Cleaning and disinfection of equipment for gastrointestinal endoscopy. Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee
Cleaning and disinfection of equipment for gastrointestinal endoscopy. Report of a Working Party of the British Society of Gastroenterology Endoscopy Committee
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胃肠内窥镜设备的清洗和消毒。
作者：
E. Bsg
百分之二的戊二醛是英国内窥镜检查单位最常用的消毒剂。不幸的是，内窥镜检查人员对戊二醛的不良反应很常见，健康与安全委员会建议大幅降低大气中戊二醛的含量，以遵守 1994 年《有害健康物质控制条例》。工作组通过审查替代消毒剂和自动清洗机/消毒器的使用，探讨了消除或尽量减少内窥镜检查装置中戊二醛暴露的方法。戊二醛的替代品必须至少具有与戊二醛一样的杀菌能力、无刺激性并且与内窥镜组件和净化设备兼容。过氧乙酸是一种高效的消毒剂，可能是戊二醛的合适替代品。过乙酸具有类似醋的气味，据称比戊二醛刺激性小。使用该试剂的经验仍然相对有限，工作组建议在获得进一步经验之前应在密封或排气通风设施中使用过乙酸。它比戊二醛贵得多，稳定性较差，并且必须储存大量。它会对内窥镜造成外观（但非功能）损坏，并且与某些清洗机/消毒器不兼容。二氧化氯是一种强氧化剂，作为消毒剂非常有效。一旦激活，必须将其储存在顶部空间很小的密封容器中。烟雾会引起刺激，需要密封或排气通风设施。该试剂可能会损坏内窥镜和自动清洗机/消毒器的一些金属和聚合物部件，因此在使用该试剂之前应与设备制造商确定兼容性。其他消毒剂如过氧化合物和季铵衍生物不太合适，因为其杀分枝杆菌和/或杀病毒活性不令人满意，或者与内窥镜和自动清洗机/消毒器不兼容。酒精虽然有效，但长时间接触会损坏镜片粘固剂。它也是易燃的，因此不适合在自动化系统中大量使用。超氧化水 (Sterilox) 是一种电化学溶液（阳极电解液），含有具有强氧化特性的自由基混合物。新鲜生成时，只要物品彻底清洁并满足严格的生成标准（即电流、pH 值、氧化还原电位），它就具有高度杀菌作用。它似乎对使用者来说是安全的，并且如果现场试验证实了实验室功效测试，并且该试剂是非破坏性的，它也可能成为戊二醛的替代品。当使用2%戊二醛进行手动和自动消毒时，建议在治疗前和患者之间将内窥镜浸泡10分钟。这将消灭细菌和病毒的繁殖体（包括乙型肝炎病毒 (HBV) 和 HIV）。建议 0.35% 过氧乙酸和二氧化氯（1100 ppm av ClO2）接触五分钟，但如果浸泡 10 分钟，也将实现杀孢子活性。每次疗程结束时，建议在戊二醛中浸泡 20 分钟，或在过氧乙酸或二氧化氯中浸泡 5 分钟。微生物学研究表明，接触 2% 戊二醛 20 分钟即可消灭大多数微生物，包括结核分枝杆菌。因此，工作组得出结论，对于艾滋病和其他免疫缺陷状态或肺结核患者进行内窥镜检查时，将内窥镜浸入 2% 戊二醛中 20 分钟就足够了。同样，当需要高水平消毒时，建议在列表开始时以及内窥镜逆行胰胆管造影 (ERCP) 病例之间浸泡 20 分钟。内窥镜的清洁和消毒应由经过培训的人员在专用房间内进行。使用清洁剂彻底清洁仍然是该过程中最重要的第一步。自动清洗机/消毒机已成为内窥镜检查装置的重要组成部分。机器必须可靠、有效、易于使用，并且在使用刺激性物质时应防止消毒剂污染大气。除非提供密闭或排气通风设施，否则不应使用消毒剂槽。优选详细的清洁和消毒方案，对此进行了描述。应尽可能使用“一次性”或可高压灭菌的配件。必须权衡未充分净化的可重复使用物品传播感染的风险和成本。重复使用标记为一次性的配件会将产品安全性能的法律责任从制造商转移到用户或其雇主，除非符合卫生部的标准，否则应避免这样做。鼓励制造商生产更多可重复使用的物品，这些物品易于清洁且可高压灭菌。对员工的健康监测是强制性的，应包括有关哮喘、皮肤和粘膜敏感性问题以及通过肺活量测定进行的肺功能的就业前调查。职业健康档案必须保存30年。参与内窥镜操作的人员应接种乙型肝炎疫苗，应戴手套和适当的防护服，并应遮盖伤口和擦伤。需要增加资金来购买内窥镜设备，包括更多的内窥镜、清洗机/消毒器、排气通风设备和一次性配件。
Two per cent glutaraldehyde is the most commonly used disinfectant in endoscopy units within the UK. Unfortunately adverse reactions to glutaraldehyde are common among endoscopy personnel and the Health and Safety Commission has recommended substantial reductions in atmospheric levels of glutaraldehyde in order to comply with the Control of Substances Hazardous to Health Regulations, 1994. The Working Party addressed ways of eliminating or minimising exposure to glutaraldehyde in endoscopy units by reviewing alternative disinfectants and the use of automated washer/disinfectors. Alternatives to glutaraldehyde must be at least as microbicidal as glutaraldehyde, non-irritating and compatible with endoscope components and decontamination equipment. Peracetic acid is a highly effective disinfectant and may be a suitable alternative to glutaraldehyde. Peracetic acid has a vinegary-like odour and is claimed to be less irritating than glutaraldehyde. Experience with this agent remains relatively limited and the Working Party recommends that peracetic acid should be used in sealed or exhaust ventilated facilities until further experience is obtained. It is considerably more expensive than glutaraldehyde, is less stable and large volumes have to be stored. It causes cosmetic (but not functional) damage to endoscopes and is not compatible with some washer/disinfectors. Chlorine dioxide is a powerful oxidising agent and highly effective as a disinfectant. Once activated it must be stored in sealed containers with little head space. Fumes cause irritation and sealed or exhaust ventilated facilities are necessary. The agent may damage some metallic and polymer components of endoscopes and automated washer/disinfectors and compatibility should be established with equipment manufacturers before the agent is used. Other disinfectants such as peroxygen compounds and quaternary ammonium derivatives are less suitable because of unsatisfactory mycobactericidal and/or virucidal activity, or incompatibility with endoscopes and automated washer/disinfectors. Alcohol is effective but, on prolonged contact, is damaging to lens cements. It is also flammable and therefore unsuitable for use in large quantities in automated systems. Superoxidised water (Sterilox) is an electrochemical solution (anolyte) containing a mixture of radicals with strong oxidising properties. It is highly microbicidal when freshly generated, provided items are thoroughly clean and strict generation criteria are met—that is, current, pH, redox potential. It seems to be safe for users and provided field trials substantiate laboratory efficacy tests, and the agent is non-damaging, it too may become an alternative to glutaraldehyde. When 2% glutaraldehyde is used for manual and automated disinfection, 10 minutes’ immersion is recom-mended for endoscopes before the session and between patients. This will destroy vegetative bacteria and viruses (including hepatitis B virus (HBV) and HIV). A five minute contact period is recommended for 0.35% peracetic acid and for chlorine dioxide (1100 ppm av ClO2), but if immersed for 10 minutes sporicidal activity will also be achieved. At the end of each session 20 minutes’ immersion in glutaraldehyde or five minutes in peracetic acid or chlorine dioxide is recommended. Microbiological studies show that 20 minutes of exposure to 2% glutaraldehyde destroys most organisms, includingMycobacterium tuberculosis. The Working Party concludes therefore that immersion of the endoscope in 2% glutaraldehyde for 20 minutes is sufficient for endoscopy involving patients with AIDS and other immunodeficiency states or pulmonary tuberculosis. Similarly, 20 minutes’ immersion is recommended at the start of the list and between cases for endoscopic retrograde cholangiopancreatography (ERCP) when high level disinfection is required. Cleaning and disinfection of endoscopes should be undertaken by trained staff in a dedicated room. Thorough cleaning with detergent remains the most important and first step in the process. Automated washer/disinfectors have become an essential part of the endoscopy unit. Machines must be reliable, effective, easy to use and should prevent atmospheric pollution by the disinfectant if an irritating agent is used. Troughs of disinfectant should not be used unless containment or exhaust ventilated facilities are provided. A detailed cleaning and disinfection regimen is preferred and this is described. Whenever possible “single use” or autoclavable accessories should be used. The risk of transfer of infection from inadequately decontaminated reusable items must be weighed against the cost. Reusing accessories labelled for single use will transfer legal liability for the safe performance of the product from the manufacturer to the user or his/her employers and should be avoided unless Department of Health criteria are met. Manufacturers are encouraged to produce more reusable items which are readily accessible for cleaning and are autoclavable. Health surveillance of staff is mandatory and should include a pre-employment enquiry regarding asthma, skin and mucosal sensitivity problems and lung function by spirometry. Occupational health records must be kept for 30 years. Those involved in endoscopic practice should be vaccinated against hepatitis B, should wear gloves and appropriate protective clothing, and should cover wounds and abrasions. Increased funding is necessary for capital purchases of endoscopic equipment, including more endoscopes, washer/disinfectors, exhaust ventilation equipment, and single use accessories.