Izindaba

Umbuzo: I-Norepinephrine umuthi otholakala kakhulu onikezwa nge-intravenously (IV) njengomuthi oqhubekayo. Uyi-vasopressor evame ukufakwa i-tit ukuze kugcinwe umfutho wegazi owanele kanye nokugeleza kwegazi okuqondiwe ezithweni kubantu abadala abagula kakhulu kanye nezingane ezine-hypotension enkulu noma ukushaqeka okuqhubekayo naphezu kokubuyiselwa kwamanzi okwanele. Ngisho namaphutha amancane ekulinganisweni noma kumthamo, kanye nokubambezeleka kokwelashwa, kungaholela emiphumeleni emibi eyingozi. I-Multicenter Health System isanda kuthumela i-ISMP imiphumela yokuhlaziywa kwezimbangela ezivamile (CCA) yamaphutha angu-106 e-norepinephrine enzeke ngo-2020 nango-2021. Ukuhlola izehlakalo eziningi nge-CCA kuvumela izinhlangano ukuthi ziqoqe izimbangela ezivamile kanye nobuthakathaka besistimu. Idatha evela ohlelweni lokubika lwenhlangano kanye namaphampu e-smart infusion yasetshenziswa ukuhlonza amaphutha angaba khona.
I-ISMP ithole imibiko eyi-16 ehlobene ne-noradrenaline ngo-2020 nango-2021 nge-ISMP National Medication Error Reporting Program (ISMP MERP). Cishe ingxenye yesithathu yale mibiko ibhekane nezingozi ezihlobene namagama afanayo, amalebula, noma ukupakishwa, kodwa awekho amaphutha abikiwe ngempela. Sishicilele imibiko yamaphutha ayisikhombisa eziguli ze-norepinephrine: amaphutha amane okulinganisa (Ephreli 16, 2020; Agasti 26, 2021; Februwari 24, 2022); iphutha elilodwa lokuhlushwa okungalungile; iphutha elilodwa lokuthambekela okungalungile komuthi; ukuphazamiseka ngengozi kokufakwa kwe-norepinephrine. Yonke imibiko eyi-16 ye-ISMP yengezwe ohlelweni lwezempilo lwe-CCA multicenter (n=106) kanye nemiphumela ehlanganisiwe (N=122) yesinyathelo ngasinye senqubo yokusebenzisa umuthi iboniswe ngezansi. Iphutha elibikiwe lifakiwe ukunikeza isibonelo sezimbangela ezithile ezivamile.
Ukunikeza Imithi. Sithole izici eziningana ezibangela amaphutha okunikeza imithi, okuhlanganisa ukusetshenziswa okungadingekile kwemiyalo yomlomo, ukunikeza i-norepinephrine ngaphandle kokusebenzisa amasethi emiyalo, kanye nemigomo engacacile noma engaqinisekile kanye/noma imingcele ye-titration (ikakhulukazi uma amasethi emiyalo engasetshenziswa). Ngezinye izikhathi imingcele ye-titration enqunyiwe iqine kakhulu noma ayisebenzi (isb., ukwenyuka okunqunyiwe kukhulu kakhulu), okwenza kube nzima ngabahlengikazi ukuthobela imithetho lapho beqapha umfutho wegazi wesiguli. Kwezinye izimo, odokotela bangase banikeze imithamo esekelwe esisindweni noma engasekelwe esisindweni, kodwa lokhu ngezinye izikhathi kuyadida. Lokhu kunikeza imithi okungavamile kwandisa amathuba okuba odokotela abasemuva benze amaphutha, okuhlanganisa namaphutha okuhlela ipompo, njengoba kunezinketho ezimbili zokufaka imithi ezitholakala kulabhulali yepompo. Ngaphezu kwalokho, ukubambezeleka kubikwe kudinga ukucaciswa kwe-oda lapho ama-oda okunikeza imithi efaka imiyalelo yokulinganisa esekelwe esisindweni kanye nemiyalelo yokulinganisa engasekelwe esisindweni.
Udokotela ucela umhlengikazi ukuba abhalele isiguli esinomfutho wegazi ongazinzile i-norepinephrine incwadi kadokotela. Umhlengikazi ufake i-oda njengoba nje udokotela ayemyalile ngomlomo: i-0.05 mcg/kg/min IV titrated to a target mean arterial pressure (MAP) engaphezu kuka-65 mmHg. Kodwa imiyalelo yomthamo kadokotela ixuba ukukhuphuka komthamo ongewona owesisindo nomthamo ophezulu osekelwe esisindweni: titrate ngesilinganiso esingu-5 mcg/min njalo ngemizuzu emi-5 kuya kumthamo omkhulu ongu-1.5 mcg/kg/min. Iphampu yokufakwa ehlakaniphile yenhlangano ayikwazanga ukwehlisa umthamo we-mcg/min uye kumthamo omkhulu osekelwe esisindweni, mcg/kg/min. Osokhemisi kwadingeka bahlole imiyalelo nodokotela, okwaholela ekubambezelekeni kokunikeza ukunakekelwa.
Lungisa futhi usabalalise. Amaphutha amaningi okulungiselela nokulinganisa abangelwa umthwalo omningi wemithi yasekhemisi, okwenziwa kube kubi kakhulu ngabasebenzi basekhemisi abadinga ukuhlushwa okuphezulu kwe-norepinephrine infusions (32 mg/250 ml) (etholakala kumakhemisi e-503B kodwa awatholakali kuzo zonke izindawo). kuholela ekusebenzeni okuningi kanye nokukhathala. Ezinye izimbangela ezivamile zamaphutha okukhipha imithi zihlanganisa amalebula e-noradrenaline afihliwe ezikhwameni eziqinile kanye nokungaqondi kwabasebenzi basekhemisi ngokuphuthuma kokukhipha imithi.
Ukufakwa kanyekanye kwe-norepinephrine ne-nicardipine esikhwameni esimnyama esiphuzi akuhambanga kahle. Ekufakweni okumnyama, uhlelo lokulinganisa luphrinte amalebula amabili, elilodwa esikhwameni sokufaka ngokwalo kanti elinye ngaphandle kwesikhwama esiphuzi. Ukufakwa kwe-norepinephrine kwafakwa ngephutha emaphaketheni e-amber abhalwe ukuthi “nicardipine” ngaphambi kokusatshalaliswa komkhiqizo ukuze usetshenziswe yiziguli ezahlukene kanye nokuphikisana nalokho. Amaphutha awazange abonwe ngaphambi kokukhipha noma ukumnika. Isiguli eselashwe nge-nicardipine sanikwa i-norepinephrine kodwa asizange sibangele ukulimala kwesikhathi eside.
zokuphatha. Amaphutha avamile afaka phakathi iphutha lomthamo noma lokuhlushwa okungalungile, iphutha lesilinganiso esingalungile, kanye nephutha lemithi elingalungile. Iningi lala maphutha libangelwa ukuhlela okungalungile kwephampu yokungenisa ehlakaniphile, ngokwengxenye ngenxa yokuba khona kokukhethwa komthamo kulabhulali yemithi, kokubili ngesisindo nangaphandle kwayo; amaphutha okugcina; ukuxhumana kanye nokuxhuma kabusha kokufakwa okuphazamisekile noma okumiswe esigulini okuqale ukufakwa okungalungile noma ukungamaki imigqa futhi akulandelanga lapho kuqala noma kuqaliswa kabusha ukufakwa. Kukhona okungahambanga kahle emakamelweni ezimo eziphuthumayo nasemakamelweni okuhlinzwa, futhi ukuhambisana kwephampu ehlakaniphile namarekhodi ezempilo kagesi (i-EHR) bekungatholakali. Ukukhishwa kwemithi okuholela ekulimaleni kwezicubu nakho kubikiwe.
Umhlengikazi wanikeza i-norepinephrine njengoba kuqondiswe ngesilinganiso esingu-0.1 µg/kg/min. Esikhundleni sokuhlela iphampu ukuthi inikeze i-0.1 mcg/kg/min, umhlengikazi wahlela iphampu ukuthi inikeze i-0.1 mcg/min. Ngenxa yalokho, isiguli sathola i-norepinephrine engaphansi ngokuphindwe ka-80 kuneyayinqunyiwe. Lapho ukumnika kwandiswa 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 ojwayelekile wesiguli wawungajwayelekile, kwanezelwa i-vasopressor yesibili.
Isitokwe kanye nokugcinwa. Amaphutha amaningi ayenzeka lapho kugcwaliswa amakhabethe okukhipha ngokuzenzakalelayo (ama-ADC) noma kushintshwa ama-norepinephrine vials ezinqoleni ezibhalwe ikhodi. Isizathu esiyinhloko salezi ziphutha zesitokwe ukulebula kanye nokupakishwa okufanayo. Kodwa-ke, ezinye izimbangela ezivamile nazo zitholiwe, njengamazinga aphansi ajwayelekile okufakwa kwe-norepinephrine e-ADC ayenganele ukuhlangabezana nezidingo zeyunithi yokunakekelwa kweziguli, okuholela ekubambezelekeni kokwelashwa uma amakhemisi kwakudingeka alungise ukufakwa kwe-norepinephrine ngenxa yokushoda. Ukwehluleka ukuskena ibhakhodi yomkhiqizo ngamunye we-norepinephrine ngenkathi kugcinwa i-ADC kungomunye umthombo ovamile wephutha.
Usokhemisi wagcwalisa ngephutha i-ADC ngesisombululo se-norepinephrine esingu-32 mg/250 ml esilungiselelwe ekhemisi edroweni lomkhiqizi elingu-4 mg/250 ml premix. Umhlengikazi uhlangabezane nephutha ngenkathi ezama ukuthola i-norepinephrine infusion engu-4 mg/250 ml evela ku-ADC. Ibhakhodi ekufakweni ngakunye ayizange iskeniwe ngaphambi kokufakwa ku-ADC. Lapho umhlengikazi eqaphela ukuthi kwakukhona isikhwama esingu-32 mg/250 ml kuphela ku-ADC (kufanele sibe sengxenyeni efrijini ye-ADC), wacela ukuhlushwa okufanele. Izixazululo zokufakelwa ze-Norepinephrine 4mg/250mL azitholakali emakhemisi ngenxa yokuntuleka komkhiqizi kwamaphakethe angu-4mg/250mL axutshwe kusengaphambili, okwaholela ekubambezelekeni kosizo lokuxuba i-infusion.
ukuqapha. Ukuqapha okungalungile kweziguli, ukuhluzwa kwe-norepinephrine ngaphandle kwemingcele ye-oda, kanye nokungalindeli ukuthi isikhwama esilandelayo sokufaka siyadingeka nini yizona zimbangela ezivame kakhulu zamaphutha okuqapha.
Isiguli esifayo esinikezwe imiyalelo yokuthi “singavuseleli” sijovwa nge-norepinephrine ukuze ihlale isikhathi eside ngokwanele ukuze umndeni waso uvalelise. Ukufakwa kwe-norepinephrine kwaphela, futhi kwakungekho sikhwama esisele ku-ADC. Umhlengikazi washayela ucingo ngokushesha ekhemisi wafuna isikhwama esisha. Ikhemisi lalingenaso isikhathi sokulungisa umuthi ngaphambi kokuba isiguli sishone futhi savalelisa umndeni waso.
Ingozi. Zonke izingozi ezingazange zibangele iphutha zibikwa ku-ISMP futhi zifaka phakathi amagama afanayo okulebula noma emithi. Imibiko eminingi ikhombisa ukuthi ukupakishwa kanye nokulebula kwamazinga ahlukahlukene okufakwe kwe-norepinephrine okunikezwa ngabathengisi be-503B kubonakala kufana kakhulu.
Izincomo zokwenza okuphephile. Cabangela izincomo ezilandelayo lapho uthuthukisa noma ubuyekeza isu lesikhungo sakho ukuze unciphise amaphutha ekusetshenzisweni okuphephile kwe-norepinephrine (kanye nezinye izidakamizwa ezicindezela imithambo yegazi):
umkhawulo wokuhlushwa. Kulinganiselwe inani elilinganiselwe lokuhlushwa kokwelashwa kweziguli zezingane kanye/noma zabantu abadala. Cacisa umkhawulo wesisindo sokufakwa okugxilile kakhulu okufanele kugcinelwe iziguli ezinemikhawulo yoketshezi noma ezidinga imithamo ephezulu ye-norepinephrine (ukunciphisa ukushintsha kwesikhwama).
Khetha indlela eyodwa yokulinganisa. Hlela imiyalelo yokufakwa kwe-norepinephrine ngokujwayelekile ngokusekelwe 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 okulinganisa i-norepinephrine kuma-microgram/kg/minute. Ezinye izibhedlela zingalinganisa umthamo ube ama-microgram ngomzuzu kuye ngokuthi udokotela ukhetha ini - zombili ziyamukeleka, kodwa izinketho ezimbili zokulinganisa azivunyelwe.
Kudinga ukunqunywa ngokwethempulethi ye-oda ejwayelekile. Kudinga umuthi we-norepinephrine osetshenziswa ithempulethi yoku-oda ejwayelekile enezinkambu ezidingekayo zokuhlushwa okufiswayo, inhloso ye-titration elinganisekayo (isb., i-SBP, umfutho wegazi we-systolic), amapharamitha we-titration (isb., umthamo wokuqala, ububanzi bomthamo, iyunithi yokwanda, kanye nemvamisa yomthamo) phezulu noma phansi), indlela yokuphatha kanye nomthamo omkhulu okungamelwe udlulwe kanye/noma udokotela ohambelayo kufanele abizwe. Isikhathi sokushintsha esizenzakalelayo kufanele sibe “i-stat” yale miyalelo ukuze ithathe indawo emgqeni wekhemisi.
Nciphisa imiyalo yomlomo. Nciphisa imiyalo yomlomo ezimweni eziphuthumayo zangempela noma lapho udokotela engakwazi ukungena noma ukubhala i-oda nge-elekthronikhi. Odokotela kumele benze amalungiselelo abo ngaphandle uma kunezimo ezingabalulekanga.
Thenga izixazululo ezenziwe kakade uma zitholakala. Sebenzisa ukugxila kwezixazululo ze-norepinephrine ezixutshwe kusengaphambili ezivela kubakhiqizi kanye/noma izixazululo ezilungiselelwe abathengisi bezinkampani zangaphandle (njenge-503B) ukuze unciphise isikhathi sokulungiselela ikhemisi, unciphise ukubambezeleka kokwelashwa, futhi ugweme amaphutha okwenziwa kwekhemisi.
ukuhlushwa okuhlukile. Hlukanisa ukuhlushwa okuhlukene ngokukwenza kuhluke ngokubonakalayo ngaphambi kokuthatha umthamo.
Nikeza amazinga e-ADC anele. Thenga i-ADC futhi unikeze imijovo ye-norepinephrine eyanele ukuhlangabezana nezidingo zesiguli. Qapha ukusetshenziswa futhi ulungise amazinga ajwayelekile njengoba kudingeka.
Dala izinqubo zokucubungula amaqoqo kanye/noma ukuhlanganisa ngokufunwa. Ngenxa yokuthi kungathatha isikhathi ukuhlanganisa ukuhlushwa okuphezulu okungakahlengwa, amakhemisi angasebenzisa amasu ahlukahlukene ukuze abeke phambili ukulungiselela nokulethwa ngesikhathi, okuhlanganisa ukukala kanye/noma ukucindezela lapho izitsha zingenalutho emahoreni ambalwa, okubangelwa indawo yokunakekela noma izaziso ze-imeyili zidinga ukulungiswa.
Iphakheji/ibhodlela ngalinye liyaskenwa. Ukuze ugweme amaphutha ngesikhathi sokulungiselela, ukusabalalisa, noma ukugcina, skena ibhakhodi esikhwameni ngasinye sokufaka i-norepinephrine noma ibhodlela ukuze kuqinisekiswe ngaphambi kokulungiselela, ukusabalalisa, noma ukugcina ku-ADC. Amabhakhodi angasetshenziswa kuphela kumalebula anamathiselwe ngqo ephaketheni.
Hlola ilebula esikhwameni. Uma kusetshenziswa isikhwama esiqinile kancane ngesikhathi sokuhlolwa komthamo okuvamile, ukufakwa kwe-norepinephrine kufanele kususwe okwesikhashana esikhwameni ukuze kuhlolwe. Ngaphandle kwalokho, beka isikhwama sokuvikela esikhanyayo phezu kokufakwa ngaphambi kokuhlolwa bese usifaka esikhwameni ngokushesha ngemva kokuhlolwa.
Dala iziqondiso. Misa iziqondiso (noma inqubo) yokumuncwa kwe-norepinephrine (noma omunye umuthi onama-titrated), okuhlanganisa amazinga ajwayelekile, amazinga omthamo ophephile, ukwanda komthamo ojwayelekile we-titration, imvamisa ye-titration (imizuzu), umthamo/isilinganiso esiphezulu, isisekelo, kanye nokuqapha okudingekayo. Uma kungenzeka, xhumanisa izincomo nohlelo lwe-titration ku-Medicines Regulatory Record (MAR).
Sebenzisa iphampu ehlakaniphile. Zonke izithasiselo ze-norepinephrine zifakwa futhi zilinganiswe kusetshenziswa iphampu ehlakaniphile yokufakwa enesistimu yokunciphisa amaphutha omthamo (i-DERS) evuliwe ukuze i-DERS ikwazi ukuxwayisa ochwepheshe bezempilo ngamaphutha angaba khona okunikeza umuthi, ukubala, noma ukuhlela.
Nika amandla ukuhambisana. Lapho kungenzeka khona, vumela iphampu yokungenisa ehlakaniphile eqondiswa kabili ehambisana namarekhodi ezempilo kagesi. Ukusebenzisana kuvumela amaphampu ukuthi agcwaliswe kusengaphambili ngezilungiselelo zokungenisa eziqinisekisiwe ezinqunywe udokotela (okungenani ekuqaleni kokulinganisa) futhi kwandisa ulwazi lwekhemisi ngokuthi kusele malini kuma-infusions alinganiselwe.
Maka imigqa bese ulandela umkhondo wamapayipi. Bhala ilebula umugqa ngamunye wokufaka ngaphezu kwephampu naseduze nendawo yokufinyelela yesiguli. Ngaphezu kwalokho, ngaphambi kokuqala noma ukushintsha isikhwama se-norepinephrine noma izinga lokufaka, hambisa ipayipi ngesandla kusuka esitsheni sesisombululo uye ephampini nasesigulini ukuqinisekisa ukuthi iphampu/isiteshi kanye nendlela yokungenisa ilungile.
Yamukela ukuhlolwa. Uma ukumnika okusha kumisiwe, kudingeka ukuhlolwa kobuchwepheshe (isb. ibhakhodi) ukuqinisekisa umuthi/isixazululo, ukuhlushwa kwemithi kanye nesiguli.
Misa ukumnika. Uma isiguli sizinzile zingakapheli amahora ama-2 kusukela simise ukumnika i-norepinephrine, cabanga ngokuthola umyalelo wokumisa kudokotela osiphathayo. Uma ukumnika sekumisiwe, khipha ngokushesha ukumnika esigulini, ukukhiphe ephampini, bese ukulahla ukuze ugweme ukunikezwa ngengozi. Ukumnika kumele futhi kukhishwe esigulini uma ukumnika kuphazamisekile isikhathi esingaphezu kwamahora ama-2.
Setha inqubo yokukhipha i-extravasation. Setha inqubo yokukhipha i-extravasation yokukhipha i-norepinephrine. Abahlengikazi kufanele baziswe ngalolu hlelo, okuhlanganisa ukwelashwa nge-phentolamine mesylate kanye nokugwema ukucindezela okubandayo endaweni ethintekile, okungadala umonakalo omkhulu wezicubu.
Hlola umkhuba wokulinganisa umthamo. Qapha ukuhambisana kwabasebenzi nezincomo zokufakwa kwe-norepinephrine, amaphrothokholi kanye nemiyalelo kadokotela ethile, kanye nemiphumela yesiguli. Izibonelo zezinyathelo zifaka phakathi ukuhambisana nemingcele ye-titration edingekayo ku-oda; ukubambezeleka ekwelashweni; ukusetshenziswa kwamaphampu ahlakaniphile ane-DERS evuliwe (kanye nokusebenzisana); qala ukufaka umthamo ngesivinini esinqunyiwe; i-titration ngokwemvamisa enqunyiwe kanye nemingcele yokulinganisa umthamo; iphampu ehlakaniphile ikuxwayisa ngemvamisa kanye nohlobo lomthamo, imibhalo yemingcele ye-titration (kufanele ihambisane nezinguquko zomthamo) kanye nokulimala kwesiguli ngesikhathi sokwelashwa.