强化眼科消毒预防眼部医院感染

【摘 要】  目的探讨与眼科有关的有效消毒方法，强化眼科消毒措施。方法对眼科环境、器械及手术术野的消毒方法进行调查分析，总结归纳出好的消毒办法，确保消毒效果。结果严格眼科的各项消毒措施，加强消毒管理，2 0 0 6年医院眼科住院患者眼部医院感染发生率为0。结论选用适合眼科特点的消毒办法，是预防与控制眼部医院感染的重要环节，可有效预防眼部医院感染发生。

【关键词】  眼科  手术器械  消毒                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             

在眼科发展的同时，眼科医院感染的风险也不断加大，全球各级医院不断有急性结膜炎院内局部流行的报道_1]，提醒我们加强眼科医院感染管理，强化消毒措施，是各级医院均待解决的问题。根据眼部医院感染的产生原因，大致可分为术后感染及非手术感染，病原菌来源包括外源性和内源性微生物两大类。非手术感染的病原菌来源最常见经由医务人员的手，其次接触污染的黏膜、器械或溶液后亦可发生感染。为此笔者对眼科环境、器械及手术术野的消毒方法进行调查分析，现报道如下。

1眼科环境的消毒

1．1空气空气质量是控制医院感染的重要环节，各诊室及病室内应定时通风换气，加强空气净化和空气流动。为了保证暗室空气的循环流通，应安装排气扇及除湿机。为保障空气质量，治疗室、换药室、暗室等重要环境或人员流动较大的场所可采用紫外线或空气消毒机进行消毒。

1．2地面、物体表面病室及诊室地面、物体表面以清洁为主，采用擦拭法，地面应湿扫。手术室、治疗室、换药室、暗室等重要环境每日用5 0 0 mg／L有效氯消毒液擦拭手能触及到的物体表面两次，地面有污染时随时清理污物，立即使用1 0 0 0 m g／L有效氯消毒液拖地，减少室内微生物污染程度。

1．3工作人员手眼科传播途径以接触传染为主，常经手进行传播。因此，每次接触患者后，必须洗手或使用速干型手消毒剂，认真做好手的消毒，保证消毒效果，防止眼一手一眼接触传播。

1．4其他对于传染性眼部疾患的患者及家属进行卫生指导，住院期间严格注意一人一巾、一人一容器，严格各项接触隔离措施，有条件的医院可对传染性眼部疾患的患者单间隔离治疗，避免同病室人员交叉感染的发生。诊疗过程中所产生的污物如敷料、棉球、手套及其他一次性医疗用品遵照废物处置原则规范分类收集，置于污染区有标识的固定容器内，每天由专人转送到医院医疗废物暂存地统一处理，并认真交接登记_2

2眼科器械的消毒

2．1基本原则重复使用的器械先去污，用酶彻底清洗，有条件的医院对结构精密的器械可采用超声清洗机清洗，再消毒或灭菌，其中感染患者用过的医疗器械执行消毒一冲洗一再消毒或灭菌的双消毒方法。手术器械及物品必须一用一灭菌，凡耐湿热且需要灭菌的眼科诊疗器械，首选压力蒸汽灭菌，应避免使用化学灭菌剂浸泡灭菌。高压蒸汽灭菌保证了灭菌效果，减少了因化学消毒剂浸泡消毒器械冲洗不彻底，导致的残留药物毒性作用及化学性眼内炎等并发症。眼科不耐高热、高压的手术用品如玻切头、电凝线、视网膜镜、硅胶海绵等可用环氧乙烷消毒。部分精密器械也可采用2戊二醛浸泡1 0 h，器械使用前，必须用灭菌水将残留的消毒液充分冲洗干净。在眼科，对患者使用过的剪子、镊子、挡眼板、泪道冲洗针头、开睑器、修氏眼压计、泪点扩张器等诊疗器械使用化学消毒剂浸泡消毒时，一定要注意消毒剂的浓度并保证消毒时间。如受水器、弯盘等使用后用5 0 0 m g／L含氯消毒液浸泡消毒3 0 m i n，清洗备用；接触式眼压计采用7 0异丙醇或7 5乙醇消毒时，应将眼压计头与7 O异丙醇或7 5乙醇接触>5 m i n，否则无法达到消毒效果l_3]。对于使用中的消毒液，要及时进行更换；无菌物品容器如碘酊、乙醇容器清洗后高压蒸汽灭菌，更换2次／周；常用的无菌敷料容器打开使用2 4 h后更换。

对传染性眼部疾病患者如急性流行性结膜炎、淋病性结膜炎等，应实施隔离治疗。使用后的医疗器械，如挡眼板、镊子、剪刀等要随时进行消毒处理，滴眼液专人专用。裂隙灯额架上垫下额的消毒纸，每例患者使用后及时更换。

2．2特殊器械消毒准分子激光仪系大型精密仪器，手术采取集约式方法，即每个手术日为多例患者手术，手术间隔时间短，对于接触人眼的器械，一定要严格灭菌。一次性手术刀片等一次性用品确保一次性使用，决不重复应用。微型角膜刀刀头、限制环、吸附环和手柄、装刀片杆等每次用后完全浸泡准分子激光仪专用消毒液中>2 mi n，蒸馏水配合软毛刷对器械进行清洗，冷吹风机吹干残留水分。负压吸引管等不能高压灭菌的器械用酶洗液洗涤干净后经过环氧乙烷消毒灭菌；电机顶端的驱动顶针可用9 9异丙醇消毒；微型角膜刀电机及其连线用7 O 9／5异丙醇手术巾擦拭消毒，冷吹风机吹干保存。3眼科手术术野的消毒安全有效的眼部消毒方法是保证眼科手术顺利进行，降低眼科手术后眼内感染的关键。消毒过程中，睑缘是需要消毒的重点部位，因为在解剖结构上，此处易引起病原菌的生长和繁殖。正常人结膜囊和眼睑皮肤等部位存在着不同种类和数量的正常菌群，在正常生理情况下并不致病，但在手术时，因正常结膜和角膜完整的组织结构及其上皮的屏障作用被破坏，菌群移位后即可发生感染。0．5聚维酮碘(P V P—I)属中效消毒剂，性质稳定、水溶性好、无刺激性和挥发性、作用缓和持久、使用安全、对皮肤黏膜无刺激且无黄染，色泽容易洗脱等特点，是一种高效、广谱、低毒的消毒杀菌剂，可用于睑缘消毒，近年来在眼科手术中广泛应用。在使用P V P—I作局部消毒的同时，往往结合应用抗菌药物眼液，抑制或清除存在于结膜囊内的病原菌，尤其是对眼部择期手术，术前应用抗菌药物眼液极大地降低了手术的眼内感染率。

目前眼科患者术野常规消毒方式：非急诊每例手术均术前3 d常规局部点抗菌药物眼液，4次／d，术前1 d剪睫毛、冲泪道、术前以0．9生理盐水加庆大霉素冲洗结膜囊，术眼敷料覆盖。术野消毒对受术者的局部消毒分阶段完成，第1阶段涂抹碘酊或7 5乙醇擦拭1次，第2阶段以0．5 P V P—I消毒涂抹两次，第3阶段先以7 5乙醇擦拭1次，然后再用0．5 P V P-I消毒涂抹3次。消毒范围每次自睑裂部开始逐渐向外扩大，单眼消毒范围上至发际颞侧至耳前，下方至上唇，鼻侧超过中线_-]。采用此种消毒方法，大大减少了眼内感染的发生，同时也减少了因局部消毒所产生的不良反应。根据眼科环境、器械及手术术野的消毒方法，我院严格了眼科的消毒管理，并在此基础上制定了适合眼科特点的预防与控制医院感染的制度及措施，2 0 0 6年我院眼科门急诊患者7 2 9 4 2例次，住院患者4 7 0 9例次，眼科手术1 1 7 1 2台次，其中眼部医院感染发生率为0，较好地控制了眼科医院感染的发生。