CN110179548B - Method for predicting catheter placement length of PICC catheter with front end trimming - Google Patents

Abstract

The invention discloses a method for predicting the length of the front-end trimmed PICC catheter. The method operates according to the following steps: (1) Measure the length L from the puncture point to the right sternoclavicular joint; (2) Measure the height and weight of the patient, record and calculate their BMI body mass index; (3) Calculate the PICC catheter Predicted length B, PICC catheter predicted length B = length L from puncture point to right sternoclavicular joint + length b determined according to height and BMI body mass index. The invention has the advantages of making the front-end trimmed PICC tube placement more individualized and precise, effectively reducing clinical complications, and being easy to operate.

Description

Method for predicting catheter placement length of PICC catheter with front end trimming

Technical Field

The invention relates to a method for predicting a PICC (peripherally inserted central catheter) catheter placement length, in particular to a method for predicting a PICC catheter placement length in front trimming.

Background

The peripherally inserted central venous catheter (PICC) has the advantages of safety, convenience, long indwelling time, low infection rate and the like, is widely applied to clinic, and can improve the accuracy of PICC puncture and reduce the occurrence of catheter ectopic by accurately predicting the catheter placement length.

Currently, the cutting PICC catheter clinically used is divided into a front end cutting mode and a rear end cutting mode. The catheter with the trimmed back end is cut according to the body surface measurement length after the catheter is placed in the body, the cut catheter part is located outside the body, the catheter with the cut front end is cut according to the body surface measurement length before the catheter is placed in the body, and the cut catheter tip part enters the blood vessel of the human body. The catheter with the trimmed front end can be used for CVP monitoring and pressurized infusion, the flow rate is high, the requirements of clinical enhanced CT radiography and large-amount fluid infusion can be met, the advantages of convenience in electrocardiogram positioning operation and the like in the catheter placing process are widely applied, and whether the length is reasonably predicted or not to directly influence the position of the tip of the catheter due to the fact that the catheter is integrally formed. At present, various guidelines and standards recommend that the position of the catheter tip should reach 1/3 sections below the superior vena cava to be close to the junction (CAJ) of the superior vena cava and the right atrium, researches show that the ectopic incidence rate of the PICC tip is 9% -27%, the position of the catheter tip is closely related to complications such as tube blockage, chemical phlebitis, thrombosis, arrhythmia and the like, and a roundabout method is mostly adopted for clinically measuring the catheter outside the PICC catheter body. Therefore, the predicted length of the PICC catheter with the trimmed front end is suitable for an individual, which directly affects the position of the catheter tip, and how to ensure that the PICC insertion length is accurate is the key to prevent the complications.

Disclosure of Invention

The invention aims to solve the technical problem of providing a method for predicting the length of a front trimming PICC catheter for tube placement, which enables the front trimming PICC catheter to be more individualized and accurate, effectively reduces clinical complications and is simple and convenient to operate.

The technical scheme adopted by the invention for solving the problems is as follows: the method comprises the following steps of operation,

(1) measuring the length L from the puncture point to the right sternoclavicular joint;

(2) measuring the height and the body mass of a patient, recording and calculating the BMI body mass index of the patient;

(3) calculating a predicted length B of the PICC catheter, wherein the predicted length B of the PICC catheter is = the length L + from the puncture point to the right sternoclavicular joint and the length B determined according to the height and BMI body mass index; when the height is less than 155cm and the BMI is more than 23.9kg per square meter, the length b is 6 cm; when the height is less than 155cm, 18.5kg per square meter and the BMI is less than or equal to 23.9kg per square meter, the length b is 7 cm; when the height is less than 155cm and the BMI is less than 18.5kg per square meter, the length b is 8 cm; when the height is not less than 155cm and not more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 7 cm; when the height is more than or equal to 155cm and less than or equal to 175cm, the height is more than or equal to 18.5kg per square meter and less than or equal to 23.9kg per square meter of BMI, the length b is 8 cm; when the height is more than or equal to 155cm and less than or equal to 175cm and the BMI is less than 18.5kg per square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 8 cm; when the height is more than 175cm, and the BMI per square meter is not more than 18.5 kg/square meter and is not more than 23.9 kg/square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is less than 18.5 kg/square meter, the length b is 10 cm.

Compared with the prior art, the invention has the following beneficial effects: (1) the accuracy of the prediction of the catheter is improved, a traditional in-vitro measurement method, namely a Rountree method, researches report that the in-vitro measurement method can cause the over-deep placement of the catheter, the incidence rate of the catheter entering the heart is 8.9% -82.1%, the incidence rate of chest distress and palpitation of patients is 3.33% -7.46%, the depth of the catheter is 1.7 +/-0.37 cm compared with that of the traditional measurement method, the length of the catheter pre-measured by the method is closer to an ideal length (P = 0.657), and 100 patients researched by the method have 5 shallow patients, 8 deep patients and 87 patients with ideal catheter tip positions; (2) the method is simple and convenient to operate, the tube placement time is shortened, the traditional in vitro measurement method, namely the Rountree method, needs three points and one bend (three points: a pre-puncture point, a sternoclavicular joint and a third intercostal space; one bend: a left side or right side inverted L-shaped bend) to fully expose the part to be measured and positioned, the method only has two points (the length from the puncture point to the right sternoclavicular joint and the predicted length obtained according to the height and the BMI body quality index) at the position to be measured, the measurement steps are simplified, the measurement time is saved, the tube placement efficiency is improved, the operation of nurses is convenient, in addition, the Rountree method has no obvious body surface of the third intercostal, particularly, patients with obesity are difficult to accurately judge, the third intercostal space is an area and is not an accurate point, the intercostal space is difficult to find, the time is long, and the method can also reduce the exposure of patients with chest diseases; (3) the method is simple, convenient and scientific, adopts the intracavitary electrocardiogram positioning technology in the implantation process, accurately positions the tip of the central venous catheter according to the change of the intracavitary electrocardiogram P wave, has high accuracy, is simple and easy to implement, can monitor the placement of the catheter in real time under the condition of not increasing the pain and economic burden of a patient, adjusts the position of the catheter at any time, ensures that the PICC puncture and the catheter positioning are completed at one time, and ensures the safety of the patient.

Drawings

FIG. 1 is an analysis diagram of the relationship between the length of the catheter measured by the Rountree method and the ideal length.

Detailed Description

The prediction method of the embodiment is as follows:

(1) measuring the length L from the puncture point to the right sternoclavicular joint;

(2) measuring the height and the body mass of a patient, recording and calculating the BMI body mass index of the patient;

(3) calculating a predicted length of the PICC catheter B, the predicted length of the PICC catheter B = length L + from puncture point to right sternoclavicular joint length B determined from height and BMI body mass index.

The subclavian vein is converged with the internal jugular vein at the rear part of the sternoclavicular joint to form a brachiocephalic vein, the left brachiocephalic vein and the right brachiocephalic vein are converged at the junction of the right first sternum rib to form a superior vena cava, the brachiocephalic vein is vertically and downwardly positioned at the plane of the right third sternum rib joint and is injected into the right atrium, the total length from the starting part of the brachiocephalic vein to the tail end of the superior vena cava is about 7-8cm (Wang Jian, China society of nursing and intravenous therapy and nursing professional committee [ M ] Beijing: the national military publishers, 2009, 95.), the negative P wave generated when the catheter enters the heart is observed in the process of catheter placement, so that the length of the downward reverse turning from the sternoclavicular joint is predicted according to the body height and.

TABLE 1 determination of Length b from height and BMI body Mass index

When the height is less than 155cm and the BMI is more than 23.9kg per square meter, the length b is 6 cm; when the height is less than 155cm, 18.5kg per square meter and the BMI is less than or equal to 23.9kg per square meter, the length b is 7 cm; when the height is less than 155cm and the BMI is less than 18.5kg per square meter, the length b is 8 cm; when the height is not less than 155cm and not more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 7 cm; when the height is more than or equal to 155cm and less than or equal to 175cm, the height is more than or equal to 18.5kg per square meter and less than or equal to 23.9kg per square meter of BMI, the length b is 8 cm; when the height is more than or equal to 155cm and less than or equal to 175cm and the BMI is less than 18.5kg per square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 8 cm; when the height is more than 175cm, and the BMI per square meter is not more than 18.5 kg/square meter and is not more than 23.9 kg/square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is less than 18.5 kg/square meter, the length b is 10 cm.

We used the self-control study of 100 patients and recorded the length using both the Rountree method and the method as different prediction methods.

The traditional roundtree method: the predicted length of the PICC catheter a = puncture point to right sternoclavicular joint length L + right sternoclavicular joint invagination to third intercostal length a.

The method comprises the following steps: PICC catheter predicted length B = length L + from puncture point to right sternoclavicular joint length B determined from height and BMI body mass index.

The height and body mass of 100 catheterized patients were measured before catheterizing, and their BMI body mass index (kg/m2) was recorded and calculated. The Western Pacific region of the world health organization and the international obesity working group recommend that the Asian population is obese with the BMI of 18.5-22.9 kg/m2 normal, 23-24.9 kg/m2 overweight and 25.0-29.9 kg/m 2.

Of the 100 PICC catheterized patients, 56 men, 44 women, age (55.78 + -13.70), height (163.16 + -7.95) cm, body mass (62.33 + -11.64) kg, BMI body mass index (23.40 + -3.85) kg/m2, among which 20 lung cancer, 14 lymphoma, 13 acute leukemia, 13 intestinal cancer, 12 breast cancer, 9 stomach cancer, 7 liver tumors, 6 gynecological tumors, and 6 others. The inclusion standard is that (1) the PICC indication is met and an informed consent is signed; (2) the body surface electrocardiogram is sinus rhythm; (3) the age is > 18 years. Exclusion criteria (1) those with mental disorder, improper operation and forced posture; (2) patients suffering from superior vena cava compression syndrome who are not suitable for catheterization; (3) atrial fibrillation and other arrhythmias or the placement of pacemakers may affect P-wave monitors; (4) placing a tube at the bedside, and after placing the tube, not shooting the X-ray chest radiography; (5) patients with massive pleural effusion and ascites causing diaphragmatic displacement or diaphragm elevation.

The adopted equipment and materials are as follows: the special monitor for the cardiovascular department of the Kerman, the SOUND PORTABLE B-type ultrasonic diagnostic apparatus, adopt the Barde high pressure resistant 4Fr multiplied by 60cm catheter or Youlijie 4Fr multiplied by 60cm catheter, and the matched PICC puncture bag.

The whole tube placing process is executed by a hospital vein treatment professional nurse according to a PICC operation procedure:

(1) the patient is subjected to horizontal position line electrocardiographic monitoring, the waveform of the electrocardiogram is frozen, and a body surface basic electrocardiogram is obtained. Recording the predicted length A = L + a of the catheter measured by the Rountree method as a control group;

(2) evaluating blood vessels, disinfecting the punctured side limbs and establishing a maximized sterile barrier;

(3) b ultrasonic guided descending vein puncture, after a guide wire is placed, an operator aligns 0 scale of an aseptic ruler with a puncture point, the other end of the aseptic ruler is delivered to an assistant, the length L from the puncture point to a right sternoclavicular joint is measured, the length B is determined according to the height of a patient and the BMI body mass index, the predicted length B = L + B of the catheter measured by the method is recorded as an observation group, and the catheter is trimmed according to the predicted length B of the catheter;

(4) slowly delivering the catheter to an entrance of an vena cava, clamping one end of a sterile crocodile clip at the tail end of a PICC built-in supporting guide wire when the catheter is exposed for 10CM, delivering the other end of the sterile crocodile clip to an assistant to replace an electrocardiogram monitoring RA electrode, observing the change of an electrocardiogram in the cavity while delivering the catheter, if the catheter is delivered to a predicted length, keeping the amplitude of an electrocardiogram P wave in the cavity unchanged, withdrawing the catheter for 5-10CM outwards, re-delivering the catheter after adjusting the body position, withdrawing a catheter sheath after the characteristic change of the electrocardiogram P wave in the cavity is found, slowly delivering the catheter again until a positive high-amplitude P wave is seen and the P wave begins to become low, generating a small negative-direction wave P wave below an electrocardiogram baseline in the initial section of the P wave, stopping delivering the catheter and withdrawing the catheter;

(5) removing the support guide wire and the heparin sealing tube, fixing the catheter by using sterile dressing, and recording the actual implantation length and the exposed length;

(6) taking positive chest X-ray photograph, observing the position of head end, and determining the ideal length C of catheter.

8 of the catheters with too deep positions are withdrawn to ideal positions, 5 of the catheters with shallow positions retain original scales, the ideal length is calculated and recorded according to the chest radiograph, and the rest 87 of the catheters with too deep positions are ideal.

The judgment criteria of the ideal position are as follows:

2016, the United states IV guide recommends that the PICC tip be located in the lower 1/3 segments of the superior vena cava near the junction of the superior vena cava and the right atrium (Infusion Nurse society. Infusion Therapy standards of practical [ J ]. InfusNurs,2016, s 38-39.), that the CAJ point is generally considered to be located between the third or fourth anterior ribs, approximately 3-4cm below the carina, and that Li Suzhou pistil (Li Suzhou, Jie, Xihui, etc.. CT studies of placement of the central venous catheter tip via the peripheral vein [ J ]. Chinese anatomy and clinical journal, 2016,21(4):31-319.DOI:10.3760/cma. J. issn.2095-7041.2016.04.008.) also indicate that the carina serves as a reliable imaging marker for the location of the head of the PICC tip, that placement of the PICC tip at about 4cm level below the carina is a distance just above the CAJ tip of the catheter, the ideal position of the PICC head is defined as 3-4cm below the carina of the trachea.

The statistical analysis method comprises the following steps:

the research is a self-contrast test research, data are recorded into an SPSS19.0 software package for statistical analysis, counting data are expressed by frequency and percentage, continuous variables conform to normal distribution and are expressed by x +/-s, continuous variables do not conform to normal distribution and are expressed by median, the difference between measurement values of a traditional method (a Rountree method), an experimental method (the method) and an ideal insertion length is tested by Kruskal-Wallis H, and multiple linear regression analysis is adopted for verifying the correlation of the experimental method.

1. The conventional method predicts the length of the catheter a 42 (40, 44) cm, the experimentally measured length B40 (39, 42) cm, and ideally the measured length C40 (38, 41) cm. Kruskal-Wallis H test analysis is carried out among the length A measured by the traditional method, the length B measured by the experimental method and the ideal measured length C. Referring to fig. 1, there are differences between A, B (P < 0.01), A, C (P < 0.01), B, C with no difference P =0.657, and the experimental method is superior to the traditional method and closer to the ideal length.

2. Ideal catheter length was predicted from height, Body Mass Index (BMI) using multiple linear regression. And (4) judging that a linear relation exists between the independent variable and the dependent variable by drawing a partial regression scatter diagram and a scatter diagram of the student residual and the predicted value.

The study observations were verified to be independent of each other (Durbin-Watson test value 1.858); and the data are proved to have equal variance by drawing a scatter diagram of the student residual error and the predicted value. The regression tolerance is more than 0.1, and multiple collinearity does not exist. In the abnormal value test, no observed value with the student deletion residual error being more than 3 times of the standard deviation exists, the data lever values are all less than 0.2, and no Cook distance existsA value greater than 1. The QQ plots show that the study data satisfy the normal assumption. The regression model has statistical significance, F (2, 97) = 36.931P<0.001, adjust R²= 0.421. The effect of the 2 independent variables incorporated on the ideal catheter length is statistically significant (P)<0.05) as shown in table 2 below.

TABLE 2 multiple Linear regression results

Note: p <0.01

The theoretical basis of the method is as follows:

the predicted length of the PICC catheter = the length from the puncture point to the right sternoclavicular joint + the length of the right sternoclavicular joint inflected down to the desired position. The first half of the traditional roundtree method and the method can be measured in real time during operation, the influence on the predicted length is determined by the second half, and the length of the second half influences the accuracy of the predicted length. The left brachiocephalic vein and the right brachiocephalic vein of anatomy are converged to form a superior vena cava, the average total length is about 7-8cm, and clinical correlation verification research determines that the average distance between the right sternoclavicular joint and the midpoint of the superior vena cava lower segment is 4.18-9.58cm, the average number is 6.78 +/-1.67 cm, and the distance is positively correlated with the height, so that the higher the height of a patient with the same body mass index is, the longer the pre-added length is, and the different pre-added lengths of the patients with the same body mass index are. Fat accumulation in abdominal cavity of obese patients raises the diaphragm to different degrees, thereby affecting the normal position of heart, and research shows that BMI of most individuals has obvious correlation with the percentage content of body fat, and can better reflect the obesity degree of organism. The higher the quality index of the adult body is, the shorter the insertion length of the tube at the same position is; each 10% change in body mass represents a 1cm change in the depth of the tube, e.g., 10% overweight minus 1cm, 10% weight loss, and (1. + -.3) cm increase. The body mass indexes of patients with the same height are different from the pre-added length, and the research shows that the implantation length of the catheter has correlation with the height and the body mass index (see table 2) R²= 0.421. Therefore, the obese patient is properly spared in the catheter reservation, otherwise the catheter reservation is easyToo long to leave, lead to exposing too much, influence and fix; on the contrary, the descending heart shadow of the diaphragm of the emaciation patient is long and narrow, and can be properly added in the prediction process.

Claims (1)

1. A method for predicting the catheter placement length of a front trimming PICC catheter is characterized by comprising the following steps: the method comprises the following steps of operation,

(1) measuring the length L from the puncture point to the right sternoclavicular joint;

(2) measuring the height and the body mass of a patient, recording and calculating the BMI body mass index of the patient;

(3) calculating a predicted length B of the PICC catheter, wherein the predicted length B of the PICC catheter is = the length L + from the puncture point to the right sternoclavicular joint and the length B determined according to the height and BMI body mass index; when the height is less than 155cm and the BMI is more than 23.9kg per square meter, the length b is 6 cm; when the height is less than 155cm, 18.5kg per square meter and the BMI is less than or equal to 23.9kg per square meter, the length b is 7 cm; when the height is less than 155cm and the BMI is less than 18.5kg per square meter, the length b is 8 cm; when the height is not less than 155cm and not more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 7 cm; when the height is more than or equal to 155cm and less than or equal to 175cm, the height is more than or equal to 18.5kg per square meter and less than or equal to 23.9kg per square meter of BMI, the length b is 8 cm; when the height is more than or equal to 155cm and less than or equal to 175cm and the BMI is less than 18.5kg per square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is more than 23.9kg per square meter, the length b is 8 cm; when the height is more than 175cm, and the BMI per square meter is not more than 18.5 kg/square meter and is not more than 23.9 kg/square meter, the length b is 9 cm; when the height is more than 175cm and the BMI is less than 18.5 kg/square meter, the length b is 10 cm.

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