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朊毒体病的处理Prion Disease ManagementI.
目的Purpose:
1.为控制、限制和防止朊毒体对病人和医护人员的传播提供指导方针。朊毒体病包括克雅病（CJD）和其他形式的传染性海状脑病。To provide guidelines in order to contain, confine and prevent the transmission of prion diseases, including Creutzfeldt-Jacob Disease (CJD) and other forms of Transmissible Spongiform Encephalopathy to patients and staff.
2.防止仪器和设备的交叉污染。To prevent cross-contamination of instruments and equipment.
3.保护病人和医护工作人员。To safeguard patients and staff.
4.提供安全的环境。To provide a safe environment.
II.方针Policy:
所有需要做脑组织活检的病人，除了已知由非朊毒体引起脑部损伤的病人，均应按照以下原则进行处理，将朊毒体病传播给其他病人和医护工作人员的危险性降低到最小，安全地处理这些病人使用过的辅助材料和设备。有以下一种或几种情况的已知或可疑朊毒体病的病人需要对其进行预防：All patients undergoing a brain biopsy for other than a known non-prion lesion will be treated according to the following protocol in order to minimize the risk of spreading prion disease to other patients or healthcare workers, and to safely dispose of supplies and equipment used for these patients. Precautions are to be used for all patients with known or suspected prion disease, including one or more of the following:
§快速进展性痴呆Rapidly progressing dementia.
§可能存在克雅病(CJD)，Gerstmann-Straussler-Scheinker 综合征(GSS)或致命性家族性失眠症(FFI)。Possible Creutzfeldt-Jakob Disease (CJD), Gerstmann-Straussler-Scheinker Syndrome (GSS), or Fatal Familial Insomnia (FFI).
§有CJD, GSS 或 FFI家族史。 Family history of CJD, GSS or FFI.
§接受人垂体激素，角膜移植或硬膜移植。Recipients of human pituitary hormone, corneal transplants or dura mater grafts.
§缺乏特殊脑损伤原因而需做脑组织活检的病人。Any brain biopsy patient without a specific lesion as the target of the biopsy.
高感染性组织：脑、硬膜、脊髓和角膜。HIGH Infectivity Tissue: Brain, dura mater, spinal cord and cornea.
中度感染性组织：脑脊液、肝脏、淋巴结、肺、肾和脾。MEDIUM Infectivity Tissue: Cerebrospinal fluid, liver, lymph nodes, lung, kidney and spleen.
低感染性组织：心脏、骨骼肌、甲状腺、肾上腺、肠、周围神经、骨髓、全血、粒白细胞、血清、脂肪组织、前列腺、睾丸、精液、胎盘、阴道分泌物、乳汁、泪液、牙龈、鼻黏膜、唾液、痰、尿和粪便。LOW/NO Infectivity tissue: Heart, skeletal muscle, thyroid gland, adrenal glands, intestine, peripheral nerves, bone marrow, whole blood, leukocytes, serum, adipose tissue, prostate, testis, semen, placenta, vaginal secretions, milk, tears, gingiva, nasal mucus, saliva, sputum, urine and feces.
除非已明确诊断为非朊毒体病，这些病人都被认为是潜在的朊毒体病患者。Unless a clear non-prion disease diagnosis is established, these patients will be considered as potentially having prion disease.
注意：对于被诊断为朊毒体病的病人如不进行脑、硬膜或角膜手术操作，只需要标准防护即可。NOTE: In the case of a patient diagnosed with a prion disease who comes to the OR for a procedure NOT involving the brain, dura mater, spinal cord or cornea, only standard precautions need be observed.
III.步骤：Procedure:
如果安排已知或怀疑朊毒体病的病人进行脑组织活检：When a brain biopsy of known or suspected prion disease is scheduled:
0.外科医生或操作者应通知可疑朊毒体病人进行脑组织活检的手术室。Surgeon or Designee will notify the Operating Room of the brain biopsy of suspected prion disease.
1.手术室 调度员或登记预约的办公室人员应告知护士长，Neuro RN3或护理主管该手术的朊毒体预防性质。The OR Scheduler or desk personnel booking the case will alert the charge nurse, Neuro RN3 or Nurse Manager of the Prion Precaution nature of the case.
2.护士长、Neuro RN3或护理主管应与外科医生进行沟通证实病人状况，保证方针中朊毒体防护措施的执行。The Charge Nurse, Neuro RN3, or Nurse Manager will consult with the Attending Surgeon to verify the patient's status warrants the Prion Precautions set forth in the policy.
3.如果防护措施已明确，护士长、Neuro RN3或护理主管应注意外科队伍中包括感控、神经病理学和环境服务人员。If these precaustions are indicated, the Charge Nurse, Neuro RN3 or Nurse Manager will notify the surgical team that is assigned to the case, Infection Control (744-9562), Neuropathology (X6315), and Environmental Services (X3131).
4.护士长应指定一名“跑腿”进入手术室。The Charge Nurse will assign a "Runner" to the room.
5.该手术应安排为指定手术室当天的最后一例手术。The case will be scheduled as the last case of the day in the designated room.
6.护士长应核对以确定手术所需辅助材料和设备随手可得，放置在神经观片室的朊毒体防护便携箱内。The Charge Nurse will check to make sure necessary supplies and equipment are at hand for the case. These are located in the Neuro Viewing Room in the Prion Precaution Cart.
a.“朊毒体防护”标志"Prion Precaution" signs
b.一次性器械和包裹Disposable instruments and packs.
c灰色焚化箱（X3）Gray incineration bins (X3)
d.一次性设备和辅助材料Disposable equipment and supplies
e.固化器Solidifier
f.1:10稀释的次氯酸钠溶液1:10 Dilute solution Sodium Hypochlorite (Bleach)
病例/病房设置：Case/Room Setup:
7.器械仅可放置于朊毒体防护盘。这些器械被认为是一次性的，在手术结束后应放入灰色焚化箱。任何跌落或被污染的器械均应放入灰色焚化箱，如有需要由跑腿放回原处。被污染的器械不能用高压灭菌器闪蒸灭菌。附随朊毒体防护盘的还有一次性电池供电的颅穿孔器/转头(Acracut)。在朊毒体防护便携箱内备有Hudson支具，以备Acracut 脱柄。还有转孔盖消毒包和带有螺丝刀的自动钻孔螺钉。Only the Prion Precaution tray will be used for instrumentation. These instruments will be considered disposable and will be placed in the gray incineration bins at case end. Any instrument dropped or contaminated will be placed in the gray incineration bin and will be replaced by the runner as needed. Contaminated instruments will NOT be flash sterilized in the autoclave. Accompanying the Prion Precaution tray will be a disposable battery powered cranial perforator/drill (Acracut). A Hudson Brace will be on the Prion Precaution cart as a back-up should the Acracut be out of stock. There is also a sterile pack of burr-hole covers and self-drilling screws with screwdrivers as needed.
8.没有任何形式可重复使用的设备、器械或辅助材料接触病人组织或体液。No reusable equipment, instruments or supplies of any kind will come in contact with patient tissues or fluids.
9.不能使用海王星机械用于吸出。应使用金属罐吸取圆盘传送带。DO NOT use the Neptune machine for suction. Use canister suction carousels.
10.除了颅穿孔器/转头，不能使用电源设备。NO power equipment will be used except disposable cranial perforator/drill.
11.仅可使用无菌和有菌的一次性物品。手术结束，手术中使用的所有物品包括器械均应放入灰色焚化箱处理。ONLY disposable items, sterile and non-sterile will be used. At case end, all items used on the case, including instrumentation, will be disposed of in the gray incineration bins.
12.手术开始前所有仪器和设备移出手术室，防止不必要的污染，除了：All equipment and supplies will be removed from the room prior to the start of the case to prevent unnecessary contamination, except:
a.Skytron 手术床Skytron OR bed
b.U形头靠（不是PINS）Mayfield headrest with horseshoe (NO PINS)
c.次级台Junior table
d.Mayo 站立台Mayo Stand
e.电烧灼器塔Bovie tower
f.吸出圆盘传送带（不是海王星）Suction carousel (NO NEPTUNE)
g.头灯盒（一个）Headlight box (ONE)
h.PACS 便携箱PACS cart
i.麻醉机Anesthesia machine
j.麻醉箱（一个，神经麻醉物品可由跑腿或麻醉技师带入）Anesthesia cart (ONE, neuro-anesthesia cart items may be brought by runner or Anesthesia Tech
13.限制手术操作人员的走动。跑腿应站在手术室门外帮助无菌核心辅助材料/器械等通行。Traffic will be limited to the staff required for the procedure. The Runner will be stationed outside the OR door to obtain sterile core supplies/instruments, etc.
14.“朊毒体防护”标志贴于手术室门上。"Prion Precautions" signs will be placed on the OR doors.
15.专门的矮灰色焚化箱用于器械、辅助材料、垃圾和亚麻织物。Special short grey biohazard incineration bins will be used for instruments, supplies, garbage and linens.
16.指定一个小的锐器盒用于手术，手术结束后应放入灰色焚化箱处理。A small sharps container will be designated for the case, and disposed of in the gray incineration bin at case end.
17.为了将设备污染降低到最低，帮助手术后的去污染，室内设备应尽可能用防渗透的帷帘覆盖。Skytron 手术台末端和底座应用防渗透的帷帘或红色生物危害袋覆盖。头靠和doughnut 用红色生物危害袋覆盖。电烧灼器塔用红色生物危害袋覆盖，剪一小孔使电线与电烙器相连。应在生物危害袋背面剪通气孔以防止设备过热。In order to minimize equipment contamination and to aid in decontamination at case end, room equipment will be covered with impervious draping as much as possible. Both ends of the Skytron table and it's base should be covered in impervious drapes or red biohazard bags. Mayfield The Mayfield headrest and doughnut should be covered with a red biohazard bag. The bovie tower should be covered with a red biohazard bad and small holes cut to pass the wires to the electrocautery units. Vent holes should be cut on the back side of this bag to prevent equipment overheating.
18.不能重复使用针、深部脑模拟器、组织活检针或吸出装置。No reusable needles, deep brain simulators, biopsy needles or suction devices will be used.
19.不能使用海王星用于吸出。应使用传统的一次性吸取圆盘传送带。Do not use the Neptune for suction. Use traditional suction carousels, which are disposable.
20.不能使用电源设备。使用Hudson支具和Gigli拉锯开颅。 No power equipment will be used. Use Hudson Brace and Gigli Saw for craniotomies.
21.尽可能使用无菌和有菌的一次性物品。除非毫无选择，使用的材料不需要洗烫。使用过的手巾和其他所有织物均放入灰色焚化箱。Disposable items, sterile and non-sterile, will be used as much as possible. No material that needs laundering will be used unless there is no other choice. Used towels and all other linens will be placed in grey incineration bins.
术中规程：Intraoperative Protocol:
22.建立mayo辅助方案：器械和盆放置于次级台，按平常方式使用站立台。mayo Scrub setup: Use a junior table for instruments and basin, and use a mayo stand in the usual fashion.
23.用一次性防渗透材料覆盖工作台面。Cover work surfaces with disposable impermeable materials.
24.锐器不应在人与人间直接传递，通常使用“中间地带”。No sharps will be passed directly from person to person. Always use a "neutral zone."
25.不推荐采用外科伤口引流。The use of surgical wound drains is not recommended.
26.使用过的海绵不能丢弃于站立台或地板，应放入背后桌子上的容器内。Sponges used will not be tossed into a prep stand or onto the floor, but should be kept contained on the back table.
27.在给病人换敷料前须戴手套。Gloves should will be donned before applying dressings to patient.
28.所有外科手术人员在离开手术室前须脱隔离衣、手套、鞋套、帽子、口罩和护目镜。门外跑腿准备干净帽子。All surgical team members will remove gown, gloves, shoe covers, hats, masks, and eye shields before leaving the room. The Runner outside the door will have clean hats available.
职业暴露Staff Exposure
29.遵守标准防护规定的所有方面内容。严格强制使用个人防护设备。保护着装包括纸质隔离衣，职业安全和卫生管理局认可的护目镜和靴子式样的鞋套。擦洗组必须戴双层手套。All aspects of standard precautions will be followed. Use of personal protection equipment will be strictly enforced. Protective attire includes paper gowns, OSHA-approved eye shields and boot-style shoe covers. The scrub team MUST double glove.
30.操作时要特别小心以防止经皮或粘膜暴露Great caution should be utilized to prevent percutaneous or mucous membrane exposure.
31.如果发生暴露，用1:10稀释的漂白水冲洗皮肤1分钟，用肥皂和水清洗，然后根据HMC方针向职员健康服务部或危急处理部门报告血源性暴露。If exposure occurs, rinse the skin with a 1:10 dilution of bleach, for one minute, wash with soap and water, and follow HMC policy for reporting blood-borne exposure to Employee Health Services (X3081) or the Emergency Department.
32.如果暴露发生于粘膜，用生理盐水或水冲洗暴露部位数分钟，报告暴露的方法同上。If exposure occurs to a mucous membrane, irrigate the area for several minutes with normal saline or water and report the exposure as above.
IV.标本处理：Handling Specimens:
如果组织需要做病理学检查：When a pathology exam of tissue is needed:
0.Circulator通知神经病理科至手术室取标本。The Circulator will notify Neuropathology to come to the room for the specimen.
1.将无菌标本杯和Telfa交给辅助人员，辅助人员依次将标本从无菌部位放入其中。A sterile specimen cup and Telfa will be given to the Scrub, who will in turn put the specimen in it from the sterile field.
2.用生物危害袋安全地运送标本。The specimen will be safely transferred into a biohazard bag.
3.标本在手术室内交给病理室人员，标本保持新鲜，没有冰冻切片。The specimen will be given to the pathologist in the room, fresh. There will be no frozen section.
4.由于有破损的可能性，为了防止不必要的污染，任何标本都不能用气动输送系统运输。The pneumatic tube system will not be used for any specimens due to possibility of breakage and to prevent unnecessary contamination.
V.仪器、设备和房间的去污染/消毒：Decontamination/Disinfection of Instruments, Equipment and the Room:
通则：General Information:
0.在废物收集房间内安装三台大型灰色焚化箱。在神经观片室或环境服务部门也有这些焚化箱。Three large Grey Incineration Bins will be placed in the room for waste collection. These bins can be found in the Neuro viewing room, or by calling Environmental Services.
1.所有器械、被单、垃圾和织物均应放入灰色焚化箱。All the instruments, drapes, trash and linens will be placed in the gray incineration bins.
2.锐器放入小的锐器盒内处理。锐器盒也要放入灰色焚化箱。Sharps will be disposed of in the small sharps container. The sharps container will be also be placed in a Gray Incineration Bin.
3.所有液体放入和吸入吸出罐内。吸出罐固化后放入灰色焚化箱。液体固化器和技术说明书保存在神经观片室的朊毒体防护便携箱内。All fluids will be contained and suctioned into suction canisters. The canisters will be solidified and placed in the Grey Incineration Bin. Fluid solidifier and instructions are kept in the Neuro Viewing room in the Prion Precautions Cart.
麻醉机：Anesthesia Machine:
4.过滤器和管道应更换。Filter and tubes will be changed.
5.机器的平坦表面和其他表面一样清洁。Flat surfaces of the machine are cleaned the same as other surfaces.
6.麻醉用的一次性材料应丢弃于灰色焚化箱。Anesthetic disposable supplies are to be discarded in gray incineration bins.
环境清洁Environmental Cleaning:
7.在操作将要结束前，通知内务部门派清洁人员到房间清洁至少1小时。病人转移后手术室门保持关闭状态。Near the end of procedure, Housekeeping will be notified to send cleaning staff to the room for at least one hour. The OR doors will be kept closed after transfer of the patient.
8.立即在内务监督人员监督下，有组织地对所有区域进行彻底清洁，包括地板， Terminal cleaning of any area, including floors, will be done immediately in an organized way and supervised by housekeeping supervisory personnel.
9.全体清洁人员必须穿隔离衣、靴子式样的鞋套、戴手套、口罩和一次性护目镜。Cleaning crew will use gown, boot-style shoe covers, gloves, mask and disposable eye shields.
10.拖把、抹布和个人防护设备（隔离衣、手套、护目镜、靴子）应按已被污染物品来处理，放入灰色焚化箱。Mops, cleaning cloths, and personal protective equipment (gowns, gloves, eye shields, bootees) will be treated as contaminated and placed in Gray Incineration Bins.
11.台面、仪器（包括车轮）和地板必须清洁，然后用1:10稀释的次氯酸钠溶液局部去污染，溶液至少保持与被污染表面接触1小时，用大量水冲洗。然后彻底清洁房间。Surfaces of tables, equipment (including wheels) and floors will be cleaned and then spot-decontaminated with 1:10 dilute bleach solution, allowing the solution to remain in contact with the contaminated surfaces for at least one hour, followed with a generous clean water rinse. Then a terminal cleaning of the room will be performed.
12.所有清洗液须吸入一次性罐中。罐子固化后放入灰色焚化箱。All cleaning fluids will be suctioned into disposable canisters. The canisters will be solidified and placed in Grey Incineration Bins.
13.灰色焚化箱的盖子要固定，通知环境服务部门即时取走焚化箱。The lids of the gray incineration bins will be secured and Environmental Services will be notified for immediate pickup of the bins.
摘自harborview medical center –感染控制手册第五节-消毒和灭菌
Infection Control ManualSection V - Disinfection & Sterilization |
发表于 2007-10-16 17:23
发表于 2007-10-16 18:55
发表于 2007-10-16 20:07
