14例输液发热反应病例的原因分析

为查明14例输液反应发生的原因,对输液、输液器及有关物品、工作人员手的细菌污染检测结果进行了分析。据检测,从残余输液、使用的输液器中检出产气肠杆菌、丝状真菌,输液器检出热原阳性,未使用的输液、输液器细菌与热原检测均为阴性;操作台与工作人员手细菌总数超标率分别为83％与91％; 病人血标本、无菌棉签均未检出细菌;室内空气与消毒液细菌总数均未超标准。因此,可能是使用中造成输液、输液器被细菌污染,引起输液时的热原反应。

ANALYSIS OF CAUSES OF FEBRILE REACTION TO FLUID INFUSION IN 14 CASES

In order to find out the causes of occurrence of fluid infusion reaction in 14 cases, the results of examination of bacterial contamination of infusion fluid, infusion set and related articles, and hands of workers involved were analyzed. According to the examination, Enterobacter aerogenes and Hyphomycetes were detected from residual infusion fluid and infusion set. The infusion set was pyrogen positive. The infusion fluid and infusion set not used yet were bacteria and pyrogen negative. Examination of working table and hands of workers found that the rate of total bacterial count exceeding the allowable level were 8.3% and 9.1 % respectively. No bacteria were detected from patients' blood samples and sterile cotten swabs. The total bacterial counts of indoor air and disinfectant solution did not exceed the allowable levels. Therefore, the infusion fluid and infusion set may be contaminated by bacteria during use, causing pyrogen reaction during fluid infusion.