Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3860_Библиотеки_им_академика_М_И_Перельмана
.pdf
134 A. H. Schoenfeld
https://t.me/med1917
mode results in a smaller volume of tissue irradiated and
a lower intensity of scattered radiation. The x-ray beam
always should be collimated to the smallest size needed
for viewing to minimize scatter to the operator and improve visualization.
The size of the patient as a determining factor in patient dose cannot be controlled. It is obvious that a larger
patient attenuates a greater fraction of the incident x-ray
beam; thus, the kVp and exposure rate must increase to
maintain the proper image brightness.
The use of cut film and digital subtraction angiographic (DSA) techniques during interventional procedures also contributes to the total effective dose equivalent the patient will receive. One study of ten patients
undergoing cerebral angiography revealed that, on average, 67% of the effective dose equivalent to the patient
was due to fluoroscopy with 26% contributed by cut film
and 7% by DSA.
9
■ Factors Affecting the Dose
to the Radiologist
Exposure to the radiologist in the interventional suite
is due to scattered radiation resulting mainly from the
Compton interaction and also from leakage radiation. All
x-ray units are required to have a protective tube housing
that limits the leakage radiation to 100 mR/hr at 1 m
when the unit is operating at the maximum technique
factors for continous radiation production.
The intensity of the scatter radiation levels in the room
depends on the exposure rate incident on the patient
and the volume of tissue in the beam. As mentioned, the
amount of scattered radiation at a distance of 1 m from
the patient is approximately 0.1% of the incident beam
intensity.
If the area of the x-ray beam entering the patient is
increased, the fraction of the beam that is scattered increases approximately in direct proportion. Thus, it is
clearly advantageous to collimate the beam as closely as
possible to minimize the scatter component, which will
decrease the exposure to the operator and improve image quality.
The patient’s size affects operator exposure because
increases in attenuation of the x-ray beam as a result of
greater patient diameter will result in higher mA and kVp
values with more scattered photons and a greater degree
of stray radiation to the radiologist.
The location of the x-ray tube also can affect the stray
radiation dose levels received by the radiologist and other
personnel in the room. In general, it is preferable to
position the x-ray tube underneath the table rather than
above it, as most of the scatter is produced near the side
of the patient first intercepted by the beam. If the tube is
placed in the lateral position, the radiologist will be ex-
TABLE 12-3.
Minimize total fluoroscopy time.
Keep image intensifier as close as possible to patient.
Do not use high level mode, if available, unless absolutely
necessary.
Keep x-ray tube underneath patient whenever possible.
Try to maintain distance from x-ray tube and patient.
Always wear lead apron and film badge(s).
Try to limit use of magnification mode.
Collimate x-ray beam to area of interest.
Keep hands out of primary beam as much as possible.
If kV is manually adjusted, use higher kV (ⱖ75) and lower mA
techniques.
Use the last image hold and pulsed fluoroscopy if available.
Summary of techniques to minimize
radiation exposure to patient and operator
posed to lower radiation levels near the image intensifier
rather than near the x-ray tube.
■ Potential for Skin Injuries to the Patient
Although fluoroscopically guided interventional procedures are often the treatment of choice for critically ill patients, there is some potential for radiation induced in-
10
jury.
Certain interventional procedures may require
long fluoroscopic exposure times along with recording of
images, which may leadto entrance skin doses of 2 Gy (200
rad) or more with subsequent skin injuries. During an interval of approximately 4 years, the FDA received reports
of skin injuries to 26 patients, including erythema, moist
desquamation, and skin necrosis.
11
The procedues resulting in skin injuriesincluded radiofrequency cardiac catheter ablation, catheter placement for chemotherapy,
transjugular interhepatic portosystemic shunt placement,
coronary angioplasty, renal angioplasty, multiple hepatic
or biliary procedures,and percutaneous cholangiography
followed by multipleembolization procedures.
The FDA
12
recommends that information be recorded
for patients that might receive a threshold dose to the skin
of 1 Gy (100 rad) or more, including identification of
those areas of the patient’s skin that may receive the dose
threshold and an estimateof thedose receivedor information that would allow estimation of thedose to those areas.
The dose to the skin may be estimated by direct measurement with placement of dosimeters on the skin during the
procedure. Alternatively, the radiation exposure rates may
be measured for the particular x-ray system and the skin
dose may be calculated if the system geometry and the
technique factors are recorded, such as kVp, mA, total
exposure time during fluoroscopy and kVp, mAs per image, and the total number of images during digital or
conventional image acquisition. Although the FDA recommends recording information for dose estimation in
cases that may approach the threshold of 1 Gy, it is prudent to record this information for all interventional
cases.
Radiation Protection
https://t.me/med1917
135
■ Summary
A summary of techniques to minimize radiation exposure
to the patient and the operator is given in Table 12-3.
REFERENCES
1. Limitation of exposure to ionizing radiation. NCRP Report no. 116.
Bethesda, MD: National Council on Radiation Protection and Measurements, 1993.
2. Use of personal monitors to estimate effective dose equivalent and
effective dose to workers for external exposure to low-LET radiation. NCRP Report no. 122. Bethesda, MD: National Council on
Radiation Protection and Measurements, 1995.
3. Niklason LT, Marx MV, Chan H-P. Interventional radiologists: occupational radiation doses and risks. Radiology 1993;187:729–733.
4. Medical x-ray, electron beam and gamma-ray protection for energies up to 50 MeV (equipment design, performance and use).
NCRP Report no. 102. Bethesda, MD: National Council on Radiation Protection and Measurements, 1989.
5. Wagner LK, Mulhern BS. Radiation-attenuating surgical gloves:
effects of scatter and secondary electron production. Radiology
1996;200:45–48.
6. Agarwal SK, Friesen EJ, Huddleston AL, et al. The effectiveness of
glass lenses in reducing exposure to the eyes. Radiology 1978;
129:810–811.
7. Tidwell A, Brahmavar S, Breton R, et al. Radiation exposures in
pulsed fluoroscopy systems: patient and physician. Med Phys
1994;21:943. (abst.)
8. Norbash AM, Busick D, Marks MP. Techniques for reducing interventional neuroradiologic skin dose: tube position rotation and
supplemental beam filtration. AJNR Am J Neuroradiol 1996;17:
41–49.
9. Feygelman VM, Huda W, Peters KR. Effective dose equivalent to
patients udergoing cerebral angiography. AJNR Am J Neuroradiol
1992;13:845–849.
10. Wagner LK, Eifel PJ, Geise RA. Potential biological effects following
high x-ray dose interventional procedures. J Vasc Inter vent Radiol
1994;5:71–84.
11. Shope TB. Radiation-induced skin injuries from fluoroscopy. Ra-
diographics 1996;16:1195–1199.
12. Recording information in the patient’s medical record that identifies the potential for serious x-ray induced skin injuries following
fluoroscopically guided procedures. Rockville, MD: Food and Drug
Administration (FDA), Department of Health and Human Ser vices, September 15, 1995.
https://t.me/med1917
M.E. HansenPhysician Health and Safety
https://t.me/med1917
13
■■■
Physician Health and Safety
in the Angiography Suite
MARGARET E. HANSEN
■ Infectious Risks
Non-bloodborne pathogens
Although blood-borne pathogens may stimulate more
concern among health care workers (HCWs) and patients, certain non-bloodborne agents are also important,
particularly in hospital settings. Many pathogens are
transmitted by droplet infection or by direct contact.
Influenza and childhood diseases such as measles and
rubella can be transmitted between HCWs and patients.
Patients can be infected by asymptomatic HCWs harboring these viruses, hence the recommendation that
all HCWs be vaccinated against these three diseases.
The elderly, the immunocompromised, and those with
chronic diseases are at greatest risk for influenza. Immunity to rubella is important for women of childbearing
age because severe fetal damage may result from congenital infection.
The incidence of tuberculosis (TB) is increasing across
the United States, especially in large cities.
some is the emergence of multidrug resistant (MDR)
strains, which can cause fulminant, rapidly fatal infection,
particularly (but not only) in human immunodeficiency
virus (HIV) -positive persons. HCWs in several cities have
been infected on thejob, and several have died as aresult.
Patients with known or suspected active TB infection
should wear masks or particulate respirators, if possible,
while undergoing procedures outside approved isolation
rooms. Standard face masks do not filter particles in the
droplet size range (1–5 lm) and are not adequate to prevent the spread of TB; for this reason, particulate respirators are preferred.
4
All radiology personnel involved in
1,2
Most worri-
procedures on patientswith active TB should wear respirators if possible.
Methicillin-resistant Staphylococcus aureus (MRSA), a serious problem in many hospitals, may be found in the
nares or on the skin of HCWs and is spread primarily by
the hands (5). Handwashing is criticalin preventing transmission of MRSA; gloves, gowns, and masks should be used
when caring for patients with this infection.
5
Bloodborne pathogens
The most important agents in this category are HIV and
the hepatitis viruses. Concern about nosocomial transmission of these agents has increased dramatically in the
past few years.
Scope of the problem
Although a great deal of publicity and concern has centered on HIV, hepatitis B and C should be regarded as
equally serious because these viruses are both more prevalent and more infectious than HIV.
breaks of HCW to patient transmission of hepatitis B virus
(HBV) have been reported, and the Centers for Disease
Control and Prevention (CDC) estimates that 8,000 to
12,000 HCWs are infected with HBV on the job each year.
3
Of these, 10% will become chronic viral carriers; about
200 deaths of HCWs are attributed to HBV-related disease
each year.
have serologic evidence of HBV exposure (⬎50% for foreign-born Asians), and 0.2 to 13% are chronic carriers.
Among hospitalized patients, at least 1% are HBV carriers, most asymptomatic and unaware of their carrier
status.
7
Between 3 and 14% of the general population
7
Hepatitis C virus (HCV) isalso prevalent in certain
6
More than 20 out-
137
138
https://t.me/med1917
M. E. Hansen
groups: studies indicate exposure in 1 to 4% of HCWs,
12% of dialysis patients, and 50 to 80% of injecting drug
users and hemophiliacs.
8,9
The prevalence of HIV infection in the United States is
estimated to be about 1% in the general population.
although it is higher in certain groups, such as emer-
11
gency department patients (6%)
and young urban
adults treated for penetrating trauma (19% in one
12
study).
in acute care hospitals ranges from 0.2% to 14.2%.
The prevalence of HIV infection among patients
13
Means and risk of transmission
Transmission of HIV, HBV, and HCV occurs through
blood contact and sexual contact. In the health care
setting, this generally involves needlestick injuries, but
contact with mucous membranes or nonintact skin also
has resulted in HIV infection.
14
Transmission after contact with intact skin has not been reported. In addition to
blood, other body fluids may be infectious. HIV has been
detected in saliva, semen, vaginal secretions, breast milk,
amniotic fluid, synovial fluid, cerebrospinal fluid, and
serous exudates from infected persons.
7
HBV can be pre-
sent in most of these fluids, too, as well as in urine and
7
feces.
HCV has not been recovered from vaginal fluid,
semen, or saliva of chronically infected persons even
when viremia is present, but otherwise has a distribution
similar to that of HBV.
7
HBV is a fairly hardy virus, able to survive on environmental surfaces for up to 7 days at room temperature, but
it is killed by bleach and other high-level disinfectants.
HIV is also readily inactivated by household bleach and
other high-level disinfectants, but it is less robust and
survives only briefly on surfaces at room temperature.
7
The risk of infection after a single parenteral exposure
depends on the infectivity of the source, the amount of
blood or other fluid transferred, and other factors. Infectivity depends on the viral titers of the source. For HBV,
the most infectious of the three viruses, the type of viral
particle present in the blood is also important; hepatitis
B e antigen (HBeAg) is the most infectious. Infection risk
after one parenteral contact with HBV ranges from 7 to
7
30%;
with HCV from 2 to 4%,7and with HIV is about
15,16
0.4%.
For a given procedure, the risk of infection
depends on the likelihood of parenteral contact during
the procedure and the source’s likelihood of infection in
addition to the above factors.
The risk of HCW-to-patient transmission is unknown
but probably is much lower than the risk in the opposite
direction. For such transmission to occur, the HCW must
be infected with a blood-borne agent and sustain an injury that causes bleeding (or have open, exudative skin
lesions, in which case the HCW should avoid patient
contact), and then his or her blood must come into
parenteral contact with the patient. Perhaps the most
common scenario in which this might occur in the angio-
graphy suite is if a needle is reused on the patient after
being contaminated with the blood of an HCW after a
needlestick injury. If such contact occurs and the HCW is
HIV positive, the risk of infecting the patient probably
10
would be about 0.4% (the same as for infection of an
HCW after a single needlestick exposure).
15,16
modeling done by the CDC to estimate the risk of an HIV
positive surgeon infecting a patient during a procedure
yielded a range of 1/42,000 to 1/420,000 procedures.
Modeling specific to vascular and interventional radiology has produced similar results, estimating the risk of
infecting a patient to be 0.03 per million procedures if
the radiologist’s HIV status is unknown and 7.5 per million procedures if the physician is HIV positive.
estimated risk of patient-to-physician transmission of HIV
for a single procedure ranges from 0.03 to 7.5 per mil-
18
lion.
Blood contacts and injuries in
vascular/interventional radiology
Needlestick injuries occur less often in interventional radiology than in surgery. A recent prospective study noted
needlestick injuries in 0.6% of interventional radiologic
19
procedures,
1.7 to 15.4% for surgical procedures.
compared with previously reported rates of
20–24
A national survey of inter ventional radiologists found an annual median injury rateof 0.3,
of 2 in a survey of surgeons.
sharps, such as leaving exposed sharps in the folds of a
7
25
compared with an annual median
26
Improper handling of
drape or under a towel, or recapping needles was a com-
19,25
mon source of injury to radiologists.
Procedure duration, operator experience level, and elective versus emergency procedure status had no effect on the risk of injury,
but the risk for nonvascular interventional procedures
was slightly higher than for other types of cases.
ous or mucous membrane exposures, including splashes
to the face, eyes, or other areas, occured in 3% of cases.
More than 70% of these blood contacts could have been
avoided by using appropriate protective gear, such as
gowns and goggles. Longer procedure duration was
strongly associated with higher risk of such exposures,
although not with higher risk of injury.
Glove perforations are another potentially important
means of blood contact. Overall, occult perforations occur in 10% of gloves used for angiographic or interventional procedures, but the relationship between the
length of time gloves are worn and the perforation rate
is strong, with 2 hours being the dividing point between
27
low and high risk.
For this reason, it is prudent to
change gloves during lengthy procedures at or before 2
hours of wear. Most of the holes are probably attributable
to mechanical stresses, such as forceful hand injection or
catching glove material in a stopcock, rather than actual
sharp injuries.
Computer
18
The
19
Cutane-
17
19
19
Physician Health and Safety 139
https://t.me/med1917
■ Risk-reduction Strategies
Universal precautions
The use of universal precautions (UP) has been recommended by the CDC since 1987 (Table 13-1.
tenet of UP is the assumption that blood and body fluids
from all patients should be considered potentially infectious. Rather than targeting the use of blood and body
fluid precautions to “high-risk” cases only, UP mandates
their routine use. Adherence to CDC infection control
recommendations, including use of UP, was voluntary
until 1992, when federal law made it mandatory.
28
The basic
7
Safety devices and personal protective gear
Many devices have been produced in attempts to reduce
the risk of injury and blood contacts during procedures.
“Needleless” intravenous systems (Fig. 13-1), self-sheathing needles, and needle-capping devices are among those
in current use; improved containers for the disposal of
sharps are now standard in most health care settings as
well.
Several products have been designed specifically for
interventional radiology, such as sharps holders for procedure trays, closed flush systems, closed-system drainage
kits, and “bloodless” arterial puncture systems.
of these products are slightly more expensive than standard versions (some of the needles may be significantly
more expensive) and do not interfere with procedure
performance. Tactile feel during guidewire introduction
may be altered with the bloodless puncture devices, how-
TABLE 13-1.
Adherence to universal precautions
Blood and body fluids from
infectious
Use of safety devices and personal protective gear
Needleless intravenous systems
Self-sheathing needles and needle-capping devices
Sharps holders
Closed flush systems
Fluid-impermeable gowns
Face shields, masks and goggles
Caps, shoe covers, gloves
Safe handling of sharp instruments
Do not recap by hand unless one-handed method is used
Maintain awareness regarding location and status of sharps
during procedure
Remove sharps from field immediately after use
Dispose of sharps promptly in appropriate container
Vaccinations
Hepatitis B
Influenza, rubella, measles
Tetanus
Future vaccines: hepatitis C, human immunodeficiency virus?
Strategies for risk reduction in
interventional radiology
all
patients are potentially
29–33
Most
ever, which should be kept in mind when these devices
are used.
34
Personal protective equipment has been available for a
long time, but some improvements have been made recently. Fluid-impermeable gowns are now widely used,
some of which offer added protection in areas where
strike-through is most likely, such as the chest and sleeves.
Clear plastic face shields and shield-mask combinations
can be used by most people, including those who wear
corrective eyeglasses. Most brands of goggles and shields
provide side shielding as well, which is requiredby current
safety standards.
Unfortunately, protective gear is not widely used in interventional radiology despite being affordable and readily available. Anecdotal evidence suggests that many radiologists often do not wear caps, masks, goggles, and shoe
covers (or even gowns) while performing procedures.
This evidence is supported by the survey of interventional
radiologists mentioned earlier,
25
which found that only
20% of radiologists who do not wear corrective eyeglasses
for procedures routinely used eye protection, and only
32% routinely wear a face mask or shield. Inconvenience
and fogging of eyeglasses are commonly cited reasons for
failure to use these items; given the many stylesof masks or
shields now available, one should be workable for almost
everyone, and persons who have such concerns should try
different brands.
Safe sharp handling
Proper handling of sharp instruments includes not recapping them by hand and prompt disposal of used sharps
in an appropriate container. Preferably, sharps should
not be recapped at all, but if this must be done, a mechanical device such as a sheath guard or a hemostat
should be used. The one-handed method in which the
cap is scooped up with the needle, fingers well away from
its tip, is also acceptable but slightly more risky. Communication between team members during procedures is
perhaps the most important element of safe handling of
sharps so that all persons involved in a case are aware of
the location and status of all sharp instruments in use. It
never should be assumed by one team member that another person has seen where a sharp has been placed;
verbal communication is essential. Removing sharps from
the field immediately after use is also important in avoiding inadvertent injury. Leaving exposed sharps in the
folds of a drape is a common cause of injury.
25
Prompt
disposal of used sharps in a puncture- and spill-proof
container is the final element in safe handling.
Vaccinations
Vaccination against HBV is recommended for all HCWs
at risk for occupational exposure to blood or other poten-
140 M. E. Hansen
https://t.me/med1917
Figure 13-1. A: Saf-Site (Burron Medical Inc., Bethlehem, PA), a “needleless” intravenous access system features a one-way
valve that is opened by inserting the syringe tip into the hub of the device; caps are also available. B: The InterLink device (Becton
Dickinson, Franklin Lakes, NJ) is similar, with a hep-lock style hub that is penetrated by the special syringe tip.
BA
tially infectious materials and now must be offered free of
charge to such employees.
7
Because it is produced by
recombinant DNA technology, the current vaccine carries no risk of pathogen transmission.
35
Booster doses
may be needed in some cases. Currently, no vaccines are
available for HCV or HIV, although intensive research
effort is under way.
Vaccination against rubella, tetanus, influenza, and
measles is recommended for all HCWs. Rubella vaccine
is contraindicated during pregnancy, which should be
avoided for 3 months after vaccination.
also is contraindicated during pregnancy.
36
Measles vaccine
37
Influenza
vaccines are formulated each year against strains thought
to be common in the coming flu season, and revaccination is needed annually.
38
■ What to Do If Exposure Occurs
Blood testing
After a parenteralexposure to blood or body fluid, therisk
of the source individual’s being infected with a bloodborne pathogen should be assessed and appropriate serologic testing performed as soon as possible (Table 13-2).
Both the source and the exposed person should be tested
for evidence of HIV, HBV, andHCV infection initially.
If the source is HIV positive, the exposed person should
be retested for HIV 3 and 6 months after exposure if the
initial test has a negative result. Safe sexual practices
should be followed during this period, and sharing of
toothbrushes, needles, or razors should be avoided. Donation of blood, organs, and sperm should be avoided as
well, and preventing pregnancy for 6 months is recommended.
39
Repeated serologic testing is recommended to be
done 6 and 9 months after exposure to HCV. If infection
is diagnosed, liver-function testing should be done to
determine whether any treatment or further follow-up is
needed.
39
HIV and hepatitis prophylaxis
If the source is HIV positive, the exposed person should
be counseled about antiviral prophylaxis using zidovudine (ZDV), an agent that is active against human retroviruses such as HIV, possibly in combination with other
antiretroviral drugs. ZDV prophylaxis is widely used, al-
TABLE 13-2.
Determine which pathogens might be involved by initial blood testing
Source: HIV, HBV, HCV if status unknown
Exposed person: HIV, HBV, HCV if status unknown
HBV exposure of nonimmune person
Start HBV vaccine series within 7 days of exposure
Give HBV immunoglobulin within 24 hr of exposure
Repeat blood testing of exposed person based on results
of initial tests
HIV-positive source: test at 3 and 6 mo if initial test negative
HCV-positive source: test at 6 and 9 mo if initial test negative
HBV-positive source: test at 4 and 6 mo after immunoglobulin
39
given
Chemoprophylaxis against HIV
Recommendations vary based on the degree of risk from exposure
For high-risk exposure, combination of three antiretroviral drugs
used
For lower-risk cases, one or two drugs recommended
Recommendations may change in the future
Counseling and follow-up
If exposed to HIV, practice safe sex, refrain from blood and organ
donation, and prevent pregnancy for 6 mo
If HCV infection develops, check liver function tests as needed
In all cases, counseling by an experienced professional is vital
,HIV, human immunodeficiency virus; HBV, hepatitis B virus, hepatitis C virus.
What to do if exposure occurs
Physician Health and Safety 141
https://t.me/med1917
though side effects are common.
40–42
If prophylaxis is
elected, it should be started as soon as possible after exposure, ideally within an hour, as HIV infection may be established within a few hours. Several dosage regimens
have been used.
39,41–43
The most recent recommendations issued by the U.S. Public Health Service in mid-1996
vary with the level of risk (based on the route of exposure
and type of material involved, i.e., blood versus other
fluids) and include the use of ZDV and one or more of the
newer antiretroviral agents, such as indinavir or saquinavir. Because these recommendations may change with
experience, and as newer drugs become available, the
best course is to report all injuries immediately and to
seek appropriate counseling regarding current recommendations.
If the source has evidence of HBV infectivity (HBsAg
or HBeAg in the blood) and the exposed person has not
been vaccinated against HBV or had a previous infection,
the HBV vaccine series should be started within 7 days of
exposure.
39
Hepatitis B immunoglobulin also should be
given within 24 hours of exposure, but the two injections
must not be given in the same site because they might
inactivate each other. Follow-up testing for development
of infection or establishment of immunity should be
done 4 to 6 months after immunoglobulin administration. Exposed persons who follow the recommended prophylaxis regimen pose little risk to patients and other
contacts, and patient-care activities need not be restricted
during the interval between tests.
39
No effective prophylaxis against HCV infection is currently available. Immunoglobulin has not been shown to
prevent HCV infection, and its use for this purpose is not
recommended. Interferon alfa, although used with some
success in the treatment of chronic HCV infection, has no
role in preventing infection.
39
Counseling is as important after exposure to a bloodborne pathogen as are the serologic testing and prophylactic measures described previously. Counseling should
be done by a health care professional who is experienced
in this area.
■ Infection Control Regulations
1992 OSHA Bloodborne pathogen standard
In 1992, the Bloodborne Pathogen Standard of the Occupational Safety and Health Administration (OSHA) became federal law.
that affect all radiologists, interventional radiologists in
particular (Table 13-3). The standard applies to all employees with potential occupational exposure to blood or
other infectious materials, except those in certain state,
county, or city facilities. Volunteers and students are not
covered unless they are also employees. Exposure need
7
This statute has several major provisions
TABLE 13 -3.
Employers must develop an exposure control plan
Employers must provide personal protective equipment and
mandate its use
Employers must provide HBV vaccination and postexposure
evaluation and treatment for HIV and hepatitis; vaccination must
be free of charge
All employees must have annual training in infection control
Employers must keep records of training sessions
Employers must keep medical records for at-risk employees,
including HBV vaccination, exposure, and treatment
Employers must provide facilities for handwashing and sharps
disposal
Use and storage of food, drink, and cosmetics prohibited in at-risk
areas
Recapping of sharps by hand prohibited
Sharps disposal containers must be leak- and puncture-proof
Contaminated laundry must be placed in labeled or color-coded bags
Specimens must be placed in labeled or color-coded bags
HBV, hepatitis B virus; HIV, human immunodeficiency virus; OSHA,
Occupational Safety and Health Administration.
Infection control regulations: 1992 OSHA
Bloodborne Pathogen Standard
not occur frequently for the standard to apply, and if any
part of a person’s job poses an exposure risk, he or she is
covered by allprovisions of the standard.
Employers must develop an exposure control plan that
identifies employees at risk, details how the standard will
be implemented, specifies how exposures will be dealt
with, is reviewed and updated at least annually, and is
accessible to employees and to OSHA.
They also must provide personal protective equipment,
including gloves, gowns, masks, goggles, caps, shoe covers, and other items as needed. The use of such equipment is mandatory whenever exposure to blood or body
fluid may be “reasonably anticipated” (no specific procedures or situations are cited in the standard), and the
equipment provided must be clean, readily available in
appropriate sizes, in good repair, and free of charge to
employees. Hypoallergenic gloves or glove liners must be
provided if needed.
In addition, HBV vaccination and postexposure evaluation and treatment for HIV and HBV must be provided.
Vaccination must be offered free of charge to all employees who are at risk an average of one or more times per
month; those declining must sign a waiver. Free booster
doses also must be provided.
All employees at risk must be trained in infection control, with sessions repeated at least once a year. Medical
records for employees at risk must include documentation of HBV vaccination, exposures, and postexposure
treatment and must be kept for the duration of employment plus 30 years.
Readily available handwashing facilities and containers
for sharps disposal must be provided. Work-practice controls must be established, such as prohibiting the use or
storage of food, drink, or cosmetics in at-risk areas; hand-
142 M. E. Hansen
https://t.me/med1917
washing immediately after removal of gloves or other
protective gear; prohibiting recapping of sharps; and immediate washing of skin and flushing of mucous membranes after contact with potentially infectious material.
Containers for the disposal of sharps are required to be
leakproof, spillproof, closable, and located as close as possible to the point(s) of sharps use. Contaminated laundry
must be placed in appropriately labeled or color-coded
bags, as must specimens. Biohazard labels or red bags/
containers must be used for all potentially infectious materials.
Recently, guidelines regarding bloodborne pathogens
were developed and published by the Society of Cardiovascular and Interventional Radiology.
44
These guidelines incorporate many elements of the OSHA standard
as well as some from other sources and are specific to
interventional radiology practice.
Resources for education and training
Many resources are available for education and training
in infection control and to assist physicians in complying
with the OSHA standard. Many commercial products,
such as videos, workbooks, and seminars, are available.
Local infectious disease specialists or infection-control
practitioners are a valuable resource; state or local medical or radiologic societies also may be able to provide
information on these topics.
REFERENCES
1. Goldsmith MF. Medical exorcism required as revitalized revenant of
tuberculosis haunts and harries the land. JAMA 1992;268:174–175.
2. Menzies D, Fanning A, Yuan L, et al. Tuberculosis among health
care workers. N Engl J Med 1995;332:92–98.
3. Centers for Disease Control. Nosocomial transmission of multidrug resistant tuberculosis among HIV-infected persons—Florida
and New York, 1988–1991. MMWR 1991;40:585–591.
4. Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on
HIV-related issues. MMWR 1990;39(RR-17):1–29.
5. Wenzel RP, Nettleman MD, Jones RN, et al. Methicillin-resistant
Staphylococcus aureus: implications for the 1990s and effective control measures. Am J Med 1991;91(Suppl 3B):221S–227S.
6. Lettau LA. The A, B, C, D, and E of viral hepatitis: spelling out the
risks for healthcare workers. Infect Control Hosp Epidemiol 1992;
13:77–81.
7. OSHA. Occupational exposure to bloodborne pathogens: final rule
(29 CFR 1910.1030). Federal Register 1991;56:64003–64182.
8. Polywka S, Laufs R. Hepatitis C virus antibodies among different
groups at risk and patients with suspected non-A, non-B hepatitis.
Infection 1991;19:81–84.
9. Alter MJ. Hepatitis C: a sleeping giant? Am J Med 1991;91(Suppl
3B):112S–115S.
10. Centers for Disease Control. HIV prevalence estimates and AIDS
case projections for the US: report based upon a workshop. MMWR
1990;39 (RR-16):1–31.
11. Kelen GD, DiGiovanna T, Bisson L, et al. Human immunodeficiency virus infection in emergency department patients:
epidemiology, clinical presentations, and risk to healthcare workers—the Johns Hopkins experience. JAMA 1989; 262:516–522.
12. Baker JL, Kelen GD, Sivertson KT, et al. Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA
1987;257:2609–2611.
13. Janssen RS, St Louis ME, Satten GA, et al. HIV infection among
patients in US acute care hospitals: strategies for counseling and
testing of hospital patients. N Engl J Med 1992;327:445–452.
14. Centers for Disease Control. Update: human immunodeficiency
virus infections in health-care workers exposed to blood of infected
patients. MMWR 1987;36:285–289.
15. Marcus Rand theCDC Cooperative NeedlestickSurveillance Group.
Surveillance of healthcare workers exposed to blood from patients
infected with the human immunodeficiency virus. N Engl J Med
1988;319:1118–1123.
16. Henderson DK, Fahey BJ, Willy M, et al. Risk for occupational
transmission of human immunodeficiency virus type 1 (HIV-1)
associated with clinical exposures: a prospective evaluation. Ann
Intern Med 1990;113:740–746.
17. Chamberland ME, Bell DM. HIV transmission from health care
worker to patient: what is the risk? Ann Intern Med 1992;116:
871–872.
18. Hansen ME, McIntire DD. HIV transmission during invasive radiologic procedures: estimate based on computer modeling. AJR Am
J Roentgenol 1996;166:263–267.
19. Hansen ME, Miller GL III, Redman HC, et al. Needlestick injuries
and blood contacts during invasive radiologic procedures. AJR Am
J Roentgenol 1993;160:1119–1122.
20. Gerberding JL, Littell C, Tarkington A, et al. Risk of exposure of
surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med 1990;322:1788– 1793.
21. Popejoy SL, Fry DE. Blood contact and exposure in the operating
room. Surg Gynecol Obstet 1991;172:480–483.
22. Hussain SA, Latif ABA, Choudhary AAAA. Risk to surgeons: a
survey of accidental injuries during operations. Br J Surg 1988;75:
314–316.
23. Tokars JI, Bell DM, Culver DH, et al. Percutaneous injuries during
surgical procedures. JAMA 1992;267:2899–2904.
24. Quebbeman EJ, Telford GL, Hubbard S, et al. Risk of blood contamination and injur y to operating room personnel. Ann Surg
1991;214:614–620.
25. Hansen ME, Miller GL III, Redman HC, et al. HIV and interventional radiology: a national survey of physician attitudes and behaviors. J
Vasc Inter vent Radiol 1993;4
26. Lowenfels AB, Wormser GP, Jain R. Frequency of puncture injuries
in surgeons and estimated risk of HIV infection. Arch Surg 1989;
124:1284–1286.
27. Hansen ME, McIntire DD, Miller GL III. Occult glove perforations:
frequency during interventional radiologic procedures. AJR Am J
Roentgenol 1992;159:131–135.
28. Centers for Disease Control. Recommendations for prevention of
HIV transmission inhealth-care settings.MMWR 1987;36(Suppl 2S).
29. Wall SD, Olcott EW, Gerberding JL. AIDS risk and risk reduction in
the radiology department. AJR Am J Roentgenol 1991;157:911–917.
30. Mueller PR, Silverman SG, Tung G, et al. New universal precautions
aspiration tray. Radiology 1989;173:278–279.
31. vanSonnenberg E, Casola G, Maysey M. Simple apparatus to avoid
inadvertent needle puncture. Radiology 1988;166:550.
32. Olsen WL, Jeffrey RB Jr, Tolentino CS. Closed system for arterial
puncture in patients at risk for AIDS. Radiology 1988;166:551–552.
33. Palestrant AM, Esplin CA, Shaw GT. A closed irrigation and drainage system for use with percutaneous abcess drainage: technical
note. Cardiovasc Intervent Radiol 1990;13:119–121.
34. Williams DM,Marx MV, KorobkinM. AIDSrisk and risk reductionin
the radiology department [commentary]. AJR Am J Roentgenol 1991;
157:919–921.
:229–236.
Physician Health and Safety
https://t.me/med1917
143
35. Hepatitis B virus vaccine inactivated. In: McEvoy GK, ed. AHFS Drug
Information. Bethesda, MD: American Society of Hospital Pharma-
cists, 1992:2026–2034.
36. Rubella virusvaccine live.In: McEvoy GK, ed. AHFSDrug Information.
Bethesda, MD: American Society of Hospital Pharmacists, 1992:
2061–2065.
37. Measles virusvaccine live. In:McEvoy GK,ed. AHFS Drug Information.
Bethesda, MD: American Society of Hospital Pharmacists, 1992:
2038–2043.
38. Influenza virus vaccine. In: McEvoy GK, ed. AHFS Drug Information.
Bethesda, MD: American Society of Hospital Pharmacists, 1992:
2034–2038.
39. Gerberding JL. Management of occupational exposures to bloodborne viruses. N Engl J Med 1995;332:444–451.
40. Zidovudine. In: McEvoy GK, ed. AHFS Drug Information. Bethesda,
MD: American Society of Hospital Pharmacists, 1992:392–401.1.
41. Centers for Disease Control. Public Health Ser vice statement on
management of occupational exposure to human immunodeficiency virus, includingconsiderations regarding zidovudine postexposure use. MMWR 1990;39(RR-1):1–14.
42. Henderson DK. Postexposure chemoprophylaxis for occupational
exposure to Human Immunodeficiency Virus type 1: current status
and prospects for the future. Am J Med 1991;91(suppl 3B):312S–
319S.
43. Centers for Disease Control.Update: provisionalPublic Health Service recommendations for chemoprophylaxis after occupational exposure toHIV. MMWR1996;45:468–472.
44. Hansen ME, Bakal CW, Dixon GD, et al. Guidelines regarding HIV
and other bloodborne pathogens in vascular/interventional radiology. J Vasc Intervent Radiol 1997;8:667–676.
Соседние файлы в папке Библиотека им академика М.И. Перельмана