Tipple M A, Shusterman N, Bland L A, McCarthy M A, Favero M S, Arduino M J, Reid M H, Jarvis W R
Hospital Infections Program, Center for Infectious Diseases, Atlanta, Georgia 30333.
ASAIO Trans. 1991 Oct-Dec;37(4):588-91.
In September 1987, patients at an outpatient dialysis center were exposed to chloramine contaminated dialysate when the carbon filter in a recently modified water treatment system failed. Forty-one patients required transfusion to treat the resultant hemolytic anemia. Epidemiologic investigation demonstrated that the mortality rate among dialysis center patients increased during the 5 months after chloramine exposure when compared with the 12 months before chloramine exposure, but no deaths could be attributed to the exposure. Chloramine is commonly used as a disinfectant in municipal water supplies, and has previously been reported to cause hemolytic anemia in patients undergoing dialysis. Hemodialysis centers in cities that use chloramine in water supplies must design water treatment systems with adequate means for removing chloramine and must monitor processed water closely to ensure that chloramine contamination does not occur. Dialysis centers that make changes in their water processing systems should evaluate all components of the system before changes are made, and must ensure that after modifications are made, processed water meets the standards set by the Association for Advancement of Medical Instrumentation.
1987年9月，一家门诊透析中心的水处理系统最近经过改造，其碳过滤器发生故障，导致患者接触到受氯胺污染的透析液。41名患者需要输血来治疗由此引发的溶血性贫血。流行病学调查表明，与氯胺暴露前的12个月相比，透析中心患者在氯胺暴露后的5个月内死亡率有所上升，但没有死亡病例可归因于此次暴露。氯胺通常用作市政供水的消毒剂，此前有报道称其会导致透析患者发生溶血性贫血。在供水使用氯胺的城市，血液透析中心必须设计具有足够手段去除氯胺的水处理系统，并必须密切监测处理后的水，以确保不会发生氯胺污染。对水处理系统进行更改的透析中心，在进行更改之前应评估系统的所有组件，并且必须确保更改后处理后的水符合医疗仪器促进协会设定的标准。
