導(dǎo)航：安全管理網(wǎng)>> 培訓(xùn)課件>> 職業(yè)健康>>正文

醫(yī)務(wù)人員的職業(yè)風(fēng)險(xiǎn)與防護(hù)

		點(diǎn) 擊數(shù)：	更新時(shí)間： 2022年12月15日
下載地址：點(diǎn)擊這里	文件大小： 2.07 MB 共54頁	文檔格式： PPT	下載點(diǎn)數(shù)： 19 點(diǎn)（VIP免費(fèi)）

全屏查看

部分內(nèi)容預(yù)覽 [文件共54頁]

本文件共54頁，只能預(yù)覽部分內(nèi)容，查看全部內(nèi)容需要下載。

注：預(yù)覽效果可能會出現(xiàn)部分文字亂碼（如口口口）、內(nèi)容顯示不全等問題，下載是正常的。

	文件大?。?.07 MB 共54頁文件格式：PPT 下載點(diǎn)數(shù)：19 點(diǎn)（VIP會員免費(fèi)）

下一篇：職業(yè)防護(hù)與護(hù)理安全管理

上一篇：化工企業(yè)職業(yè)安全防護(hù)

文本預(yù)覽

僅提取頁面文字內(nèi)容，供快速閱讀使用。

2022/12/15
1
醫(yī)務(wù)人員的職業(yè)風(fēng)險(xiǎn)與防護(hù)
備注：1
備注：醫(yī)院的宗旨是救死扶傷，以人為本；醫(yī)務(wù)人員責(zé)任攜于生命，重于泰山；從醫(yī)院職業(yè)安全的要求來看，沒有醫(yī)務(wù)人員自身的安全更談不上病人的安全，職業(yè)安全是以病人為中心，治病救人的保證。
職業(yè)防護(hù)安全是近來醫(yī)務(wù)人員特別是護(hù)理人員越來越關(guān)注的話題，護(hù)理人員工作在臨床第一線，與病人接觸最為密切，職業(yè)暴露的危險(xiǎn)大，在臨床護(hù)理工作中存在著許多職業(yè)感染機(jī)會，要有職業(yè)安全防范意識，采取防范措施，減少職業(yè)危害。
2022/12/15
2
         隨著現(xiàn)代醫(yī)療技術(shù)的進(jìn)步，各種侵入性檢查和治療操作的增多以及疾病譜的變化，使醫(yī)院感染問題變得日趨復(fù)雜。醫(yī)務(wù)人員職業(yè)暴露的危險(xiǎn)性不斷增大。因此，醫(yī)務(wù)人員更是處于傳染病等感染性疾病的威脅中。 
2022/12/15
3
全球嚴(yán)重急性呼吸綜合征(ＳＡＲＳ)暴發(fā)100天
ＳＡＲＳ首先在中國南方發(fā)生,首例病人發(fā)生在2002年11月底,有1名感染的醫(yī)生,曾在香港ＳＡＲ旅館9樓住宿1晚。他至少傳染了16名同一樓層的旅客和探訪者以及其他人群。
2003年3月12日ＷＨＯ第一次發(fā)出ＳＡＲＳ威脅全球警報(bào)，到6月19日剛好為100天,30個(gè)國家報(bào)告病例,到5月22日全球病例總數(shù)超過8000例。
香港最初發(fā)生的138例SARS病人中，醫(yī)務(wù)人員占50％，共69例，另外還有實(shí)習(xí)醫(yī)學(xué)生16例，共占發(fā)病人數(shù)的61％；加拿大多倫多出現(xiàn)144例SARS病人時(shí)，醫(yī)務(wù)人員共73例，占51％，臺灣發(fā)病到610例時(shí)，90％的發(fā)病人數(shù)與醫(yī)院感染有關(guān)。——資料來源于：龔震宇.疾病監(jiān)測,2003,18(12). (浙江省疾病預(yù)防控制中心, 譯自ＷＥＲ2003,78(26):217-220　楊小平審校)
2022/12/15
4
SARS的暴發(fā)凸顯了醫(yī)務(wù)人員的職業(yè)風(fēng)險(xiǎn)
研究表明，在這場浩劫中，醫(yī)務(wù)人員大多數(shù)是受到本地區(qū)第一批傳染性非典型肺炎感染沖擊。調(diào)查中醫(yī)務(wù)人員傳染性非典型肺炎感染率最高。
醫(yī)院是病人的集散地，也是病原的集散地。
醫(yī)護(hù)是以高尚而受人們尊重的職業(yè)響譽(yù)于世，而醫(yī)護(hù)也是一項(xiàng)高度危險(xiǎn)的職業(yè)。
對醫(yī)院感染控制而論，醫(yī)院就是疫源地
2022/12/15
5
  關(guān)愛您的病人             關(guān)愛您自己       做好職業(yè)暴露防護(hù)      利己        利家     利社會
2022/12/15
6
   醫(yī)療機(jī)構(gòu)有義務(wù)采取控制感染的防護(hù)措施，來減少醫(yī)務(wù)人員可能受到的感染危險(xiǎn)。
2022/12/15
7
1991年美國勞動(dòng)部職業(yè)安全局(OSHA)制訂法規(guī)要求對暴露于經(jīng)血傳播性微生物的醫(yī)務(wù)人員進(jìn)行職業(yè)保護(hù)，各種防護(hù)措施被大量推薦
1983年美國疾病控制中心（CDC）制訂了《醫(yī)務(wù)人員感染控制指南》，并在隨后的十幾年中頒布了大量保護(hù)醫(yī)務(wù)人員免受血液暴露的文件。
2000年11月6日，美國總統(tǒng)克林頓簽署了有關(guān)針頭安全操作及防止刺傷的法令。
2022/12/15
8
2022/12/15
9
   醫(yī)務(wù)人員更要樹立風(fēng)險(xiǎn)意識，在醫(yī)療、護(hù)理工作中自覺做好職業(yè)防護(hù)。
2022/12/15
10
常見職業(yè)暴露的途徑
感染經(jīng)血液傳播
感染經(jīng)空氣傳播
感染經(jīng)飛沫傳播
感染經(jīng)接觸傳播
2022/12/15
11
血源傳播病原體的職業(yè)暴露
2022/12/15
12
細(xì)菌感染
流產(chǎn)布氏桿菌
白喉棒狀桿菌
淋球菌
黃疸出血型鉤端螺旋體 
海洋分枝桿菌
結(jié)核分枝桿菌
豚鼠支原體
沙螨
立氏立克次體
金黃色葡萄球菌
化膿鏈球菌
梅毒螺旋體
病毒感染
克雅病病毒
登革熱病毒
愛博拉/馬爾堡病毒
乙型肝炎病毒
丙型肝炎病毒
庚肝病毒
類人猿皰疹病毒
單純皰疹病毒
帶狀皰疹病毒
人類免疫缺陷病毒
類人猿免疫缺陷病毒
真菌感染
   皮炎芽生菌
   新生隱球菌
   申克孢子絲菌
原蟲感染
    惡性瘧原蟲
    鼠弓形蟲
腫瘤
    人類結(jié)腸腺癌
    肉瘤
      經(jīng)血液傳播的病原體 (blood-borne pathogen)
2022/12/15
13
我國重要的血源傳播病原體流行現(xiàn)狀
我國是HBV的高發(fā)地區(qū)， HBV表面抗原的攜帶率為8％～20％，約有1.3億人。
HCV自90年代以來感染率也呈上升趨勢，感染率約為3％。
 我國AIDS的流行已經(jīng)進(jìn)入快速增長期。據(jù)專家估計(jì)至2010年可達(dá)到1000萬人。 
2022/12/15
14
血液傳播
傳播概率極高
與他人共用注射器或醫(yī)療器械
接受未經(jīng)篩查的血液
接受未經(jīng)篩查的器官或組織移植
醫(yī)務(wù)人員工作中發(fā)生職業(yè)暴露，被針頭刺傷，粘膜接觸液體等
其他意外事故

備注：14
2022/12/15
15
美國醫(yī)務(wù)人員職業(yè)暴露感染AIDS/HIV的確診病例和可能病例, June 2001*
					          Documented 	          Possible
Occupation                                           Transmission (No.)        Transmission ( No.)  
Dental worker, including dentist		  ----	                                  6
Embalmer/morgue technician			     1		 	  2
Emergency medical technician/paramedic	  ----			12
Health aide/attendant   			     1		      	15
Housekeeper/maintenance worker 		     2	       		13
Laboratory technician, clinical 			    16	      		17
Laboratory technician, nonclinical		      3		               ---- 
Nurse 					    24			34
Physician, nonsurgical			      6			12
Physician , surgical				   ----		  	  6
Respiratory therapist 			      1		       	  2
Technician, dialysis				      1		                  3
Technician, surgical				      2		 	  2
Technician/therapist, other than above		   ----			  9
Other healthcare occupations			   ----		  	  4 
Total    					     57		      	137
* http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
備注：15
備注：This chart shows the number of U.S. healthcare personnel with documented and possible occupationally acquired AIDS/HIV infection reported to CDC, by occupation, as of June 2001. Fifty-seven workers had documented HIV seroconversion temporally associated with an occupational exposure. An additional 137 episodes are considered possible occupational HIV transmissions. These workers report a history of occupational exposure to blood, other infectious body fluids, or laboratory solutions containing HIV, and report no other risk for HIV infection, but HIV seroconversion after a specific exposure was not documented. The occupational group with the most documented and possible transmissions is nurses. 
2022/12/15
16
職業(yè)感染的影響因素
一.  病原體的種類

二. 暴露的類型

三. 病毒接種量

四. 病毒滴度
備注：16
備注：Three major factors influence the occupational risk of bloodborne infection. These factors  must all be considered  to fully understand the risk to healthcare personnel. First, if the patient population has a high prevalence of bloodborne infection, the risk to healthcare personnel is higher. Second, the risk of infection transmission after a blood exposure varies by type of exposure and the virus to which exposure occurs. Lastly, healthcare personnel who are frequently exposed to blood, especially if they work with sharp objects such as needles, have a higher risk of exposure to a bloodborne viruses than those rarely coming in contact with blood. In the next few slides, we will discuss each of these factors.
2022/12/15
17
不同病原體職業(yè)傳播的危險(xiǎn)性
  Source
	HBV
		HBeAg +
		HBeAg -

HCV

HIV

22.0-30.0%
1.0-6.0%

1.8%

0.3%
一. 病原體的種類
 Risk
備注：17
備注：The risk of HBV transmission after a percutaneous exposure to HBV-infected blood, without postexposure treatment, varies, depending on the e-antigen status of the source. If the source is e-antigen positive, the risk of transmission will be up to 30%, whereas if the source is e-antigen negative, the risk is from 1-6%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%, with a range of 0-7%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%, or 1 in 300 exposures (with a 95% confidence interval of 0.2%-0.5%). The average risk is based on aggregate data, and may not apply to specific exposure events.
2022/12/15
18
血液、體液職業(yè)暴露類型 NaSH June 1995-December 2000 (n=12,678) 
* Excluding intact skin exposures and clean needlesticks.  Exposures involving more than one site (4% of all exposures) are counted as one exposure according to the highest risk route for bloodborne virus transmission.
經(jīng)皮損傷
10,378 (82%)
經(jīng)粘膜損傷
1817 (14%)
破損皮膚
352 (3%)
咬傷
131 (1%)
*
二. 暴露類型
備注：18
備注：This pie chart shows the types of exposures to blood and body fluids reported to NaSH between June 1995 and December 2000. There were 12,678 exposures reported, with percutaneous exposures accounting for 82% followed by mucous membrane exposures, non-intact skin, and bites. Contacts with intact skin and clean needlesticks are excluded, because they are not considered exposures.

2022/12/15
19
不同暴露方式HIV感染的危險(xiǎn)性
 經(jīng)皮損傷      Percutaneous	           0.3%

經(jīng)粘膜損傷  Mucous membrane      0.09%

破損皮膚      Non-intact skin             <0.1%

二. 暴露類型
備注：19
備注：In prospective studies of healthcare personnel, the average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% and after a mucous membrane exposure, approximately 0.09%. Although HIV transmission after non-intact skin exposure has been documented, the average risk for transmission by this route has not been precisely quantified, but is estimated to be less than the risk for mucous membrane exposures.
2022/12/15
20
  
2022/12/15
21
經(jīng)皮損傷的器械類型NaSH June 1995-December 2000 (n=10,378)
Hollow-bore needle (60%)
Solid sharp (32%)
   Suture needle  (17%)                
                       Scalpel (7%)
                        Other (8%) 
Glass (2%)
Other/ unknown (6%)
Hypodermic needle
29%
Winged steel needle
12%
IV stylet
        Phlebotomy needle *
                       Other hollow-bore needle
6%
3%
10%
* Vacuum tube collection/holder/needle
三. 暴露類型
備注：21
備注：This chart shows the distribution of devices involved in the percutaneous injuries reported to NaSH from June 1995 through December 2000.  Many different devices were associated with the 10,378 injuries reported during that period.  The most commonly implicated devices were hollow-bore needles, shown in blue, and accounting for 60% of  percutaneous injuries.
2022/12/15
22
51例經(jīng)皮損傷HIV感染的器械類型*June 2001
* http://www.cdc.gov/hiv/pubs/facts.htm#Transmission
三. 暴露類型
備注：22
備注：For the 50 documented cases of HIV infection associated with the 51 percutaneous injuries from the previous slide, the types of sharp objects implicated are shown on this pie chart. The largest portion of the pie, in red, represents hollow-bore needles. Other sharp objects represented on this chart include scalpels, in peach, and broken vials, in green. The purple slice represents cases where the sharp object causing the injury was unknown.
2022/12/15
23
  
2022/12/15
24
經(jīng)皮暴露于HIV職業(yè)傳播危險(xiǎn)因素* 
Risk Factor				Adjusted OR ratio (95% CI)

Deep injury				   		15 (6.0-41)
Visible blood on device				6.2 (2.2-21)
Procedure involving needle			4.3 (1.7-12)
  placed in artery or vein
Terminal illness in source patient		5.6 (2.0-16)
Postexposure use of zidovudine		0.19 (0.06-0.52)

*Cardo et al., New Engl J Med 1997;337:1485-90.
三. 病毒接種量
備注：24
備注：In a retrospective case-control study of healthcare personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein. An increased risk was also associated with exposure to blood from source persons with terminal illness, possibly reflecting either a higher titer of HIV in blood late in the course of AIDS or other factors. Postexposure use of zidovudine was associated with a decreased risk of HIV transmission. 
2022/12/15
25
不同體液HBV的滴度
         高		          中度	             低度/未查到

血液		        精液		            尿
        血清		    陰道分泌物               糞便
    傷口滲出物       	       唾液		          汗液
							          眼淚							                             乳汁
四. 病毒滴度
備注：25
備注：As mentioned earlier, one factor to consider in assessing the risk of infection is the body substance to which healthcare personnel are exposed. This shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. 
2022/12/15
26
職 業(yè) 暴 露 后 預(yù) 防
postexposure prophylaxis, PEP
2022/12/15
27
暴露后預(yù)防措施
處理傷口
報(bào)告暴露
評估感染的危險(xiǎn)性
暴露方式和嚴(yán)重程度
源病人的血源感染狀況
合適的治療，隨訪和咨詢
備注：27
備注：The key elements of postexposure management are listed here. Over the next few slides, wound management, exposure reporting, assessment of the infection risk by type and severity of exposure,  determination of the bloodborne status of the source person, and appropriate treatment, follow-up, and counseling are explored in more detail. 
2022/12/15
28
醫(yī)務(wù)人員艾滋病病毒職業(yè)暴露防護(hù)工作指導(dǎo)原則（試行） 
用肥皂液和流動(dòng)水清洗污染的皮膚，用生理鹽水沖洗粘膜。 
如有傷口，應(yīng)當(dāng)在傷口旁端輕輕擠壓，盡可能擠出損傷處的血液，再用肥皂液和流動(dòng)水進(jìn)行沖洗；禁止進(jìn)行傷口的局部擠壓。 
受傷部位的傷口沖洗后，應(yīng)當(dāng)用消毒液，如：75%酒精或者0.5%碘伏進(jìn)行消毒，并包扎傷口；被暴露的粘膜，應(yīng)當(dāng)反復(fù)用生理鹽水沖洗干凈。 
  處理傷口
2022/12/15
29
同濟(jì)醫(yī)院醫(yī)務(wù)人員職業(yè)暴露后處理流程
報(bào)告科室醫(yī)院感染管理小組進(jìn)行局部處理
填寫報(bào)告卡
到感染疾病科就診、隨訪和咨詢
報(bào)告醫(yī)院感染科及保健科

報(bào)告暴露
報(bào)告和記錄損傷患者姓名、器械和環(huán)境
備注：29
備注：It is important to collect and record information about the exposure on an exposure report, and to maintain the confidentiality of both the worker and the source patient.  An exposure report should include the date and time that the exposure occurred, as well as details of what procedure was being performed, where, how, and what device (if any) was involved.  If a device was involved, OSHA requires that the brand and manufacturer of the device be recorded. Details such as the route of exposure, body substance involved, and volume or duration of contact also should be included. Additionally, information about the source person and exposed person, if known, is critical, along with exposure management details, which will be discussed later.
2022/12/15
30
2022/12/15
31
  
 
        無論事故大小，均應(yīng)對職
業(yè)暴露者的個(gè)人情況進(jìn)行保密。
   保密！
2022/12/15
32
評估感染的危險(xiǎn)
暴露類型
經(jīng)皮損傷
粘膜
完整皮膚
咬傷
體液類型
血液
血性液體
具有潛在感染性的體液或組織
源病人
 HBsAg 
 HCV 
 HIV 
未知，則根據(jù)流行病學(xué)和臨床證據(jù)進(jìn)行評估
備注：32
備注：To assess the risk of infection, first consider the type of exposure. Those that pose a risk of infection are percutaneous injuries, mucous membrane exposures, exposures to non-intact skin, and bites resulting in blood exposure. In general, percutaneous injuries pose a greater risk than mucous membrane and non-intact skin exposures.  The next thing to consider is the body substance involved in the exposure. Although blood and bloody fluid exposures are the most risky, there are other potentially infectious fluids or tissues, such as semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluid.  Finally, the infection status of the source of the exposure must be evaluated. If the source is known but infection status unknown, HBV, HCV, and HIV testing should be performed.  However, if the source is unknown, information on the type of exposure, and body substance, along with any other pertinent information must be considered before deciding postexposure management.
2022/12/15
33
暴露源是否疫苗接種及有無抗體
未接種疫苗
接種疫苗  
    應(yīng)答者
    無應(yīng)答者

不清楚有無抗體
源病人 HBsAg 陽性必須治療

HBIG x 1 加上疫苗接種計(jì)劃

不需要治療

HBIG x 1加上重新疫苗接種或
HBIG x  2

檢測暴露源 anti-HBs
1.  有抗體，不需治療
無抗體， HBIG x 1加上
     加強(qiáng)劑量疫苗復(fù)種

HBV暴露后處理方案
治療、隨訪和咨詢
治療、隨訪和咨詢
備注：33
備注：For exposures to HBV, the HBsAg status of the source (in pink) and the hepatitis B vaccination and vaccine-response status of the exposed worker (in green) have to be considered for PEP. Vaccination should be initiated for any unvaccinated personnel exposed to blood or body fluids. When HBIG is indicated, it should also be administered as soon as possible after exposure, and may be administered simultaneously with hepatitis B vaccine at a separate site.  No PEP is necessary for personnel who are known responder to the vaccine. Exposed personnel who are known NOT to have responded to a primary vaccine series should receive a single dose of HBIG and the first dose of a second hepatitis B vaccine series as soon as possible after exposure. The same approach is recommended for personnel who did not respond to a 3-dose vaccine series and have not completed a second 3-dose vaccine series. For personnel who failed to respond a second vaccine series, 2 doses of HIBG should be administered (first dose after exposure and second dose 1 month later). Exposed personnel who have an unknown antibody response should be tested for anti-HBs. If the level is adequate, no treatment is necessary. If the level is inadequate, a single dose of HBIG, along with a vaccine booster should be administered.
2022/12/15
34
暴露源是否疫苗接種及有無抗體

未接種疫苗

接種疫苗
    應(yīng)答者

無應(yīng)答者

不清楚有無抗體

源病人未檢測或感染狀況不清時(shí)
 
開始疫苗接種計(jì)劃

不需治療

源病人HBsAg陽性必須治療

檢測暴露源 anti-HBs
有抗體，不需治療
無抗體，加強(qiáng)劑量復(fù)種，1-2 后重新檢測
 HBV暴露后處理方案
治療、隨訪和咨詢
備注：34
備注：As mentioned previously, all unvaccinated personnel exposed to blood or body fluid should initiate the hepatitis B vaccine series, regardless of the status of the source. Persons with a high risk exposure to HBV (from an untested or unknown source) who are known not to have responded to a primary vaccine series should be treated as if the source were HBsAg positive, and should receive a single dose of HBIG and the first dose of a second hepatitis B vaccine series as soon as possible after exposure. This option is preferred for vaccine nonresponders who did not complete a second 3-dose vaccine series. Alternatively, persons who previously completed a second vaccine series but failed to respond should receive two doses of HBIG, one dose as soon as possible after exposure, and the second dose 1 month later. Persons exposed to HBsAg-positive blood or body fluids who have an unknown antibody response should be tested for anti-HBs. If the level is adequate, no treatment is necessary. If the level is inadequate, a single dose of HBIG, along with a vaccine booster should be administered. After the appropriate prophylaxis is determined, the next consideration is follow-up testing.
2022/12/15
35
HBV 處理的有效性*
Regimen
多劑量HBIG注射，且第一
劑在暴露一周內(nèi)執(zhí)行

乙肝疫苗接種

HBIG 加上乙肝疫苗接種

Prevention of HBV Infection
			70-75%

70-75%
			85-95%
* Estimated for adults, based on perinatal data
備注：35
備注：The efficacy of HBV prophylaxis varies by the regimen used and e antigen status of the source.  In the first column is the prophylaxis regimen, and in the second column is the efficacy of the regimen at preventing HBV infection, based on data from studies of perinatal transmission of HBV where mothers were HBsAg- and HBeAg-positive. Multiple doses of HBIG alone, when initiated within 1 week of exposure, can prevent 70-75% of HBV infection. Similarly, hepatitis B vaccine series alone can prevent 70-75% of HBV infection.  However, it is estimated that the combination of HBIG and the hepatitis B vaccine series can prevent HBV infection in 85-95% of cases.   
2022/12/15
36
HCV暴露后處理
暴露后尚無有效的預(yù)防措施
免疫球蛋白無效
抗病毒藥物（如：干擾素）僅對感染病人有效
FDA不建議使用抗病毒藥物進(jìn)行暴露后預(yù)防
執(zhí)行感染控制措施避免皮下針刺傷最重要
備注：36
備注：For HCV, there is no recommended postexposure prophylaxis. Immunoglobulin is not effective, and there are currently no data on the use of antivirals, which may be effective only with established infection, and are not FDA approved for this setting. 
2022/12/15
37
基本用藥程序:為兩種逆轉(zhuǎn)錄酶制劑，使用常規(guī)治療劑量，連續(xù)使用28天。

強(qiáng)化用藥程序:是在基本用藥程序的基礎(chǔ)上，同時(shí)增加一種蛋白酶抑制劑，使用常規(guī)治療劑量，連續(xù)使用28天。
預(yù)防性用藥應(yīng)當(dāng)在發(fā)生艾滋病病毒職業(yè)暴露后盡早開始，最好在4小時(shí)內(nèi)實(shí)施，最遲不得超過24小時(shí)；即使超過24小時(shí)，也應(yīng)當(dāng)實(shí)施預(yù)防性用藥。
HIV暴露后處理
備注：37
2022/12/15
38
治療不良反應(yīng)的危險(xiǎn)性
傳播的危險(xiǎn)性
HIV暴露后處理
暴露后預(yù)防
    PEP

備注：38
備注：Ultimately, the decision to use postexposure prophylaxis must balance the risk of transmission against the risk of adverse effects associated with the use of prophylaxis.
2022/12/15
39
 HIV暴露后處理的基本方案
基本方案
	Zidovudine (ZDV):	200 mg tid  (300 mg PO bid)
	Lamivudine (3TC):	150 mg bid

替代基本方案 
   Didanosine (ddI):	200 mg bid (125 mg bid if <60 kg)
   Stavudine (d4T):	40 mg bid   (30 mg bid if <60 kg)

Stavudine (d4T):	40 mg bid   (30 mg bid if <60 kg)
   Lamivudine (3TC):	150 mg bid

備注：39
備注：Most HIV exposures will warrant a two-drug regimen with two nucleoside analogues, as shown on this slide. The standard “basic” regimen consists of 200 milligrams of ZDV taken three times a day (tid) or 300 milligrams taken orally two times a day, in conjunction with 150 milligrams of 3TC taken two times a day (bid).   In addition, two alternate basic regimens also may be considered. 
2022/12/15
40
HIV暴露后處理的加強(qiáng)方案
加強(qiáng)方案
	基本方案基礎(chǔ)上加以下一種藥物:
	
	Indinavir (IDV): 	800 mg q8h 
	Nelfinavir (NFV):	750 mg tid or 1250 mg bid
	Efavirenz (EFV):	600 mg daily
	Abacavir (ABC):	300 mg bid
	
	
備注：40
備注：The addition of a third drug to the two-drug regimen should be considered for exposures that pose an increased risk for transmission. Agents to consider as a third drug include indinavir (800 milligrams taken every 8 hours), nelfinavir, efavirenz, and abacavir.  The choice of drug should take into account the advantages and disadvantages of each drug, including the complexity of the regimen, serious toxicity, and the possibility of drug interaction with other drugs which the exposed person may already be taking.
2022/12/15
41
經(jīng)皮損傷HIV PEP方案選擇

暴露方式

較輕
嚴(yán)重
HIV 陽性,1類

基本方案

加強(qiáng)方案
HIV陽性, 2類

加強(qiáng)方案

加強(qiáng)方案
HIV 不明

不需要PEP

不需要PEP
源病人的感染狀況
1類：無癥狀或病毒載量低  
2類：有癥狀、AIDS或病毒載量高
備注：41
備注：The recommended HIV postexposure prophylaxis for a percutaneous injury is based on the infection status of the source and the exposure type. A basic regimen for postexposure prophylaxis is recommended if the source is HIV positive, but asymptomatic or has a known low viral load AND the exposure was less severe (class 1). However, if the exposure was more severe, OR if the source is symptomatic, has AIDS, or has a known high viral load (class 2), regardless of the severity of the exposure, an expanded postexposure prophylaxis regimen is recommended. If the source’s HIV status is unknown, generally no postexposure prophylaxis is warranted, however, a basic 2-drug postexposure prophylaxis regimen could be considered in settings where exposure to HIV-infected persons is likely.
2022/12/15
42
暴露方式

較輕

嚴(yán)重
HIV 陽性,1類

基本方案

基本方案
HIV陽性,2類

基本方案

加強(qiáng)方案
HIV 不明

不需要 PEP

不需要 PEP
源病人的感染狀況

1類：無癥狀或病毒載量低 
2類：有癥狀、AIDS或病毒載量高
粘膜和破損皮膚暴露的HIV PEP方案選擇 
備注：42
備注：The basic regimen of postexposure prophylaxis is recommended for mucous membrane and non-intact skin exposures, regardless of the volume of the exposure, if the source is HIV positive but asymptomatic or has a known low viral load (class 1), OR if the volume of exposure was small AND the source is symptomatic, has AIDS or has a known high viral load (class 2).  However, if the volume of exposure was large AND the source is symptomatic, has AIDS or has a known high viral load (class 2), an expanded postexposure prophylaxis regimen is recommended. Generally, if the source’s HIV status is unknown, regardless of the volume of exposure, no postexposure prophylaxis is warranted.

2022/12/15
43
被暴露者的血清學(xué)追蹤檢測 
暴露源陽性項(xiàng)目	暴露后檢測時(shí)間	暴露后檢測時(shí)間	暴露后檢測時(shí)間	暴露后檢測時(shí)間	暴露后檢測時(shí)間
抗HIV	當(dāng)天	4周	8周	12周	6個(gè)月
HbsAg	當(dāng)天	3個(gè)月			6個(gè)月
抗HCV	當(dāng)天	3周	3個(gè)月		6個(gè)月
梅毒抗體	當(dāng)天	6周	10周		
2022/12/15
44

職 業(yè) 暴 露 前 預(yù) 防
2022/12/15
45
         雖然醫(yī)務(wù)人員是處在與病魔斗爭的第一線，但相對來說，醫(yī)務(wù)人員接收的相關(guān)信息也較多。只要預(yù)防得當(dāng)，疾病感染率應(yīng)該是遠(yuǎn)低于普通人群的。即使是不幸“中招”，也應(yīng)更容易在早期發(fā)現(xiàn)。
2022/12/15
46
預(yù)防原則
提高乙肝疫苗的接種率
執(zhí)行安全操作
使用安全銳器
實(shí)施標(biāo)準(zhǔn)預(yù)防
備注：46
備注：Preventing transmission of bloodborne viruses in healthcare settings requires a multifaceted approach, including promoting hepatitis B vaccination of all healthcare personnel who may have contact with blood, considering all patients as potentially infectious, using appropriate barriers to prevent blood and body fluid contact, and preventing percutaneous injuries, by eliminating unnecessary needle use, implementing safety devices (devices with safety features), using safe work practices when handling needles and other sharp devices,  and safely disposing sharps and blood-contaminated materials.
2022/12/15
47
美國醫(yī)務(wù)人員與普通人群HBV的發(fā)病率(1985-1999) 
醫(yī)務(wù)人員
普通人群
提高乙肝疫苗的接種率
備注：47
備注：This graph shows a 90% decline in the incidence of HBV infections in healthcare personnel from the year 1985 to 1999. In the early to mid 1980’s, the incidence of HBV infection in healthcare personnel was much higher than in the general population.  However, following the 1987 publication of universal precaution guidelines and the 1991 Occupational Safety and Health Administration requirement that employers provide HBV vaccination to healthcare personnel, the incidence in healthcare personnel has dropped below that in the general population.

2022/12/15
48
將輸液導(dǎo)管與無
針系統(tǒng)連接
整個(gè)過程中應(yīng)從容不迫
使用真空采血系統(tǒng)
如患者抵抗或慌張，可尋求幫助
洗手、戴手套
在手術(shù)室中，使用消毒盤傳遞器械 - 不要直接傳遞
執(zhí)行安全操作
2022/12/15
49
使用安全銳器
銳器造成的經(jīng)皮損傷是醫(yī)療機(jī)構(gòu)中經(jīng)血液傳播病原體最常見的原因，使用有安全設(shè)計(jì)器械才能有效降低經(jīng)皮損傷。
安全設(shè)計(jì)包括取消不必要的針頭、安全設(shè)計(jì)不是增加危險(xiǎn)的附屬物、安全設(shè)計(jì)在使用時(shí)能自動(dòng)激活，在處理過程中能保持有效的保護(hù)作用，從而既可以保護(hù)廢物處理者又能保護(hù)使用者。
安全設(shè)計(jì)應(yīng)操作簡單，使用者不需要培訓(xùn)（或簡單培訓(xùn)）就會使用。
2022/12/15
50
實(shí)施標(biāo)準(zhǔn)預(yù)防(standard precaution)
定義
   認(rèn)為病人的血液、體液、分泌物、排泄物均具有傳染性，須進(jìn)行隔離。凡接觸上述物質(zhì)者均必須采取防護(hù)措施，而不論是否具有明顯的血跡污染或是否接觸非完整的皮膚與粘膜。
特點(diǎn)
  既要防止血源性疾病的傳播，也要防止非血源性疾病的傳播;
  強(qiáng)調(diào)雙向防護(hù)；
  根據(jù)各種疾病的主要傳播途徑，采取相應(yīng)的隔離措施。
2022/12/15
51
其他傳播途徑的職業(yè)暴露
2022/12/15
52
以傳播途徑為根基的預(yù)防措施
預(yù)防措施	傳播途徑	病例	防護(hù)裝備
空氣	空氣	肺結(jié)核
麻疹 
水痘	N95 口罩
飛沫	飛沫及呼吸道分泌物	德國麻疹
	外科口罩
接觸	包括吞入	疥瘡
部分耐藥性細(xì)菌
	手套、膠圍裙/保護(hù)衣
備注：52
2022/12/15
53
重在預(yù)防!
保護(hù)病人…保護(hù)醫(yī)務(wù)人員…
促進(jìn)醫(yī)療質(zhì)量!
備注：53
備注：Prevention is Primary.

網(wǎng)友評論 more

職業(yè)健康最新內(nèi)容

03-07