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Umbuzo: I-Norepinephrine lichiza elifumanekayo eliphezulu elilawulwa nge-intravenously (IV) njenge-infusion eqhubekayo. I-vasopressor edlalwa ngokuqhelekileyo ukugcina uxinzelelo lwegazi olwaneleyo kunye ne-perfusion ye-organ ekujoliswe kuyo kubantu abadala abagula kakhulu kunye nabantwana abane-hypotension enzima okanye ukothuka okuqhubekayo nangona ukubuyisela okwaneleyo kwamanzi. Nokuba iimpazamo ezincinci kwi-titration okanye idosi, kunye nokulibaziseka kunyango, kunokukhokelela kwiziphumo ebezingalindelekanga eziyingozi. Inkqubo yezeMpilo ye-Multicenter isanda kuthumela i-ISMP iziphumo zohlalutyo oluqhelekileyo lwesizathu (CCA) kwiimpazamo ze-106 ze-norepinephrine ezenzeka kwi-2020 kunye ne-2021. Ukuhlola iziganeko ezininzi kunye ne-CCA kuvumela imibutho ukuba iqokelele izizathu eziqhelekileyo zengcambu kunye nobuthathaka benkqubo. Idatha evela kwinkqubo yokunika ingxelo yombutho kunye neepompo zokufakelwa ezihlakaniphile zasetyenziselwa ukuchonga iimpazamo ezinokuthi zibe khona.
I-ISMP ifumene iingxelo ze-16 ezinxulumene ne-noradrenaline kwi-2020 kunye ne-2021 ngokusebenzisa iNkqubo yeNgxelo yeMpaza yeSizwe ye-ISMP (ISMP MERP). Malunga nesinye kwisithathu sezi ngxelo zithetha ngeengozi ezinxulumene namagama afanayo, iilebhile, okanye ukupakishwa, kodwa akukho zimpazamo zichaziweyo. Siye sapapasha iingxelo zeempazamo ezisixhenxe zesigulane se-norepinephrine: iimpazamo ezine ze-dosing (Aprili 16, 2020; Agasti 26, 2021; ngoFebruwari 24, 2022); impazamo enye yogxininiso olungachanekanga; impazamo enye yetitration engalunganga yechiza; uphazamiseko ngengozi yokufakwa kwe-norepinephrine. Zonke iingxelo ze-ISMP ze-16 zongezwa kwinkqubo yezempilo ye-CCA emininzi (n = 106) kunye neziphumo ezidibeneyo (N = 122) kwisinyathelo ngasinye kwinkqubo yokusetyenziswa kweziyobisi iboniswe ngezantsi. Impazamo echaziweyo ibandakanyiwe ukunika umzekelo wezinye izizathu eziqhelekileyo.
Chaza. Siye sachonga izinto ezininzi ezibangelayo ezinxulumene neempazamo zokumisela, kubandakanywa ukusetyenziswa ngokungeyomfuneko kwemiyalelo yomlomo, ukumisela i-norepinephrine ngaphandle kokusetyenziswa kweeseti zomyalelo, kunye neethagethi ezingacacanga okanye ezingaqinisekanga kunye / okanye i-titration parameters (ingakumbi ukuba iisethi zomyalelo zingasetyenziswanga). Ngamanye amaxesha imilinganiselo ye-titration emiselweyo ingqongqo kakhulu okanye ayinakwenzeka (umzekelo, ukunyuswa okumiselweyo kukhulu kakhulu), okwenza kube nzima kubongikazi ukuthobela xa behlola uxinzelelo lwegazi lwesigulane. Kwezinye iimeko, oogqirha banokumisela imilinganiselo esekelwe kwisisindo okanye i-non-weight-based doses, kodwa oku ngamanye amaxesha kudideke. Oku kuchaza ngaphandle kwebhokisi kwandisa amathuba okuba oogqirha abasezantsi benze iimpazamo, kubandakanywa iimpazamo zeprogram yepompo, ekubeni iinketho ezimbini ze-dosing zikhoyo kwilayibrari yempompo. Ukongezelela, ukulibaziseka kwabikwa kufuna ukucaciswa komyalelo xa imimiselo yokumisela iquka imiyalelo ye-dosing esekelwe kwisisindo kunye ne-non-weight-based dosing.
Ugqirha ucela umongikazi ukuba abhale umyalelo we-norepinephrine kwisigulane esinoxinzelelo lwegazi olungazinzanga. Umongikazi wangena kumyalelo ngokuchanekileyo njengoko ugqirha wayalela ngomlomo: 0.05 mcg / kg / min IV titrated to target mean mean arterial pressure (MAP) ngaphezu kwe-65 mmHg. Kodwa imiyalelo yedosi kagqirha ixuba ukunyuswa kwedosi engekho-ubunzima kunye ne-dose-based based dose: i-titrate kwizinga le-5 mcg / min yonke imizuzu ye-5 ukuya kwi-dose ephezulu ye-1.5 mcg / kg / min. Impompo yokufakelwa kwe-smart yombutho ayikwazanga ukwenza idosi ye-mcg/min ukuya kubunzima obusekwe kumthamo omkhulu, mcg/kg/min. Oosokhemesti kwafuneka bajonge imiyalelo koogqirha, nto leyo ekhokelele ekulibazisekeni ekuboneleleni ngokhathalelo.
Lungiselela kwaye usasaze. Iimpazamo ezininzi zokulungiselela kunye ne-dosing zibangelwa ngumthwalo ogqithiseleyo womsebenzi we-pharmacy, owenziwe nzima ngabasebenzi be-pharmacy abafuna i-concentration enkulu ye-norepinephrine infusions (32 mg / 250 ml) (ekhoyo kwii-pharmacy zokuqulunqa i-503B kodwa ayifumaneki kuzo zonke iindawo). kukhokelela kwimisebenzi emininzi kunye nokudinwa. Ezinye izizathu eziqhelekileyo zokusabalalisa iimpazamo ziquka iileyibhile ze-noradrenaline ezifihliweyo kwiingxowa ezikhanyayo kunye nokungabikho kokuqonda ngabasebenzi basekhemesti ukungxamiseka kokuhambisa.
I-co-infusion ye-norepinephrine kunye ne-nicardipine kwingxowa emnyama ye-amber ayihambanga kakuhle. Ukufakwa okumnyama, inkqubo yokudosa iprinte iilebhile ezimbini, enye kwibhegi yokugalela ngokwayo kunye nenye ingaphandle kwebhegi ye-amber. I-Norepinephrine infusions ifakwe ngokungahambi kakuhle kwiipakethi ze-amber ezibhalwe "nicardipine" ngaphambi kokusasazwa kwemveliso ukuze isetyenziswe zizigulane ezahlukeneyo kunye ngokufanayo. Iimpazamo azizange ziqatshelwe ngaphambi kokukhutshwa okanye ukuchithwa. Isigulane esiphathwe nge-nicardipine sanikwa i-norepinephrine kodwa ayizange ibangele ingozi yexesha elide.
ulawulo. Iimpazamo eziqhelekileyo ziquka idosi engachanekanga okanye impazamo yoxinaniso, impazamo yezinga elingalunganga, kunye nempazamo yechiza engachanekanga. Uninzi lwezi mpazamo zibangelwa yinkqubo engachanekanga yempompo yokufaka i-smart, ngokuyinxenye ngenxa yobukho bokukhethwa kwethamo kwithala leencwadi leziyobisi, zombini ngobunzima nangaphandle kwayo; iimpazamo zokugcina; uxhulumaniso kunye nokudityaniswa kwakhona kwe-infusions ephazamisekileyo okanye emisiweyo kwisigulane yaqala ukunyuswa okungalunganga okanye ayizange iphawule imigca kwaye ayizange ilandele xa iqala okanye iphinda iqalise ukuxutywa. Kukho into engahambanga kakuhle kumagumbi onxunguphalo kunye namagumbi okusebenza, kwaye ukuhambelana kwempompo ehlakaniphile kunye neerekhodi zezempilo ze-elektroniki (EHR) zazingekho. Ukongezwa okukhokelela ekonakaleni kwezicubu kuye kwaxelwa kwakhona.
Umongikazi walawula i-norepinephrine njengoko ilawulwa kwinqanaba le-0.1 µg / kg / min. Esikhundleni sokucwangcisa ipompo ukuhambisa i-0.1 mcg / kg / min, umongikazi wacwangcisa umpompo ukuhambisa i-0.1 mcg / min. Ngenxa yoko, isigulane safumana amaxesha angama-80 ngaphantsi kwe-norepinephrine kunokuba imiselwe. Xa ukufakwa kuthotywa kancinci kancinci kwaye kwafikelela kumyinge we-1.5 µg/min, umongikazi wagqiba ekubeni ufikelele kumlinganiselo obekiweyo we-1.5 µg/kg/min. Ngenxa yokuba i-arterial pressure yesigulane yayingaqhelekanga, i-vasopressor yesibini yongezwa.
Uluhlu kunye nokugcinwa. Uninzi lweempazamo zenzeke xa kuzaliswa iikhabhinethi ezizenzekelayo zokukhupha (ADCs) okanye ukutshintsha i-norepinephrine vials kwiinqwelo ezinekhowudi. Esona sizathu siphambili sezi mpazamo zoluhlu kukuleyibheli kunye nokupakishwa okufanayo. Nangona kunjalo, ezinye izizathu eziqhelekileyo nazo zichongiwe, njengamanqanaba asezantsi e-norepinephrine infusions kwi-ADC ayenganelanga ukuhlangabezana neemfuno zecandelo lokunyamekela isigulane, okukhokelela ekulibazisekeni kwonyango ukuba ii-pharmacy kufuneka zenze i-infusions ngenxa yokunqongophala. Ukungaphumeleli ukuskena ibhakhowudi yemveliso nganye ye-norepinephrine ngelixa ugcina i-ADC ngomnye umthombo oqhelekileyo wempazamo.
Usokhemisti waphinda wagcwalisa i-ADC ngempazamo kwikhemesti-elungiselelwe i-32 mg / 250 ml isisombululo se-norepinephrine kumenzi we-4 mg / 250 ml premix drawer. Umongikazi wadibana nephutha ngelixa ezama ukufumana i-4 mg / 250 ml i-norepinephrine infusion evela kwi-ADC. Ibhakhowudi kwi-infusion yomntu ngamnye ayizange iskenwe phambi kokuba ifakwe kwi-ADC. Xa umongikazi eqaphela ukuba kukho i-32 mg / 250 ml kuphela isikhwama kwi-ADC (kufuneka ibe kwindawo efrijini ye-ADC), wacela ukugxininiswa okuchanekileyo. I-Norepinephrine 4mg / 250mL izisombululo ze-infusion azifumaneki kwii-pharmacy ngenxa yokungabikho komenzi we-premixed 4mg / 250mL iipakethi, okubangelwa ukulibaziseka ekuxubeni uncedo lwe-infusion.
esweni. Ukujongwa okungalunganga kwezigulane, i-titration ye-norepinephrine infusions ngaphandle kweeparameters zomyalelo, kunye nokungalindeli xa i-bag infusion elandelayo ifunekayo zizona zizathu eziqhelekileyo zokujonga iimpazamo.
Isigulana esifayo esinemiyalelo yokuba "ungavuseleli" sitofwe nge-norepinephrine ukuze ihlale ixesha elide ngokwaneleyo ukuba intsapho yakhe ivalelise. I-norepinephrine infusion iphelile, kwaye kwakungekho ngxowa esecaleni kwi-ADC. Unesi ngokukhawuleza wabiza ikhemesti kwaye wafuna ibhegi entsha. Ikhemesti yayingenaxesha lokulungisa iyeza ngaphambi kokuba isigulana sisweleke kwaye yathi ndlela-ntle kusapho lwakhe.
Ingozi. Zonke iingozi ezingakhange zibangele impazamo zixelwa kwi-ISMP kwaye zibandakanya ukuleyibhile okufanayo okanye amagama eziyobisi. Uninzi lweengxelo zibonisa ukuba ukupakishwa kunye nokuleyibhile koxinzelelo lwee-norepinephrine infusions ezinikezelwa ngabangaphandle be-503B zibonakala zifana ngokufanayo.
Iingcebiso zokwenza ngokukhuselekileyo. Qwalasela ezi ngcebiso zilandelayo xa uphuhlisa okanye uhlaziya isicwangciso soncedo lwakho ukunciphisa iimpazamo ekusebenziseni ngokukhuselekileyo i-norepinephrine (kunye nezinye i-vasopressor) infusions:
ukunciphisa ukugxila. Ibekwe emgangathweni inani eliqingqiweyo lokugxila kunyango lwabantwana kunye/okanye izigulane zabantu abadala. Cacisa umda wobunzima beyona infusion igxininiswe kakhulu ukuba igcinelwe izigulane ezinothintelo lwamanzi okanye ezifuna iidosi eziphezulu ze-norepinephrine (ukunciphisa utshintsho lwengxowa).
Khetha indlela enye yokudosa. Ukulinganisa i-norepinephrine infusion prescriptions ngokusekwe kubunzima bomzimba (mcg/kg/min) okanye ngaphandle kwayo (mcg/min) ukunciphisa umngcipheko wempazamo. I-American Society of Health System Pharmacists (ASHP) iMigangatho yoKhuseleko lweMigangatho ye-Initiative4 incoma ukusetyenziswa kweeyunithi zedosi ye-norepinephrine kwi-micrograms / kg / ngomzuzu. Ezinye izibhedlele zinokumisela idosi kwi-micrograms ngomzuzu ngokuxhomekeke kukhetho lukagqirha - zombini ziyamkeleka, kodwa iinketho ezimbini zokudosa azivumelekanga.
Ifuna ukumisela ngokwethemplethi ye-odolo eqhelekileyo. Ifuna i-norepinephrine infusion prescription usebenzisa itemplate yokuodola esemgangathweni kunye nemimandla efunekayo yoxinaniso olufunwayo, ithagethi ye-titration enokulinganiswa (umzekelo, i-SBP, uxinzelelo lwegazi lwe-systolic), imilinganiselo ye-titration (umzekelo, idosi yokuqala, uluhlu lwethamo, iyunithi yokunyuka, kunye ne-dosing frequency) phezulu okanye phantsi), indlela yokulawula kunye nedosi ephezulu engafanele igqithwe kunye / okanye ugqirha ohambayo kufuneka abizwe. Ixesha elimiselweyo lokutshintsha kufuneka libe “yi-stat” ukuze ezi odolo zithathe indawo ephambili emgceni wekhemesti.
Nciphisa imiyalelo yomlomo. Ukunciphisa imiyalelo yomlomo kwiimeko ezingxamisekileyo okanye xa ugqirha engakwazi ukungena okanye ukubhala umyalelo ngekhompyutha. Oogqirha bamele bazenzele awabo amalungiselelo ngaphandle kokuba kukho iimeko ezithethelelayo.
Thenga izisombululo esele zenziwe xa zikhona. Sebenzisa i-concentrations ye-premixed norepinephrine solutions ezivela kubakhiqizi kunye / okanye izisombululo ezilungiselelwe ngabathengisi beqela lesithathu (ezifana ne-503B) ukunciphisa ixesha lokulungiselela i-pharmacy, ukunciphisa ukulibaziseka kwonyango, kunye nokuphepha iimpazamo zokuqulunqa iikhemisi.
ukugxila okwahlukileyo. Yahlula ukugxininiswa okwahlukeneyo ngokubenza bahluke ngokubonakalayo phambi kokudosa.
Ukubonelela ngemigangatho eyaneleyo ye-ADC. Gcina kwi-ADC kwaye unikeze i-norepinephrine infusions eyaneleyo ukuhlangabezana neemfuno zesigulane. Ukubeka iliso kusetyenziso kwaye uhlengahlengise amanqanaba asemgangathweni njengoko kufuneka.
Yenza iinkqubo zokusetyenzwa kweebhetshi kunye/okanye ukudibanisa kwimfuno. Ngenxa yokuba kunokuthatha ixesha ukuxuba uxinaniso olungahlawulelwanga, iikhemesti zinokusebenzisa iindlela ezahlukeneyo zokubeka phambili ukulungiselela kwangexesha kunye nokuhanjiswa, kubandakanywa idosi kunye / okanye ukucinezela xa izitya zingenanto phakathi kweeyure, ezibangelwa yindawo yokunyamekela okanye izaziso ze-imeyile kufuneka zibe. ilungisiwe.
Ipakethe/ivial nganye iyaskenwa. Ukuze ugweme iimpazamo ngexesha lokulungiselela, ukusabalalisa, okanye ukugcinwa, skena ibhakhowudi kwisikhwama ngasinye se-norepinephrine infusion okanye i-vial yokuqinisekisa ngaphambi kokulungiswa, ukusabalalisa, okanye ukugcinwa kwi-ADC. Iibhakhowudi zingasetyenziswa kuphela kwiilebhile ezincanyathiselwe ngqo kwiphakheji.
Jonga ileyibhile ebhegini. Ukuba isikhwama esikhanyayo sisetyenziswe ngexesha lokujonga i-dosing yesiqhelo, i-norepinephrine infusion kufuneka isuswe okwethutyana kwi-bag yokuvavanya. Ngenye indlela, faka isikhwama sokukhusela ukukhanya phezu kwe-infusion ngaphambi kokuvavanya kwaye uyibeke engxoweni ngokukhawuleza emva kovavanyo.
Yenza izikhokelo. Ukuseka izikhokelo (okanye iprothokholi) ye-infusion titration ye-norepinephrine (okanye enye iyeza ene-titrated), kubandakanywa ugxininiso oluqhelekileyo, uluhlu lwedosi ekhuselekileyo, ukunyuswa kwedosi ye-titration eqhelekileyo, i-titration frequency (imizuzu), i-dose ephezulu / izinga, isiseko, kunye nokubeka iliso okufunekayo. Ukuba kunokwenzeka, qhagamshela iingcebiso kwi-titration order kwiRekhodi yoLawulo lwaMayeza (MAR).
Sebenzisa impompo ehlakaniphile. Zonke i-norepinephrine infusions zifakwe kwaye zifakwe kwi-titrated kusetyenziswa ipompo yokufaka i-smart infusion kunye neNkqubo yokuNcitshiswa kweNgcaciso yeDose (DERS) enikwe amandla ukwenzela ukuba i-DERS inokwazisa abaqeqeshi bezempilo kwiimpazamo ezinokubakho zokumisela, ukubala, okanye iinkqubo.
Yenza Ukuhambelana. Apho kunokwenzeka, vula impompo yokufakelwa ehlakaniphileyo ehambelana ne-bi-directional ehambelana neerekhodi zempilo zombane. Ukusebenzisana kuvumela iimpompo ukuba zizaliswe kwangaphambili ngemimiselo yokufakwa kwe-infusion eqinisekisiweyo echazwe ngugqirha (ubuncinci ekuqaleni kwe-titration) kwaye kwandisa ulwazi lwe-pharmacy malunga nokuba kungakanani okusele kwi-infusions ene-titrated.
Phawula imigca kwaye ulandele imibhobho. Faka ileyibhile kumgca ngamnye wokugalela ngaphezulu kwempompo kwaye kufutshane nendawo yokufikelela kwesigulana. Ukongezelela, ngaphambi kokuba uqale okanye utshintshe isikhwama se-norepinephrine okanye i-infusion rate, hambisa ngesandla i-tubing ukusuka kwisitya sesisombululo ukuya kumpompo kunye nesigulane ukuqinisekisa ukuba ipompo / ishaneli kunye nendlela yokulawula ichanekile.
Yamkela ukuhlolwa. Xa ukufakelwa okutsha kunqunyanyisiwe, uhlolo lobugcisa (umzekelo ibhakhowudi) luyafuneka ukuze kuqinisekiswe ichiza/isisombululo, ukuxinana kwechiza kunye nesigulana.
Yeka ukunyuswa. Ukuba isigulane sizinzile kwiiyure ze-2 zokuyeka ukunyuswa kwe-norepinephrine, cinga ngokufumana umyalelo wokuyeka kugqirha onyangayo. Emva kokuba i-infusion imisiwe, ngokukhawuleza unqamule i-infusion kwisigulane, uyisuse kwipompo, kwaye uyilahle ukuze ugweme ukulawulwa ngengozi. I-infusion kufuneka inqanyulwe kwakhona kwisigulane ukuba i-infusion iphazamisekile ngaphezu kweeyure ezingama-2.
Misela i-protocol ye-extravasation. Misela i-extravasation protocol ye-frothing norepinephrine. Abahlengikazi kufuneka baxelelwe ngolu luhlu, kubandakanywa unyango kunye ne-phentolamine mesylate kunye nokuphepha koxinzelelo olubandayo kwindawo echaphazelekayo, enokunyusa umonakalo wezicubu.
Vavanya ukuziqhelanisa netitration. Ukubeka iliso ekuthotyelweni kwabasebenzi kunye neengcebiso zokunyuswa kwe-norepinephrine, iiprothokholi kunye nemigqaliselo ethile kagqirha, kunye neziphumo zesigulane. Imizekelo yamanyathelo ibandakanya ukuthotyelwa kwemilinganiselo ye-titration efunekayo kumyalelo; ukulibaziseka kunyango; ukusetyenziswa kweempompo ezihlakaniphile ezine-DERS enikwe amandla (kunye nokusebenzisana); qalisa ukumiliselwa ngesantya esimiselweyo; i-titration ngokwexesha elimiselweyo kunye neeparamitha zedosi; impompo ehlakaniphile ikwazisa ngokuphindaphindiweyo kunye nodidi lwedosi, amaxwebhu eeparamitha ze-titration (kufuneka ihambelane notshintsho lwethamo) kunye nokulimala kwesigulana ngexesha lonyango.