Iindaba

Umbuzo: I-Norepinephrine liyeza elifumaneka kakhulu elinikwa ngemithambo yegazi (IV) njengokufakwa okuqhubekayo. Liyi-vasopressor edla ngokufakwa i-tit ukuze kugcinwe uxinzelelo lwegazi olufanelekileyo kunye nokujolisa ekuphumeni kwamalungu omzimba kubantu abadala abagula kakhulu kunye nabantwana abane-hypotension enzima okanye ukothuka okuqhubekayo nangona ulwelo luphinda lubuyele emanzini ngokwaneleyo. Kwaneempazamo ezincinci kwi-titration okanye kwidosi, kunye nokulibaziseka kunyango, kunokukhokelela kwimiphumo emibi eyingozi. I-Multicenter Health System isandula ukuthumela i-ISMP iziphumo zohlalutyo lwesizathu esiqhelekileyo (CCA) kwiimpazamo ezili-106 ze-norepinephrine ezenzeka ngo-2020 nango-2021. Ukuphonononga iziganeko ezininzi nge-CCA kuvumela imibutho ukuba iqokelele izizathu eziqhelekileyo kunye nobuthathaka benkqubo. Idatha evela kwinkqubo yokunika ingxelo yombutho kunye neepompo ze-smart infusion zisetyenzisiwe ukuchonga iimpazamo ezinokubakho.
I-ISMP ifumene iingxelo ezili-16 ezinxulumene ne-noradrenaline ngo-2020 nango-2021 ngeNkqubo yokuNika iNgxaki yeMithi yeSizwe ye-ISMP (ISMP MERP). Malunga nesinye kwisithathu sezi ngxelo zijongane neengozi ezinxulumene namagama afanayo, iileyibhile, okanye ukupakisha, kodwa akukho mpazamo zibikiweyo ngokwenene. Sipapashe iingxelo zeempazamo ezisixhenxe zezigulane ze-norepinephrine: iimpazamo ezine zokulinganisa (ngo-Epreli 16, 2020; ngo-Agasti 26, 2021; ngoFebruwari 24, 2022); impazamo enye yoxinzelelo olungalunganga; impazamo enye yokulinganisa okungalunganga kwesiyobisi; ukuphazamiseka ngengozi kokufakwa kwe-norepinephrine. Zonke iingxelo ezili-16 ze-ISMP zongezwe kwinkqubo yezempilo ye-CCA multicenter (n=106) kwaye iziphumo ezidibeneyo (N=122) zenyathelo ngalinye kwinkqubo yokusebenzisa iziyobisi ziboniswe ngezantsi. Impazamo ebikiweyo ifakiwe ukubonelela ngomzekelo wezizathu eziqhelekileyo.
Ukumisela amayeza. Sichonge izinto ezininzi ezibangela iingxaki ezinxulumene neempazamo zokumisela amayeza, kuquka ukusetyenziswa ngokungeyomfuneko kwemiyalelo yomlomo, ukunika i-norepinephrine ngaphandle kokusebenzisa iiseti zemiyalelo, kunye neethagethi ezingacacanga okanye ezingaqinisekanga kunye/okanye iiparameter ze-titration (ingakumbi ukuba iiseti zemiyalelo azisetyenziswa). Ngamanye amaxesha iiparameter ze-titration ezimiselweyo zingqongqo kakhulu okanye azisebenzi (umz., ukunyuka okumiselweyo kukhulu kakhulu), okwenza kube nzima kubahlengikazi ukuthobela xa bejonga uxinzelelo lwegazi lomguli. Kwezinye iimeko, oogqirha banokunika iidosi ezisekelwe kubunzima okanye ezingasekelwe kubunzima, kodwa oku ngamanye amaxesha kuyabhideka. Oku kumisela amayeza ngaphandle kwebhokisi kwandisa amathuba okuba oogqirha abangaphantsi benze iimpazamo, kuquka iimpazamo zokucwangcisa ipompo, kuba kukho iindlela ezimbini zokulinganisa amayeza ezikhoyo kwithala leencwadi lepompo. Ukongeza, ukulibaziseka kubikwe ukuba kufuna ukucaciswa kweodolo xa imiyalelo yokumisela amayeza ibandakanya imiyalelo yokulinganisa amayeza esekelwe kubunzima kunye nemiyalelo yokulinganisa amayeza engasekelwe kubunzima.
Ugqirha ucela umongikazi ukuba abhale umyalelo we-norepinephrine kwisigulana esinoxinzelelo lwegazi olungaguqukiyo. Umongikazi ufake umyalelo kanye njengoko ugqirha wayeyalele ngomlomo: 0.05 mcg/kg/min IV titrated to a target mean arterial pressure (MAP) engaphezulu kwe-65 mmHg. Kodwa imiyalelo yedosi kagqirha idibanisa ukunyuka kwedosi okungengobunzima kunye nedosi ephezulu esekelwe kubunzima: titrate ngesantya se-5 mcg/min rhoqo emva kwemizuzu emi-5 ukuya kwidosi ephezulu ye-1.5 mcg/kg/min. Ipompo ye-infusion ekrelekrele yombutho ayizange ikwazi ukulinganisa idosi ye-mcg/min ukuya kwidosi ephezulu esekelwe kubunzima, mcg/kg/min. Iingcali zekhemesti kwafuneka zijonge imiyalelo koogqirha, nto leyo ekhokelele ekulibazisekeni kokubonelela ngononophelo.
Lungisa kwaye usasaze. Iimpazamo ezininzi zokulungiselela kunye nokulinganisa zibangelwa ngumsebenzi omninzi wekhemesti, owenzeka mandundu ngabasebenzi bekhemesti abafuna uxinaniso oluphezulu lwe-norepinephrine infusions (32 mg/250 ml) (efumaneka kwiikhemesti ze-503B formula kodwa azifumaneki kuzo zonke iindawo). zikhokelela ekusebenzeni ixesha elide kunye nokudinwa. Ezinye izizathu eziqhelekileyo zeempazamo zokuhambisa ziquka iilebhile ze-noradrenaline ezifihliweyo kwiingxowa eziqinileyo kunye nokungaqondi kakuhle kwabasebenzi bekhemesti ngokungxamiseka kokuhambisa.
Ukufakwa kwe-norepinephrine kunye ne-nicardipine kwingxowa emnyama ye-amber akuhambanga kakuhle. Kwi-infusion emnyama, inkqubo yokulinganisa iprinte iilebheli ezimbini, enye kwingxowa yokufaka i-infusion ngokwayo kwaye enye ngaphandle kwengxowa ye-amber. Ukufakwa kwe-norepinephrine kwafakwa ngempazamo kwiipakethi ze-amber ezibhalwe "i-nicardipine" ngaphambi kokuba imveliso isasazwe ukuze isetyenziswe zizigulane ezahlukeneyo kwaye ngokuchaseneyo. Iimpazamo azizange zibonwe ngaphambi kokunikezelwa okanye ukutofiwa. Isigulana esanyangwa nge-nicardipine sanikwa i-norepinephrine kodwa asizange sibangele monakalo wexesha elide.
ulawulo. Iimpazamo eziqhelekileyo ziquka impazamo yedosi engalunganga okanye yoxinzelelo, impazamo yesantya esingalunganga, kunye nempazamo yeziyobisi engalunganga. Uninzi lwezi mpazamo lubangelwa kukuhlelwa okungalunganga kwepompo yokungenisa ekrelekrele, ngokuyinxenye ngenxa yokubakho kokukhethwa kwedosi kwithala leencwadi lamayeza, zombini ngobunzima nangaphandle kwayo; iimpazamo zokugcina; uqhagamshelo kunye nokunxibelelana kwakhona kwe-infusions ephazamisekileyo okanye emiswe kwisigulana eqalise i-infusion engalunganga okanye ayizange iphawule imigca kwaye ayizange iyilandele xa iqala okanye iphinda iqalise i-infusion. Kukho into engahambanga kakuhle kumagumbi ongxamiseko nakumagumbi okusebenza, kwaye ukuhambelana kwepompo ekrelekrele neerekhodi zempilo ze-elektroniki (EHR) bekungafumaneki. Ukukhupha i-extravas okukhokelela ekonakaleni kwezicubu nako kuye kwaxelwa.
Umongikazi wamnika i-norepinephrine njengoko kuyalelwe ngesantya se-0.1 µg/kg/min. Endaweni yokucwangcisa ipompo ukuba inike i-0.1 mcg/kg/min, umongikazi wacwangcisa ipompo ukuba inike i-0.1 mcg/min. Ngenxa yoko, isigulana safumana i-norepinephrine engaphantsi ngokuphindwe ka-80 kuneyayiceliwe. Xa i-infusion yancitshiswa kancinci kancinci yaza yafikelela kwisantya se-1.5 µg/min, umongikazi wagqiba kwelokuba ufikelele kumda omiselweyo we-1.5 µg/kg/min. Ngenxa yokuba uxinzelelo oluphakathi lwemithambo yegazi yesigulana lwalusangaqhelekanga, kongezwa i-vasopressor yesibini.
Isitokhwe kunye nokugcinwa. Iimpazamo ezininzi zenzeka xa kuzaliswa iikhabhathi ezizenzekelayo (ii-ADC) okanye kutshintshwe ii-norepinephrine vials kwiinqwelo ezinekhowudi. Isizathu esiphambili sezi mpazamo zesitokhwe kukulebhelisha okufanayo kunye nokupakishwa. Nangona kunjalo, ezinye izizathu eziqhelekileyo zichongiwe, ezifana namanqanaba aphantsi okufakwa kwe-norepinephrine kwi-ADC anganelanga ukuhlangabezana neemfuno zeyunithi yokhathalelo lwezigulane, nto leyo ekhokelela ekulibazisekeni konyango ukuba iikhemesti kufuneka zilungise ukufakwa kwe-infusions ngenxa yokunqongophala. Ukungaphumeleli ukuskena i-barcode yemveliso nganye ye-norepinephrine ngelixa ugcina i-ADC ngomnye umthombo oqhelekileyo wempazamo.
Ingcali yezemithi izalise i-ADC ngesisombululo se-norepinephrine esingama-32 mg/250 ml esilungiselelwe yikhemesti kwidrowa yomenzi we-4 mg/250 ml premix. Umongikazi ufumene impazamo ngelixa ezama ukufumana i-4 mg/250 ml norepinephrine infusion evela kwi-ADC. Ibhakhowudi kwi-infusion nganye ayizange iskeniwe ngaphambi kokuba ibekwe kwi-ADC. Xa umongikazi waqonda ukuba kukho ibhegi engama-32 mg/250 ml kuphela kwi-ADC (kufuneka ibe kwindawo efrijini ye-ADC), wacela uxinaniso oluchanekileyo. Izisombululo ze-infusion ze-Norepinephrine 4mg/250mL azifumaneki kwiikhemesti ngenxa yokuba umenzi akafumani iipakethe ze-4mg/250mL ezixutywe kwangaphambili, nto leyo ebangele ukulibaziseka ekuncediseni ukuxuba i-infusion.
Ukubeka esweni. Ukubeka esweni gwenxa izigulane, ukuhluzwa kwe-norepinephrine ngaphandle kwemilinganiselo ye-oda, kunye nokungalindeli ukuba ibhegi elandelayo yokufaka i-infusion iya kufuneka nini zezona zinto zixhaphakileyo zokubeka esweni iimpazamo.
Isigulana esifayo esinikwe imiyalelo yokuba “singavuseleli” sinikwa i-norepinephrine ukuze ihlale ixesha elide ngokwaneleyo ukuze usapho lwaso lukwazi ukuvalelisa. Ukufakwa kwe-norepinephrine kwaphela, kwaye kwakungekho bhegi iseleyo kwi-ADC. Umongikazi wafowunela ikhemesti ngoko nangoko waza wafuna ibhegi entsha. Ikhemesti yayingenalo ixesha lokulungiselela amayeza ngaphambi kokuba isigulana sisweleke size sivalelise usapho lwaso.
Ingozi. Zonke iingozi ezingakhange zibangele impazamo zixelwa kwi-ISMP kwaye ziquka amagama afanayo okulebhelisha okanye amayeza. Uninzi lweengxelo lubonisa ukuba ukupakishwa kunye nokulebhelisha kwamanqanaba ahlukeneyo okutsalwa kwe-norepinephrine okunikezelwa ngabathengisi be-503B kubonakala ngathi kufana kakhulu.
Iingcebiso malunga nokusebenza ngokukhuselekileyo. Cinga ngezi ngcebiso zilandelayo xa uphuhlisa okanye uhlaziya icebo lesikhungo sakho lokunciphisa iimpazamo ekusebenziseni ngokukhuselekileyo i-norepinephrine (kunye nezinye i-vasopressor) infusions:
umlinganiselo woxinzelelo. Imiselwe inani elilinganiselweyo loxinzelelo kunyango lwezigulane zabantwana kunye/okanye zabantu abadala. Cacisa umda wobunzima bokufakwa kwe-infusion okugxininisiweyo kakhulu omele ugcinwe kwizigulane ezinemida yolwelo okanye ezifuna iidosi eziphezulu ze-norepinephrine (ukunciphisa utshintsho lwebhegi).
Khetha indlela enye yokulinganisa. Misela imiyalelo yokufakwa kwe-norepinephrine ngokwemilinganiselo ngokusekelwe kubunzima bomzimba (mcg/kg/min) okanye ngaphandle kwayo (mcg/min) ukunciphisa umngcipheko wempazamo. I-American Society of Health System Pharmacists (ASHP) Safety Standards Initiative4 icebisa ukusetyenziswa kweeyunithi zokulinganisa i-norepinephrine kwi-micrograms/kg/minute. Ezinye izibhedlele zinokwenza imilinganiselo ibe yi-micrograms ngomzuzu kuxhomekeke kukhetho lukagqirha - zombini ziyamkeleka, kodwa iindlela ezimbini zokulinganisa azivumelekanga.
Ifuna ukumiselwa ngokwetemplate yeodolo eqhelekileyo. Ifuna iodolo ye-norepinephrine esebenzisa itemplate yeodolo eqhelekileyo enamabala afunekayo oxinzelelo olufunekayo, ithagethi ye-titration enokulinganiswa (umz., i-SBP, uxinzelelo lwegazi lwe-systolic), iiparameter ze-titration (umz., idosi yokuqala, uluhlu lwedosi, iyunithi yokunyusa, kunye nokuphindaphinda kwedosi) phezulu okanye ezantsi), indlela yokusetyenziswa kunye nedosi ephezulu ekungafuneki idlulwe kunye/okanye ugqirha okhoyo kufuneka abizwe. Ixesha lokutshintsha elimiselweyo kufuneka libe "ngumthetho" ukuze ezi odolo zithathe indawo kumgca wekhemesti.
Nciphisa imiyalelo yomlomo. Nciphisa imiyalelo yomlomo kwiimeko ezingxamisekileyo okanye xa ugqirha engakwazi ukungena okanye ukubhala iodolo nge-elektroniki. Oogqirha kufuneka benze amalungiselelo abo ngaphandle kokuba kukho iimeko ezinokubangela ingxaki.
Thenga izisombululo esele zenziwe xa zifumaneka. Sebenzisa ubuninzi bezisombululo ze-norepinephrine ezixutywe kwangaphambili ezivela kubavelisi kunye/okanye izisombululo ezilungiselelwe ngabathengisi beqela lesithathu (ezifana ne-503B) ukunciphisa ixesha lokulungiselela ikhemesti, ukunciphisa ukulibaziseka konyango, kunye nokuphepha iimpazamo zokwenziwa kwekhemesti.
Uxinzelelo olwahlukileyo. Yahlula uxinaniso olwahlukileyo ngokulwenza lwahluke ngokubonakalayo ngaphambi kokuba uluthathe.
Nika amanqanaba afanelekileyo e-ADC. Thenga i-ADC kwaye unike i-norepinephrine infusions eyaneleyo ukuhlangabezana neemfuno zesigulana. Jonga ukusetyenziswa kwaye ulungise amanqanaba aqhelekileyo njengoko kufuneka.
Yenza iinkqubo zokucubungula ibhetshi kunye/okanye ukongeza xa kuyimfuneko. Ngenxa yokuba kungathatha ixesha ukudibanisa uxinaniso oluphezulu olungahlawulelwanga, iikhemesti zinokusebenzisa amaqhinga ahlukeneyo okubeka phambili ukulungiswa kunye nokuhanjiswa ngexesha elifanelekileyo, kubandakanya ukudosa kunye/okanye ukucinezela xa izikhongozeli zingenanto kwiiyure ezimbalwa, ezibangelwa yindawo yokhathalelo okanye izaziso ze-imeyile kufuneka zilungiselelwe.
Iphakheji/ibhotile nganye iyaskenwa. Ukuze kuthintelwe iimpazamo ngexesha lokulungiselela, ukusasazwa, okanye ukugcinwa, skena ibhakhowudi kwibhegi nganye ye-norepinephrine infusion okanye ibhotile ukuze kuqinisekiswe ngaphambi kokulungiswa, ukusasazwa, okanye ukugcinwa kwi-ADC. Iibhakhowudi zingasetyenziswa kuphela kwiileyibhile ezincamatheliswe ngqo kwiphakheji.
Jonga ilebheli ebhegini. Ukuba kusetyenziswa ibhegi engavaliyo kakhulu ngexesha lokuhlolwa kwedosi rhoqo, i-norepinephrine infusion kufuneka isuswe okwethutyana ebhegini ukuze ivavanywe. Okanye, beka ibhegi yokukhusela ekhaphukhaphu phezu kwe-infusion ngaphambi kovavanyo kwaye uyibeke ebhegini emva kovavanyo.
Yenza izikhokelo. Misela izikhokelo (okanye iprotokholi) yokufakwa kwe-norepinephrine (okanye elinye iyeza elinomlinganiselo), kubandakanya ubuninzi obuqhelekileyo, uluhlu lwedosi ekhuselekileyo, ukunyuka kwedosi eqhelekileyo yomlinganiselo, ukuphindaphinda kwe-titration (imizuzu), idosi/isantya esiphezulu, isiseko, kunye nokubeka esweni okufunekayo. Ukuba kunokwenzeka, nxibelelanisa iingcebiso nomyalelo womlinganiselo kwiRekhodi yoLawulo lwaMayeza (MAR).
Sebenzisa ipompo ekrelekrele. Zonke ii-norepinephrine infusions zifakwa kwaye zilinganiswe kusetyenziswa ipompo ekrelekrele eneDose Error Reduction System (DERS) evuliweyo ukuze i-DERS ikwazi ukwazisa iingcali zezempilo ngeempazamo ezinokubakho zokumisela amayeza, ukubala, okanye iinkqubo.
Vumela Ukuhambelana. Apho kunokwenzeka, vumela ipompo yokungenisa ehlakaniphileyo emacala omabini ehambelana neerekhodi zempilo ze-elektroniki. Ukusebenzisana kuvumela iipompo ukuba zizaliswe kwangaphambili ngoseto lokungenisa oluqinisekisiweyo oluchazwe ngugqirha (ubuncinane ekuqaleni kokulinganisa) kwaye kwandisa ulwazi lwekhemesti malunga nokuba kushiyeke malini kwi-infusions elinganisiweyo.
Phawula imigca uze ulandelele imibhobho. Bhala umgca ngamnye wokufaka amanzi ngaphezulu kwepompo kwaye kufutshane nendawo yokufikelela kwisigulane. Ukongeza, ngaphambi kokuba uqale okanye utshintshe ibhegi ye-norepinephrine okanye izinga lokufaka amanzi, hambisa ityhubhu ngesandla ukusuka kwisitya sesisombululo ukuya kwipompo nakwisigulane ukuqinisekisa ukuba ipompo/umjelo kunye nendlela yokungenisa amanzi ichanekile.
Yamkela uhlolo. Xa kumiswe utyando olutsha, kufuneka uvavanyo lobuchwephesha (umz. ibhakhowudi) ukuqinisekisa ukuba iyeza/isisombululo singakanani, ubungakanani beyeza kunye nesigulana.
Yeka ukumnika. Ukuba isigulana sizinzile kwiiyure ezi-2 emva kokuyeka ukumnika i-norepinephrine, cinga ngokufumana umyalelo wokumyekisa kugqirha onyangayo. Nje ukuba ukumnika kumiswe, susa ngoko nangoko ukumnika kwisigulana, ukususe kwimpompo, uze ulahle ukuze uphephe ukunikwa ngengozi. Ukumnika kufuneka kukhutshwe kwisigulana ukuba ukumnika kuphazamisekile kangangeeyure ezi-2.
Misela iprotokholi yokukhupha i-extravasation. Misela iprotokholi yokukhupha i-extravasation ye-norepinephrine. Abahlengikazi kufuneka baziswe ngale ndlela, kuquka unyango nge-phentolamine mesylate kunye nokuphepha ukucinezelwa okubandayo kwindawo echaphazelekayo, okunokwenza umonakalo omkhulu kwizicubu.
Vavanya indlela yokusebenza yokulinganisa umthamo. Jonga ukuthobela kwabasebenzi iingcebiso zokufaka i-norepinephrine, iiprotokholi kunye nemiyalelo ethile kagqirha, kunye neziphumo zesigulana. Imizekelo yamanyathelo ibandakanya ukuthobela iiparameter zokulinganisa umthamo ezifunekayo kwi-odolo; ukulibaziseka kunyango; ukusetyenziswa kweepompo ezikrelekrele ezine-DERS ezivunyiweyo (kunye nokusebenzisana); qala ukufaka umthamo ngesantya esimiselweyo; ukulinganisa umthamo ngokweeparameter ezimiselweyo kunye nedosi; ipompo ekrelekrele ikwazisa ngesantya kunye nohlobo lwedosi, uxwebhu lweeparameter zokulinganisa umthamo (kufuneka zihambelane notshintsho lwedosi) kunye nomonakalo wesigulana ngexesha lonyango.