CN113080937A - Method for predicting PICC (peripherally inserted Central catheter) catheter placement length - Google Patents

Abstract

The invention discloses a method for predicting PICC (peripherally inserted central catheter) catheter placement length, which comprises the following steps: step 1, before placing the tube, measuring the vertical distance B from the lower edge of the inner end of the right clavicle on the X-ray chest positioning sheet to 1 vertebral body below the trachea bulge; step 2, taking the patient in a horizontal position, extending the arm on the puncture side by 90 degrees, and measuring the distance A from the puncture point to the right sternoclavicular joint; and 3, calculating the PICC catheter implantation length L = A + B-2 cm. The PICC catheter placement length prediction method is simple and easy to implement, easy to operate clinically, high in accuracy and capable of ensuring that the tip of the catheter falls in the optimal area range. Because the data are derived from chest radiographs and human body measurement, errors caused by human body difference in the traditional method are avoided, and the method has better adaptability (the method is still effective when being applied to a humpback patient).

Description

Method for predicting PICC (peripherally inserted Central catheter) catheter placement length

Technical Field

The invention relates to a method for predicting PICC (peripherally inserted central catheter) catheter length, in particular to a method for measuring and calculating PICC catheter length.

Background

Peripherally Inserted Central Catheter (PICC) is widely used in clinical practice, and is recognized as a safe and less traumatic intravenous infusion route in the process of long-term intravenous infusion or periodic chemotherapy, but the tip position of the catheter is of great importance to achieve an ideal treatment effect. The accuracy of PICC puncture can be improved, the emergence of catheter dystopy is reduced to accurate prediction catheterization length.

The INS recommends that the optimal location of the PICC tip within the patient be the medial inferior vena cava 1/3, 3-4cm above the junction of the superior vena cava with the right atrium, and not be able to access the right atrium or right ventricle. However, in actual operation, the results of foreign investigation show that 34.2% of patients have improper PICC catheter tip positions, and relevant reports of the incidence rate of tip dislocation in China^[5]6.7 to 34.2 percent. The PICC tip ectopy is divided into two cases, one is ectopy caused by the PICC tip mistakenly entering a non-central vein, and the other is ectopy caused by improper length of the PICC. Usually, the catheter is too long, and the tip of the catheter enters the heart ectopically, when the catheter is too long and ectopic, arrhythmia can be caused, serious patients can cause heart perforation, and the catheter enters the right atrium to cause death of the patients. In addition, the catheter is positioned too shallowly, which can increase the occurrence of thrombosis and infection. How to place PICC tips in ideal locations becomes a hot spot for intravenous care personnel research. In recent years, the technology for positioning the catheter tip in real time is rapidly developed, the intracardiac electrocardiogram specific P wave form change can assist the positioning of the valve type PICC head end, but contraindications comprise that the ECG heart rhythm of a patient is abnormal and P wave abnormality exists (for example, pacemaker, atrial fibrillation and tachycardia exist), at present, the technology is mainly applied to a larger hospital, particularly a third hospital, and is difficult to implement in a basic hospital due to the limitation of technology, equipment and the like. In addition, Digital Subtraction Angiography (DSA) is rarely used for pure catheter localization due to the high cost and limited radiation exposure of patients and medical personnel. After the placement of the tube, the X-ray radiography is still the gold standard of PICC positioning, the most common method before the PICC placement is to pre-measure the length in vitro, and the accuracy of the measured length has a remarkable meaning for the correct position of the tip of the catheter, so that it is very important to find a simple, accurate and conveniently popularized measuring method.

Currently, the measuring method for researching enthusiasm at home and abroad is a Rountree method, namely, a patient lies down, arms are unfolded by 90 degrees, and a method of reversely folding downwards to the 3 rd intercostal space from a puncture point to a right sternoclavicular joint is adopted, but the PICC catheter is easily placed too deeply and into the right atrium when the measuring method is applied to the country. In-vitro measurements of Huangqimei et al in China were carried out by the in-line method, and 11.5% (13 out of 113 cases) of the location were shallow. The PICC tube-placing length caliper is developed according to the height of a patient in Rituhua and the like, the tube-placing length of the patient can be found out according to the height through the caliper, the method is summary of clinical work experience, and the accuracy of the method is subject to large sample size research. The study results of xuxia and the like, which are improved in vitro measurement methods, cannot be concluded due to the influence of factors such as differences in optimal position settings of the PICC catheter tip and obesity of patients. Foreign Perin G et al also consider that there is no reliable evidence to give a specific solution. However, the roundree method and the domestic improvement method are consistent in the distance from the puncture point to the right sternoclavicular joint, and are different in the distance after invagination. INS2016 edition "infusion therapy practice Standard" teaches that determining a desired inserted catheter length by means of postural measurements includes measurements from a preoperative chest film. The distance after the reverse folding is accurately measured from the chest piece, and the distance from the puncture point to the right sternoclavicular joint is taken as the length of the catheter implantation, so that the key point of the PICC catheter with accurate implantation length is formed.

Through retrieval, chinese patent application CN 110179548A discloses a method for predicting the length of a PICC catheter for front trimming, where the predicted length of the PICC catheter B = the length L + from the puncture point to the right sternoclavicular joint determined by the height and BMI body mass index. This scheme has the front end and prunes PICC and puts more individuation, accurate, effectively reduces clinical complication and easy and simple to handle's advantage.

However, the method for predicting the puncture length according to the height and the BMI body mass index is an indirect prediction method, and is particularly not applicable to people with special body types such as humpback and the like, so that the prediction method has certain limitation.

Disclosure of Invention

The present invention is directed to overcoming the above-mentioned deficiencies in the art and providing a method for predicting the length of a PICC catheter that will allow the length of catheter inserted therein to reach the desired location.

In order to achieve the purpose, the invention provides the following technical scheme: a method for predicting PICC catheter placement length is characterized by comprising the following steps:

step 1, before placing the tube, measuring the vertical distance B from the lower edge of the inner end of the right clavicle on the X-ray chest positioning sheet to 1 vertebral body below the trachea bulge;

step 2, taking the patient in a horizontal position, extending the arm on the puncture side by 90 degrees, and measuring the distance A from the puncture point to the right sternoclavicular joint;

and 3, calculating the PICC catheter implantation length L = A + B-2 cm.

PICC puts accuracy rate evaluation index of managing: the distance of the tip of the catheter on the chest piece below the carina is measured by adopting a ruler, the position of the catheter is accurate when the distance is 0cm-4cm below the carina, and if the insertion target of the tip of the catheter is arranged at the center of the range, the success rate of catheter placement can be greatly ensured even if certain errors exist. In combination with the human skeletal features, the inventor believes that 1 vertebral body under the tracheal bulge of the anterior chest piece of the catheterization can be regarded as the ideal position which the tip of the catheter is expected to reach, namely the target position which the tip of the catheter is to reach. The inventors have found that PICC catheters run parabolically in the body through the subclavian vein to the innominate vein to the termination point (middle lower 1/3 of the superior vena cava) (white line portion in fig. 1, gray line portion in fig. 2). The inventor further imagines that when the PICC catheter passes through a puncture blood vessel (first, basilic vein, second, brachial vein, but not head vein), axillary vein, subclavian vein and innominate vein, and reaches the termination point-the middle lower part 1/3 of superior vena cava, this route is compared with the measurement route of the roundtree method which is a keen measurement method at home and abroad, especially when the catheter passes through subclavian vein, innominate vein, and reaches the termination point-the middle lower part 1/3 of superior vena cava, because the catheter does not reach the right sternoclavian joint and is in a parabolic downward direction, this section of the route measured by the roundtree method presents a right triangle (the catheter actually runs close to the hypotenuse of the right triangle, and the measurement route is two right triangles), and because the sum of the two sides of the triangle is greater than the third side, this may be a report that the PICC catheter is too deeply inserted in the country, the reason for placement in the right atrium. The inventors therefore speculate that: the ideal PICC catheter length is a function of the conventional rounder measurements. The inventors then began to analyze and summarize a large amount of clinical data and concluded that: the distance after the reverse folding of the Rountree method is accurately measured from the chest radiograph, and the distance from the puncture point to the right sternoclavicular joint is subtracted by 2cm, so that the accuracy of the PICC catheterization length can be ensured. The inventors subsequently participated in a number of clinical trials and clinical data showed that the results were in line with expectations.

The PICC catheter placement length prediction method is simple and easy to implement, easy to operate clinically, high in accuracy and capable of ensuring that the tip of the catheter falls in the optimal area range. Because the data are derived from chest radiographs and human body measurement, errors caused by human body difference in the traditional method are avoided, and the method has better adaptability (the method is still effective when being applied to a humpback patient).

Drawings

Fig. 1 is an X-ray chest positive image (catheter orientation and measurement path) after catheterization.

Figure 2 is a schematic view of the orientation of the catheter.

Detailed Description

In order to make the objects, technical solutions and advantages of the embodiments of the present invention clearer, the technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention.

Article preparation

X-ray chest film (the latest chest film in a hospital electronic medical record system), tape measure (1 mm minimum scale, produced by BD company, the scale is corrected by using a standard steel ruler, the maximum error is less than 0.2 mm), PICC catheter is a three-way valve type catheter produced by Padd company, the catheter size is 4Fr, a disposable PICC catheterization puncture bag, 250ml of sterile physiological saline, 1 count of 2% lidocaine, disposable syringes (20 ml and 1 ml), 75% ethanol, 0.5% iodophor, a blood vessel ultrasonic guidance system (5 visual acuity, linear array probe, frequency 5-10 mHz) BD introducer kit (21G), an ultrasonic probe coupling agent, a modified Seldinger kit of the BD company and a camera.

PICC puts a tub record table

The content includes general data such as name, age, sex, hospital admission number, diagnosis, date of intubation, placement site and vein, distance (cm) from puncture point to right sternoclavicular joint, length measured on chest piece before operation, length of placement/length of catheter exposure, arm circumference, whether ultrasound guidance is provided, seldinger technique, position of catheter end X-ray chest piece, length of trachea bulge to catheter tip, distance between catheter tip and 1 vertebral body under bulge, and chest piece photograph before and after placement.

Object of putting tube

Selecting a patient to be placed in the PICC in a certain hospital, and bringing the patient into the standard: (1) patients are conscious and willing to accept PICC; (2) the age is more than or equal to 18 years, and no history of mental diseases and family history exists; (3) the front of the tube is provided with a conventional vertical position chest film and a back and front position chest film. Exclusion criteria: (1) patients with PICC contraindication; (2) the right sternoclavicular joint cannot be accurately positioned; (3) a patient with a failed catheterization and a catheter tip which is ectopic and fails to reach a predetermined position; (4) patients who cannot stand for photography.

146 men and 126 women; 28 years minimum, 100 years maximum, age (64.6 ± 12.4) years; the PICC 234 cases are required to be implanted because of the periodic chemotherapy; the PICC is required to be placed in 22 cases of long-term intravenous infusion; 16 cases of hypertonic drug infusion are required to be placed in the PICC. The vein is implanted into 186 cases of right basilic vein, 31 cases of right brachial vein, 3 cases of right median vein, 44 cases of left basilic vein, 7 cases of left brachial vein and 1 case of left median vein. And (3) disease diagnosis: 47 cases of intestinal cancer, 35 cases of lung cancer, 19 cases of cerebrovascular disease, 18 cases of lymphoma, 17 cases of breast cancer, 17 cases of esophageal cancer, 16 cases of gastric cancer, 14 cases of liver cancer, 14 cases of leukemia, 11 cases of ovarian cancer, 7 cases of pancreatic cancer, 7 cases of infection accompanied by skin pressure injury, 5 cases of cervical cancer, 3 cases of multiple myeloma, 3 cases of cholangiocarcinoma and other 39 cases.

Method for measuring and calculating length of pipe

Step 1, before placing the tube, measuring the vertical distance B from the lower edge of the inner end of the right clavicle on the X-ray chest positioning sheet to 1 vertebral body below the trachea bulge (measuring the distance between 2 points by using workstation software, and reading the value on a caliper of the chest sheet). The vertical black line near the spine in fig. 1 has a length B, i.e., the vertical black line in fig. 2.

Step 2, the patient takes the horizontal position, the arm on the puncture side is extended by 90 degrees, and the distance A from the puncture point to the right sternoclavicular joint is measured (horizontal black line in figure 2). The horizontal black line at the clavicle in fig. 1 is the distance from the starting position of the curvature of the cannula in the body (near the inner end of the subclavian vein) to the right sternoclavian joint, which black line is a fraction of distance a.

And 3, adding the two, and subtracting 2cm to obtain the length of the catheter, namely the length L = A + B-2cm of the PICC catheter. As can be seen from fig. 2, the tubing runs as follows: the puncture point was followed by the basilic vein, the axillary vein, the subclavian vein, the innominate vein and the superior vena cava to the endpoint (middle inferior 1/3 of the superior vena cava). The gray part curve (parabola) in the figure contains the subclavian vein and the innominate vein as parts.

Pipe placing method

The PICC special nurse is used for placing the tubes according to the standard tube placing process.

And (2) placing a tube, namely measuring the distance (B) from the lower edge of the inner end of the right clavicle to 1 vertebral body below the trachea bulge on the thoracic sheet in the front correction position of the tube. 2. Selecting puncture blood vessels on the elbow and the upper arm of a patient, preferably selecting basilic veins, positioning a marking pen for the planned puncture blood vessels, extending the arms at the puncture side by 90 degrees, and measuring the distance (A) from the puncture point to the right sternoclavicular joint and the circumference of the upper arm. 3. A, B is added to 2cm as the length of the catheter intended to be placed. 4. Establishing a maximum sterile barrier, performing target venipuncture under the traditional method or the ultrasonic-guided MST technology, feeding into an introducing sheath after blood return, gently feeding into a catheter from the introducing sheath at a constant speed, ordering the lower jaw of a patient to be tightly attached to a puncture side shoulder peak to block an internal jugular vein when 25cm is fed, and continuously feeding into the catheter until the preset feeding length is up to stop. 5. B ultrasonic exploration is carried out to determine whether the cervical internal vein is ectopic, and if so, treatment is carried out according to the treatment flow of the cervical internal ectopic. 6. Removing the supporting guide wire, trimming the catheter, installing the connector, the heparin cap, the normal saline pulse catheter and the positive pressure sealing tube, and carrying out X-ray chest radiography catheter positioning after local proper fixation.

Method for determining ideal position of catheter tip

1. The 1 vertebral body under the tracheal bulge of the anterior chest piece of the catheterization is the ideal position which the tip of the catheter is expected to reach.

2. The distance between the tip of the X-ray chest film reading catheter and 1 vertebral body below the trachea bulge after the catheter is placed is smaller, and the position of the tip of the catheter is more ideal.

Statistical method

Statistical software SPSS 17.0 statistical software is applied to perform data statistics. The accuracy (percentage of 1/3 catheter tip below the superior vena cava) and consistency (percentage of ± 1 cm and difference in distance between the catheter tip and the inferior carina 1 vertebral body) of the catheter length in the correct location of the PICC catheter tip using chest film in conjunction with in vitro measurements were calculated.

Test results

272 patients were successfully placed into the PICC catheter, and the lengths of the catheters were measured before the placement according to the method for calculating the length of the catheter placement of the present invention, and the vertical distance (8.2 + -0.98) cm from the lower edge of the inner end of the right clavicle on the chest piece at the front position after the chest standing position by X-ray to 1 vertebral body below the carina was measured, with the minimum distance of 5cm and the maximum distance of 10.5 cm. All the positions of the tips of the patient catheters are judged by adopting X-ray chest pictures of the rear vertical position and the front rear vertical position after tube placement, and the positions of the tips of the catheters are judged according to the X-ray chest picture results of the rear vertical position and the front vertical position after tube placement. The detailed distribution of the catheter tip and carina corresponding positions is shown in Table 1 in comparison with the chest radiograph showing that the catheter tip is located below the carina (2.65. + -. 0.95) cm, the minimum is 0cm, and the maximum is 6.2 cm. The length of the catheter placement calculated by the chest radiography and the in vitro measurement method can ensure that the tip of the catheter is accurately positioned, and the accuracy rate is 93.8 percent (255/272). The specific distribution of the catheter tip to the location of the subcarina 1 cone is shown in Table 2 (less negative values and more positive values), and the distance between the catheter tip and the subcarina 1 cone (-0.5 + -0.95) cm, with a variance of 76.5% (208/272) within + -1 cm.

Table 1 catheter tip on the breast at the position corresponding to the carina (n = 272)

Trachea hump lower scale (cm)	Number of examples	Percentage of
			< 0 (i.e., short of breath)Pipe hump)	0	0%
0-2	68	25%
			2-4	187	68.8%
＞4	17	6.2%

Table 2 catheter tip location on chest piece corresponding to the inferior 1 vertebral body of carina (n = 272)

Distance (cm) to the lower 1 vertebral body of the carina	Number of examples	Percentage of
			＞-2	3	1%
-2~-1.1	34	12.5%
			-1~-0.1	101	37.1%
0~1	107	39.3%
			1.1~2	17	6.3%
＞2	10	3.7%

Small knot

The PICC catheter placement length obtained by combining the chest radiography with an in vitro measurement calculation formula improves the accuracy of the pre-measured catheter placement length, so that the tip of the catheter can reach the lower 1/3 sections of the superior vena cava or be close to the connection part of the superior vena cava and the right atrium, and the consistency with the target area predicted to be reached by the tip of the catheter before placement is high. The technique is simple to operate, does not increase personnel investment, achieves the purpose of improving the accurate arrival rate of the PICC by utilizing the existing medical resources, and is worthy of clinical popularization.

In addition to the above embodiments, the present invention may have other embodiments. All technical solutions formed by adopting equivalent substitutions or equivalent transformations fall within the protection scope of the claims of the present invention.

Claims (2)

1. A method for predicting PICC catheter placement length is characterized by comprising the following steps:

step 1, before placing the tube, measuring the vertical distance B from the lower edge of the inner end of the right clavicle on the X-ray chest positioning sheet to 1 vertebral body below the trachea bulge;

step 2, taking the patient in a horizontal position, extending the arm on the puncture side by 90 degrees, and measuring the distance A from the puncture point to the right sternoclavicular joint;

and 3, calculating the PICC catheter implantation length L = A + B-2 cm.

2. The method of predicting PICC placement length of claim 1, wherein: the vertical distance B is obtained by workstation software measurement.

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