Izindaba

Umbuzo: I-Norepinephrine iyisidakamizwa esitholakala kakhulu esilawulwa nge-intravenously (IV) njengokufakwa okuqhubekayo. I-vasopressor evame ukubizwa ngokuthi i-titrated ukuze igcine umfutho wegazi owanele futhi iqondise ukugeleza kwesitho kubantu abadala abagula kakhulu kanye nezingane ezine-hypotension enzima noma ukushaqeka okuqhubekayo naphezu kokubuyisela uketshezi okwanele. Ngisho namaphutha amancane ku-titration noma umthamo, kanye nokulibaziseka ekwelashweni, kungaholela emiphumeleni eyingozi eyingozi. I-Multicenter Health System isanda kuthumela i-ISMP imiphumela yokuhlaziywa kwembangela evamile (CCA) yamaphutha angu-106 we-norepinephrine enzeke ngo-2020 no-2021. Ukuhlola izenzakalo eziningi nge-CCA kuvumela izinhlangano ukuthi ziqoqe izimbangela zezimpande ezivamile kanye nokuba sengozini kwesistimu. Idatha evela kuhlelo lokubika lwenhlangano namaphampu ahlakaniphile okufakwayo asetshenzisiwe ukuze kuhlonzwe amaphutha angaba khona.
I-ISMP ithole imibiko ehlobene ne-noradrenaline engu-16 ngo-2020 nango-2021 ngoHlelo Lokubika Iphutha Lemithi Likazwelonke le-ISMP (ISMP MERP). Cishe ingxenye eyodwa kwezintathu yale mibiko yayiphathelene nezingozi ezihlobene namagama afanayo, amalebula, noma ukupakishwa, kodwa awekho amaphutha abikiwe ngempela. Sishicilele imibiko yamaphutha ayisikhombisa esiguli se-norepinephrine: amaphutha amane omthamo (April 16, 2020; Agasti 26, 2021; February 24, 2022); iphutha elilodwa lokugxila okungalungile; iphutha elilodwa le-titration engalungile yomuthi; ukuphazamiseka ngephutha ukumnika norepinephrine. Yonke imibiko engu-16 ye-ISMP yengezwe ohlelweni lwezempilo lwe-CCA multicenter (n=106) futhi imiphumela ehlanganisiwe (N=122) yesinyathelo ngasinye senqubo yokusetshenziswa kwezidakamizwa iboniswa ngezansi. Iphutha elibikiwe lifakiwe ukunikeza isibonelo sezizathu ezijwayelekile.
Nikeza. Sibone izici ezimbalwa eziyimbangela ezihlotshaniswa namaphutha okuchaza, okuhlanganisa ukusetshenziswa okungadingekile kwemiyalo yomlomo, ukuchaza i-norepinephrine ngaphandle kokusebenzisa amasethi omyalo, kanye nezinhloso ezingacacile noma ezingaqinisekile kanye/noma nemingcele ye-titration (ikakhulukazi uma amasethi womyalo engasetshenziswa). Kwesinye isikhathi imingcele ye-titration enqunyiwe iqine kakhulu noma ayisebenzi (isb., ukunyuswa okunqunyiwe kukhulu kakhulu), okwenza kube nzima kubahlengikazi ukuthobela lapho beqapha umfutho wegazi wesiguli. Kwezinye izimo, odokotela bangase banikeze imithamo esekelwe isisindo noma engeyona isisindo, kodwa lokhu ngezinye izikhathi kuyadideka. Lokhu kuchaza okungaphandle kwebhokisi kwandisa amathuba okuba odokotela abaphansi benze amaphutha, kuhlanganise namaphutha ohlelo lwepompo, njengoba izinketho ezimbili zokudosa zitholakala kumtapo wezincwadi wepompo. Ukwengeza, ukubambezeleka kwabikwa kudinga ukucaciswa kwe-oda lapho imiyalo yokunquma ihlanganisa imiyalelo ye-dosing esekelwe isisindo kanye ne-non-weight-based dosing.
Udokotela ucela umhlengikazi ukuba abhale incwadi kadokotela ye-norepinephrine esigulini esinomfutho wegazi ongazinzile. Umhlengikazi ufake i-oda njengoba nje udokotela eyalile ngomlomo: 0.05 mcg/kg/min IV titrated to target mean mean arterial pressure (MAP) ngaphezu kuka-65 mmHg. Kodwa imiyalelo yemithamo kadokotela ihlanganisa ukukhuphuka komthamo ongasekelwe esisindweni ngesilinganiso esiphezulu esisekelwe isisindo: i-titrate ngesilinganiso esingu-5 mcg/min njalo ngemizuzu emi-5 kuya kumthamo omkhulu we-1.5 mcg/kg/min. Iphampu yokufaka ehlakaniphile yenhlangano ayikwazanga ukulinganisa umthamo we-mcg/min ukuya kudosi esekelwe isisindo esikhulu, mcg/kg/min. Osokhemisi kudingeke ukuthi bahlole imiyalelo kodokotela, okuholele ekubambezelekeni kokuhlinzeka ngosizo.
Lungiselela futhi usabalalise. Amaphutha amaningi okulungiselela kanye nemithamo abangelwa umsebenzi wekhemisi oweqile, okhuliswa abasebenzi basekhemisi abadinga ukugxiliswa okuphezulu kwe-norepinephrine infusions (32 mg/250 ml) (etholakala kumakhemisi okwakhiwa kwe-503B kodwa ayitholakali kuzo zonke izindawo). kuholela ekwenzeni izinto eziningi kanye nokukhathala. Ezinye izimbangela ezivamile zamaphutha okukhipha zihlanganisa amalebula e-noradrenaline afihlwe ezikhwameni eziqinile kanye nokuntula ukuqonda kwabasebenzi basekhemisi mayelana nokuphuthuma kokukhishwa.
Ukufakwa ngokubambisana kwe-norepinephrine ne-nicardipine esikhwameni senhlaka emnyama akuhambanga kahle. Ukuze uthole ukufakwa okumnyama, uhlelo lokudosa luphrinte amalebula amabili, elinye esikhwameni sokufakwa ngokwalo kanye nelinye ngaphandle kwesikhwama se-amber. I-Norepinephrine infusions ifakwe ngokungafanele emaphaketheni e-amber abhalwe ukuthi "i-nicardipine" ngaphambi kokusatshalaliswa komkhiqizo ukuze usetshenziswe iziguli ezahlukene futhi ngokuphambene nalokho. Amaphutha awazange abonwe ngaphambi kokukhipha noma ukuthakwa. Isiguli esaphathwa nge-nicardipine sanikezwa i-norepinephrine kodwa ayizange ibangele ukulimala kwesikhathi eside.
ezokuphatha. Amaphutha avamile ahlanganisa umthamo ongalungile noma iphutha lokugxilisa ingqondo, iphutha lesilinganiso esingalungile, nephutha elingalungile lezidakamizwa. Iningi lala maphutha abangelwa ukuhlelwa okungalungile kwepompo yokufaka ehlakaniphile, ngokwengxenye ngenxa yokuba khona kokukhethwa komthamo emtatsheni wezincwadi wezidakamizwa, kokubili ngesisindo nangaphandle kwawo; amaphutha esitoreji; ukuxhunywa nokuxhunywa kabusha kokufakwa okuphazamisekile noma okumisiwe esigulini kuqale ukumnika okungalungile noma akuzange kumake imigqa futhi akuzange kuyilandele lapho iqala noma iqala kabusha ukumnika. Kukhona okungahambanga kahle emakamelweni ezimo eziphuthumayo nasemagunjini okuhlinza, futhi ukusebenzisana kwepompo ehlakaniphile namarekhodi ezempilo ka-elekthronikhi (EHR) bekungatholakali. Kubikwe nokwengezwa okuholela ekulimaleni kwezicubu.
Umhlengikazi unikeze i-norepinephrine njengoba iqondiswe ngenani lika-0.1 µg/kg/min. Esikhundleni sokuhlela iphampu ukuthi ilethe u-0.1 mcg/kg/min, umhlengikazi uhlele iphampu ukuthi ilethe u-0.1 mcg/min. Ngenxa yalokho, isiguli sathola i-norepinephrine ngaphansi izikhathi ezingu-80 kunalokho esinqunyiwe. Lapho ukumnika kwehliswa kancane kancane futhi kwafinyelela izinga elingu-1.5 µg/min, umhlengikazi wahlulela ukuthi wayesefinyelele umkhawulo omkhulu onqunyiwe ongu-1.5 µg/kg/min. Ngenxa yokuthi umfutho wegazi ophansi wesiguli wawungajwayelekile, kwengezwe i-vasopressor yesibili.
Inventory kanye nesitoreji. Amaphutha amaningi ayenzeka lapho kugcwalisa amakhabethe okukhipha okuzenzakalelayo (ADCs) noma ukushintsha izitsha ze-norepinephrine ezinqoleni ezinekhodi. Isizathu esiyinhloko salawa maphutha e-inventory ukulebula okufanayo nokupakishwa. Kodwa-ke, ezinye izimbangela ezivamile ziye zabonakala, njengamazinga aphansi ajwayelekile e-norepinephrine infusions ku-ADC ayenganele ukuhlangabezana nezidingo zeyunithi yokunakekelwa kwesiguli, okuholela ekubambezelekeni kokwelashwa uma amakhemisi kufanele enze i-infusions ngenxa yokushoda. Ukwehluleka ukuskena ibhakhodi yomkhiqizo ngamunye we-norepinephrine ngenkathi ugcina i-ADC omunye umthombo ovamile wephutha.
Usokhemisi ugcwalise kabusha i-ADC ngephutha ngesixazululo se-norepinephrine esilungiselelwe ekhemisi esingu-32 mg/250 ml edroweni lomkhiqizi le-premix elingu-4 mg/250 ml. Umhlengikazi uhlangabezane nephutha ngenkathi ezama ukuthola i-4 mg/250 ml ye-norepinephrine infusion evela kwa-ADC. Ibhakhodi ekufakweni ngakunye komuntu ngamunye ayizange iskenwe ngaphambi kokuthi ibekwe ku-ADC. Lapho umhlengikazi ebona ukuthi kwakukhona kuphela isikhwama esingu-32 mg/250 ml ku-ADC (kufanele sibe yingxenye efriji ye-ADC), wacela ukugxilisa ingqondo okulungile. Izixazululo zokumnika i-Norepinephrine 4mg/250mL azitholakali emakhemisi ngenxa yokushoda komkhiqizi wamaphakethe angu-4mg/250mL axutshwe ngaphambili, okuholela ekubambezelekeni ekuxubeni kosizo lokumnika.
qapha. Ukuqapha okungalungile kweziguli, i-titration ye-norepinephrine infusions ngaphandle kwemingcele ye-oda, nokungalindeli ukuthi isikhwama sokumnika esilandelayo sidingeka nini yizimbangela ezivame kakhulu zamaphutha okuqapha.
Isiguli esifayo esinemiyalo yokuthi “ungavuseleli” sijova i-norepinephrine ukuze sihlale isikhathi eside ngokwanele ukuze umndeni waso uvalelise. Ukufakwa kwe-norepinephrine kwaphela, futhi kwakungekho sikhwama esisele ku-ADC. Unesi ngokushesha wabiza ikhemisi wafuna isikhwama esisha. Ikhemisi alibanga naso isikhathi sokulungisa umuthi ngaphambi kokuba isiguli sidlule emhlabeni wase evalelisa emndenini waso.
Ingozi. Zonke izingozi ezingazange zibangele iphutha zibikwa ku-ISMP futhi zihlanganisa amalebula afanayo noma amagama ezidakamizwa. Imibiko eminingi ibonisa ukuthi ukupakishwa nokulebula kokugxiliswa okuhlukahlukene kwe-norepinephrine infusions okunikezwa ngabangaphandle abangu-503B kubonakala kucishe kufane.
Izincomo zokwenza okuphephile. Cabangela izincomo ezilandelayo lapho uthuthukisa noma ubuyekeza isu lesikhungo sakho ukuze unciphise amaphutha ekusetshenzisweni okuphephile kwe-norepinephrine (kanye namanye ama-vasopressor) infusions:
nciphisa ukugxila. Kufanekiselwa inani elilinganiselwe lokugxila ekwelapheni izingane kanye/noma iziguli zabantu abadala. Cacisa umkhawulo wesisindo somuthi ogxiliswe kakhulu ozogcinelwa iziguli ezinokuvinjelwa uketshezi noma ezidinga imithamo ephezulu ye-norepinephrine (ukunciphisa izinguquko zesikhwama).
Khetha indlela eyodwa yokudosa. Misa imiyalelo yokumnika i-norepinephrine njengesekelwe esisindweni somzimba (mcg/kg/min) noma ngaphandle kwayo (mcg/min) ukuze unciphise ingozi yephutha. I-American Society of Health System Pharmacists (ASHP) Safety Standards Initiative4 incoma ukusetshenziswa kwamayunithi omthamo we-norepinephrine kuma-micrograms/kg/minute. Ezinye izibhedlela zingase zilinganise umthamo ube ama-micrograms ngomzuzu kuye ngokuthandwa udokotela - kokubili kuyamukeleka, kodwa izinketho ezimbili zomthamo azivunyelwe.
Idinga ukuchazwa ngokuya kwesifanekiso se-oda elijwayelekile. Idinga incwadi kadokotela yokumnika i-norepinephrine kusetshenziswa ithempulethi yoku-oda evamile enezinkambu ezidingekayo zokugxilisa ingqondo okufunayo, ithagethi ye-titration elinganisekayo (isb, i-SBP, umfutho wegazi we-systolic), imingcele ye-titration (isb, umthamo wokuqala, ububanzi bethamo, iyunithi yokukhuphuka, kanye nemvamisa yomthamo) phezulu noma phansi ), indlela yokuphatha kanye nesilinganiso esiphezulu esingafanele seqiwe kanye / noma udokotela okhona kufanele abizwe. Isikhathi esizenzakalelayo sokushintsha kufanele sibe “isibalo” ukuze lawa ma-oda aze kuqala kulayini wekhemisi.
Nciphisa imiyalo yomlomo. Nciphisa imiyalo yomlomo ezimweni eziphuthumayo zangempela noma lapho udokotela engakwazi ukufaka noma ukubhala i-oda nge-elektroniki. Odokotela kufanele bazenzele izinhlelo zabo ngaphandle uma kunezimo ezithethelelayo.
Thenga izixazululo esezilungile uma sezitholakala. Sebenzisa ukugxila kwezixazululo ze-norepinephrine ezixutshwe ngaphambili ezivela kubakhiqizi kanye/noma izixazululo ezilungiselelwe abathengisi bezinkampani zangaphandle (ezifana ne-503B) ukunciphisa isikhathi sokulungiselela ikhemisi, ukunciphisa ukubambezeleka kokwelashwa, nokugwema amaphutha okwakhiwa kwekhemisi.
ukugxila okuhlukile. Hlukanisa ukugxilisa okuhlukene ngokukwenza kuhluke ngokubonakalayo ngaphambi kokuthatha umthamo.
Nikeza amazinga esilinganiso se-ADC anele. Thenga ku-ADC futhi unikeze infusions eyanele ye-norepinephrine ukuze uhlangabezane nezidingo zesiguli. Gada ukusetshenziswa futhi ulungise amazinga ajwayelekile njengoba kudingeka.
Dala izinqubo zokucutshungulwa kweqoqo kanye/noma ukuhlanganisa ngokufunwayo. Ngenxa yokuthi kungathatha isikhathi ukuxuba ukugxiliswa okuphezulu okungahlengiwe, amakhemisi angasebenzisa amasu anhlobonhlobo ukubeka phambili ukulungiselela nokulethwa ngesikhathi, okuhlanganisa ukudosa kanye/noma ukucindezela lapho iziqukathi zingenalutho phakathi namahora, okubangelwa iphuzu lokunakekelwa noma izaziso ze-imeyili kudingeka ilungisiwe.
Iphakheji/ibhodlela ngalinye liyaskeniwa. Ukuze ugweme amaphutha ngesikhathi sokulungiselela, ukusatshalaliswa, noma ukugcinwa, skena ibhakhodi esikhwameni ngasinye sokumnika i-norepinephrine noma ibhodlela ukuze iqinisekiswe ngaphambi kokulungiswa, ukusatshalaliswa, noma ukugcinwa ku-ADC. Amabhakhodi angasetshenziswa kuphela kumalebula anamathiselwe ngqo kuphakheji.
Hlola ilebula esikhwameni. Uma isikhwama esingaqinile sisetshenziswa ngesikhathi sokuhlolwa kwemithamo evamile, ukumnika kwe-norepinephrine kufanele kukhishwe okwesikhashana esikhwameni ukuze kuhlolwe. Ngaphandle kwalokho, faka isikhwama sokuvikela ukukhanya phezu kokuwuthela ngaphambi kokuhlolwa bese usifaka esikhwameni ngokushesha ngemva kokuhlolwa.
Dala imihlahlandlela. Sungula imihlahlandlela (noma iphrothokholi) ye-infusion titration ye-norepinephrine (noma esinye isidakamizwa esine-titrated), okuhlanganisa ukugxila okujwayelekile, ububanzi bethamo eliphephile, ukukhushulwa komthamo we-titration okuvamile, imvamisa ye-titration (amaminithi), umthamo omkhulu/izinga, isisekelo, nokuqapha okudingekayo. Uma kungenzeka, xhumanisa izincomo ku-titration oda Kurekhodi Lokulawula Imithi (MAR).
Sebenzisa iphampu ehlakaniphile. Wonke ama-norepinephrine infusions afakwa futhi afakwe i-titrated kusetshenziswa iphampu yokufaka ehlakaniphile ene-Dose Error Reduction System (DERS) enikwe amandla ukuze i-DERS ikwazi ukuxwayisa ochwepheshe bezempilo ngamaphutha angaba khona emithi, ukubala, noma ohlelo.
Nika amandla Ukuvumelana. Lapho kungenzeka khona, nika amandla iphampu yokufaka ehlakaniphile enezinhlangothi ezimbili ehambisana namarekhodi ezempilo kagesi. Ukusebenzisana kuvumela amaphampu ukuthi agcwaliswe kusengaphambili ngezilungiselelo zokufakwa eziqinisekisiwe ezinqunywe udokotela (okungenani ekuqaleni kwe-titration) futhi kwandisa ukuqwashisa kwekhemisi ukuthi kungakanani okusele ekufakweni okune-titrated.
Maka imigqa bese ulandelela amapayipi. Lebula umugqa ngamunye wokumnika ngenhla kwepompo naseduze kwendawo yokufinyelela yesiguli. Ukwengeza, ngaphambi kokuqala noma ukushintsha isikhwama se-norepinephrine noma izinga lokumnika, hambisa ishubhu ngesandla usuka esitsheni sesixazululo uye epompo kanye nesiguli ukuze uqinisekise ukuthi iphampu/umzila kanye nomzila wokuphatha kulungile.
Yamukela ukuhlolwa. Uma ukumnika okusha kumisiwe, ukuhlolwa kobuchwepheshe (isb. ibhakhodi) kuyadingeka ukuze kuqinisekiswe umuthi/isixazululo, ukugcwala kwezidakamizwa kanye nesiguli.
Misa ukumnika. Uma isiguli sizinzile kungakapheli amahora angu-2 wokuyeka ukumnika i-norepinephrine, cabanga ukuthola umyalelo wokuyeka kudokotela owelaphayo. Uma ukumnika kumisiwe, nqamula ngokushesha ukumnika esigulini, ukususe empompini, bese ulahla ukuze ugweme ukuphathwa ngengozi. Ukumnika kufanele futhi kunqanyulwe esigulini uma ukumnika kuphazanyiswa isikhathi esingaphezu kwamahora ama-2.
Setha iphrothokholi ye-extravasation. Setha iphrothokholi ye-extravasation ye-frothing norepinephrine. Abahlengikazi kufanele baziswe ngalolu hlelo, okuhlanganisa ukwelashwa nge-phentolamine mesylate nokugwema ukucindezela okubandayo endaweni ethintekile, okungase kubhebhethekise ukulimala kwezicubu.
Linganisa umkhuba we-titration. Gada ukuthotshelwa kwabasebenzi nezincomo zokufakwa kwe-norepinephrine, izivumelwano kanye nemiyalelo kadokotela ethize, kanye nemiphumela yesiguli. Izibonelo zezinyathelo zihlanganisa ukuhambisana nemingcele ye-titration edingekayo ku-oda; ukubambezeleka kokwelashwa; ukusetshenziswa kwamaphampu ahlakaniphile ane-DERS enikwe amandla (kanye nokusebenzisana); qala ukumnika ngesilinganiso esinqunyiwe; i-titration ngokuya ngemvamisa enqunyiwe kanye nemingcele ye-dosing; iphampu ehlakaniphile ikwazisa ngobuningi kanye nohlobo lomthamo, imibhalo yemingcele ye-titration (kufanele ihambisane nezinguquko zomthamo) kanye nokulimala kwesiguli ngesikhathi sokwelashwa.