n 1. 2. 3. 4. 5. 6. Silicone 80% Softer-nurse insertion Bursting pressure: 5. 5 -11. 5 atm 125 psi 4 Fr ID: 0. 024” Flow rate: saline 500 m. L/hr intrafat 250 m. L/hr Occlusion: higher 11/5/2020 • Polyurethane 1. 20% 2. Stiffer-traumatic 3. Bursting pressure: 19 -25 atm 350 psi 4. 4 Fr ID: 0. 032” 5. Flow rate: saline 1000 m. L/hr intrafat 500 ml/hr 6. Occlusion: lower 45

Power Injection of X-ray contrast (X) Manufacturer Recommended: 1. Max flow rates < 3000 m. L /hr 2. Infusion pressure <100 psi n Listed rate: 4 Fr Silicone: not recommended for power injection 4 Fr polyurethane : 0. 3 m. L/ sec Rate needed for liver triphasic study: 2. 5 cc/sec May be 5 Fr silicone, 4 -5 Fr polyurethane for routine abd CT n 11/5/2020 46

Reference n n Sung-Yu Chu Kee-Min Yeow The use of peripherally inserted central catheter (PICC) in adult with acute leukemia: Chin J Radiol 2004； 29： 61 -66 Kee-Min Yeow　Cheng-Hsu Wang　Ta-Hsing Liao　Jen-Shi Chen The Groshong Peripheral Inserted Central (PIC) Catheter: Iinitial Experience with Ultrasound-guided Insertion Accepted : Chin J Radiol 1999； 24(2)： 61 -66 Bottino J, Mc. Credie KB, Groschel DHM, Lawson M. Long-term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer 1979; 43: 1937 -43 Care of your peripherally inserted central catheter - A guide for patients and their families 11/5/2020 48

THANKS FOR YOUR ATTENTION!! 11/5/2020 49

Common Types Of CVCs Hickman or PICC Line Dialysis Broviac Catheter Catheter 11/5/2020 Implantable Ports 50

導管大小比較表 French Diameter Ga size (mm) uge 11/5/2020 1. 6 0. 5 25 2. 0 0. 6 23 3. 0 1. 0 20 4. 0 1. 3 18 5. 0 1. 6 16 6. 0 2. 0 14 9. 0 3. 0 　 51

各類導管之血栓成形性（Thrombogenicity）的比較表 材料 血栓成形性 導管表面 硬度 Siliconlene 中等 粗造 低 Polyethylene 中等 粗造 高 Polyurethrance 低 平滑 低 Teflon 高 平滑 高 Polyvinylchoride 高 平滑 高 Tecoflex 低 平滑 低 11/5/2020 52

導管沖洗 為維持導管通暢減少血栓形成，其不同導管沖洗頻率不同 導管種類 沖洗方式 1. Nontunnoled CVC 沖洗液 1~2 ml Heparin solution， daily 2. Tunnled CVC 沖洗液 3~4 ml Heparin solution， daily 3. PICC Groshong： 5 ml ，0. 9 N/S，7 days 4. Port 3~5 ml， 4 wks Heparin沖洗常用濃度為 100 u/ml 11/5/2020 53

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