Nkhani

Funso: Norepinephrine ndi mankhwala omwe amapezeka kwambiri omwe amaperekedwa kudzera m'mitsempha (IV) ngati mankhwala opitilira. Ndi vasopressor yomwe nthawi zambiri imayikidwa kuti isunge kuthamanga kwa magazi kokwanira komanso kufalikira kwa ziwalo mwa akuluakulu odwala kwambiri komanso ana omwe ali ndi kuthamanga kwa magazi kwambiri kapena kugwedezeka komwe kumapitilira ngakhale kuti madzi akumwa mokwanira. Ngakhale zolakwika zazing'ono pakuwonjezeka kapena mlingo, komanso kuchedwa kwa chithandizo, zitha kubweretsa zotsatira zoyipa. Multicenter Health System posachedwapa idatumiza ISMP zotsatira za kusanthula kwa common cause analysis (CCA) pa zolakwika 106 za norepinephrine zomwe zidachitika mu 2020 ndi 2021. Kufufuza zochitika zingapo ndi CCA kumalola mabungwe kusonkhanitsa zomwe zimayambitsa komanso zovuta za dongosolo. Deta kuchokera ku pulogalamu yowunikira ya bungwe ndi ma pump anzeru olowetsedwa idagwiritsidwa ntchito kuzindikira zolakwika zomwe zingachitike.
ISMP idalandira malipoti 16 okhudzana ndi noradrenaline mu 2020 ndi 2021 kudzera mu ISMP National Medication Error Reporting Program (ISMP MERP). Pafupifupi gawo limodzi mwa magawo atatu a malipoti awa adalankhula za zoopsa zokhudzana ndi mayina ofanana, zilembo, kapena ma phukusi, koma palibe zolakwika zomwe zanenedwa. Tafalitsa malipoti a zolakwika zisanu ndi ziwiri za odwala a norepinephrine: zolakwika zinayi pa mlingo (Epulo 16, 2020; Ogasiti 26, 2021; February 24, 2022); cholakwika chimodzi cha kuchuluka kolakwika; cholakwika chimodzi cha titration yolakwika ya mankhwala; kusokonekera mwangozi kwa norepinephrine infusion. Malipoti onse 16 a ISMP adawonjezedwa ku CCA multicenter health system (n=106) ndipo zotsatira zonse pamodzi (N=122) pa gawo lililonse la njira yogwiritsira ntchito mankhwala zikuwonetsedwa pansipa. Cholakwika chomwe chanenedwacho chaphatikizidwa kuti chipereke chitsanzo cha zifukwa zina zodziwika bwino.
Kulemba Mankhwala. Tapeza zinthu zingapo zomwe zimayambitsa zolakwika pakupereka mankhwala, kuphatikizapo kugwiritsa ntchito malamulo osafunikira pakamwa, kupereka norepinephrine popanda kugwiritsa ntchito malamulo, ndi zolinga zosamveka bwino kapena zosatsimikizika komanso/kapena magawo a titration (makamaka ngati malamulo sakugwiritsidwa ntchito). Nthawi zina magawo a titration omwe amalembedwa amakhala okhwima kwambiri kapena osagwira ntchito (monga, kuchuluka kwa mankhwala omwe amalembedwa kumakhala kwakukulu kwambiri), zomwe zimapangitsa kuti zikhale zovuta kwa anamwino kutsatira malangizo akamayang'anira kuthamanga kwa magazi kwa wodwala. Nthawi zina, madokotala amatha kupereka mlingo wozikidwa pa kulemera kapena wosazikidwa pa kulemera, koma nthawi zina izi zimasokoneza. Kulemba mankhwala kumeneku kumawonjezera mwayi woti madokotala ena azichita zolakwika, kuphatikizapo zolakwika pa pulogalamu ya pump, popeza njira ziwiri zoperekera mlingo zilipo mu laibulale ya pump. Kuphatikiza apo, kuchedwa kunanenedwa kuti kumafuna kufotokozera bwino dongosolo pamene malamulo opereka mankhwala anali ndi malangizo ozikidwa pa kulemera ndi osazikidwa pa kulemera.
Dokotala akupempha namwino kuti alembe mankhwala a norepinephrine kwa wodwala yemwe ali ndi kuthamanga kwa magazi kosakhazikika. Namwinoyo adalemba dongosolo monga momwe dokotala adalamulira pakamwa: 0.05 mcg/kg/min IV titrated to a target mean arterial pressure (MAP) yoposa 65 mmHg. Koma malangizo a dokotala a mlingo amasakaniza kuchuluka kwa mlingo wosakhala wolemera ndi mlingo wapamwamba kwambiri wolemera: titrate pamlingo wa 5 mcg/min mphindi 5 zilizonse mpaka mlingo wapamwamba kwambiri wa 1.5 mcg/kg/min. Pumpu yanzeru ya bungweli sinathe kukweza mlingo wa mcg/min kufika pa mlingo wapamwamba kwambiri wolemera, mcg/kg/min. Akatswiri a zamankhwala adayenera kuyang'ana malangizo ndi madokotala, zomwe zidapangitsa kuti chisamaliro chichedwe.
Konzani ndi kugawa. Zolakwika zambiri zokonzekera ndi kupereka mankhwala zimachitika chifukwa cha kuchuluka kwa ntchito yogulitsa mankhwala, zomwe zimawonjezeka chifukwa cha ogwira ntchito ku pharmacy omwe amafuna kuchuluka kwakukulu kwa norepinephrine (32 mg/250 ml) (yomwe imapezeka m'ma pharmacy a 503B koma siipezeka m'malo onse). zimayambitsa kuchita zinthu zambiri nthawi imodzi komanso kutopa. Zina zomwe zimayambitsa zolakwika zoperekera mankhwala ndi monga zilembo za noradrenaline zobisika m'matumba opepuka komanso kusamvetsetsa kwa ogwira ntchito ku pharmacy za kufunika kopereka mankhwala mwachangu.
Kulowetsedwa pamodzi kwa norepinephrine ndi nicardipine mu thumba lakuda la amber sikunayende bwino. Pa kulowetsedwa kwakuda, njira yoperekera mankhwala inasindikiza zilembo ziwiri, chimodzi pa thumba loperekera mankhwalalo ndi china kunja kwa thumba la amber. Kulowetsedwa kwa norepinephrine kunayikidwa mwangozi m'maphukusi a amber olembedwa kuti "nicardipine" mankhwalawo asanagawidwe kuti agwiritsidwe ntchito ndi odwala osiyanasiyana komanso mosemphanitsa. Zolakwika sizinaoneke asanaperekedwe kapena kuperekedwa. Wodwala yemwe adalandira nicardipine anapatsidwa norepinephrine koma sanawononge nthawi yayitali.
oyang'anira. Zolakwika zomwe zimachitika kawirikawiri zimaphatikizapo kulakwitsa kwa mlingo kapena kuchuluka kwa mankhwala, kulakwitsa kwa mlingo wolakwika, ndi kulakwitsa kwa mankhwala kolakwika. Zolakwika zambirizi zimachitika chifukwa cha pulogalamu yolakwika ya pampu yanzeru yolowetsera mankhwala, chifukwa cha kupezeka kwa kusankha kwa mlingo mu laibulale ya mankhwala, ponse pawiri polemera komanso popanda; zolakwika zosungira; kulumikizana ndi kulumikizidwanso kwa ma infusions osokonezeka kapena oyimitsidwa kwa wodwalayo omwe adayamba kulowetsera molakwika kapena osalemba mizere ndipo sanawatsatire poyambitsa kapena kuyambiranso kulowetsera. Chinachake chinalakwika m'zipinda zadzidzidzi ndi m'zipinda zochitira opaleshoni, ndipo kuyanjana kwa pampu yanzeru ndi zolemba zaumoyo zamagetsi (EHR) sikunapezeke. Kuchuluka kwa zinthu zomwe zimapangitsa kuti minofu iwonongeke kwanenedwanso.
Namwino anapereka norepinephrine motsatira malangizo a mlingo wa 0.1 µg/kg/min. M'malo mokonza pampu kuti ipereke 0.1 mcg/kg/min, namwinoyo anakonza pampu kuti ipereke 0.1 mcg/min. Zotsatira zake, wodwalayo analandira norepinephrine yocheperako nthawi 80 kuposa yomwe inalembedwa. Pamene kulowetsedwako kunachepetsedwa pang'onopang'ono ndikufika pa mlingo wa 1.5 µg/min, namwinoyo anaganiza kuti wafika pamlingo wapamwamba kwambiri womwe unalembedwa wa 1.5 µg/kg/min. Popeza kuthamanga kwa magazi kwa wodwalayo kunali kosazolowereka, anawonjezera vasopressor yachiwiri.
Zinthu zosungidwa ndi kusungidwa. Zolakwika zambiri zimachitika podzaza makabati odziyimira pawokha (ADCs) kapena kusintha ma norepinephrine m'magalimoto olembedwa. Chifukwa chachikulu cha zolakwika izi ndi zolemba ndi ma phukusi omwewo. Komabe, zifukwa zina zodziwika bwino zapezekanso, monga kuchuluka kochepa kwa norepinephrine infusions ku ADC komwe sikunali kokwanira kukwaniritsa zosowa za chipinda chosamalira odwala, zomwe zimapangitsa kuti chithandizo chichedwe ngati ma pharmacy amayenera kupanga infusions chifukwa cha kusowa. Kulephera kusanthula barcode ya chinthu chilichonse cha norepinephrine posunga ADC ndi chifukwa china chofala cha cholakwika.
Wogulitsa mankhwala molakwika adadzaza ADC ndi yankho la norepinephrine la 32 mg/250 ml lokonzedwa ndi mankhwala mu kabati ya 4 mg/250 ml ya premix ya wopanga. Namwino adapeza cholakwika pamene akuyesera kulandira 4 mg/250 ml ya norepinephrine kuchokera ku ADC. Barcode pa infusion iliyonse sinasankhidwe isanayikidwe mu ADC. Namwino atazindikira kuti panali thumba la 32 mg/250 ml lokha mu ADC (liyenera kukhala mufiriji ya ADC), adapempha kuchuluka koyenera. Mayankho a infusion a Norepinephrine 4mg/250mL sapezeka m'ma pharmacies chifukwa cha kusowa kwa wopanga ma paketi a 4mg/250mL osakanizidwa, zomwe zidapangitsa kuti kusakaniza chithandizo cha infusion kuchedwe.
Kuyang'anira odwala molakwika, kugawa kwa norepinephrine mu milingo yosiyana, komanso kusayembekezera nthawi yomwe thumba lotsatira la infusion lidzafunikire ndizomwe zimayambitsa zolakwika zowunikira.
Wodwala amene akumwalira atalamulidwa kuti “musamutse mpweya” akulandira jakisoni wa norepinephrine kuti apitirize nthawi yayitali kuti banja lake lithe kutsanzikana. Kulowetsedwa kwa norepinephrine kunatha, ndipo panalibe thumba lina mu ADC. Namwino nthawi yomweyo anaimbira foni pharmacy ndikupempha thumba latsopano. Pharmacy inalibe nthawi yokonzekera mankhwalawo wodwalayo asanamwalire ndipo anatsanzikana ndi banja lake.
Ngozi. Zoopsa zonse zomwe sizinabweretse cholakwika zimanenedwa ku ISMP ndipo zimaphatikizapo mayina ofanana a mankhwala kapena mayina a mankhwala. Malipoti ambiri akusonyeza kuti ma CD ndi zilembo za kuchuluka kosiyanasiyana kwa norepinephrine infusions komwe kumaperekedwa ndi 503B outsourcers zikuwoneka kuti ndizofanana kwambiri.
Malangizo okhudza machitidwe otetezeka. Ganizirani malangizo otsatirawa popanga kapena kusintha njira ya chipatala chanu kuti muchepetse zolakwika pakugwiritsa ntchito bwino norepinephrine (ndi mankhwala ena opondereza mitsempha):
kuchepetsa kuchuluka kwa mankhwala. Yokhazikika pa kuchuluka kochepa kwa mankhwala ochizira ana ndi/kapena odwala akuluakulu. Tchulani malire a kulemera kwa mankhwala ochizira kwambiri omwe ayenera kuperekedwa kwa odwala omwe ali ndi madzi ochepa kapena omwe amafunikira norepinephrine yambiri (kuti achepetse kusintha kwa thumba).
Sankhani njira imodzi yoperekera mlingo. Sinthani mankhwala a norepinephrine potengera kulemera kwa thupi (mcg/kg/min) kapena popanda (mcg/min) kuti muchepetse chiopsezo cha zolakwika. Bungwe la American Society of Health System Pharmacists (ASHP) Safety Standards Initiative4 limalimbikitsa kugwiritsa ntchito mayunitsi a norepinephrine mu ma microgram/kg/minute. Zipatala zina zimatha kugawa mlingo kukhala ma microgram pamphindi kutengera zomwe dokotala akufuna - zonse ziwiri ndizovomerezeka, koma njira ziwiri zogawa siziloledwa.
Amafuna kumwa mankhwala motsatira chitsanzo cha dongosolo lokhazikika. Amafuna mankhwala a norepinephrine pogwiritsa ntchito chitsanzo cha dongosolo lokhazikika lomwe lili ndi magawo ofunikira kuti akwaniritse kuchuluka komwe mukufuna, cholinga choyezera cha titration (monga, SBP, kuthamanga kwa magazi), magawo a titration (monga, mlingo woyambira, kuchuluka kwa mlingo, gawo lowonjezera, ndi kuchuluka kwa mlingo) mmwamba kapena pansi), njira yoperekera mankhwala ndi mlingo waukulu womwe sayenera kupitirira ndi/kapena dokotala womulandira ayenera kuyimbidwa. Nthawi yokhazikika yosinthira iyenera kukhala "stat" kuti maoda awa akhale patsogolo pamzere wa pharmacy.
Chepetsani malamulo olankhulidwa pakamwa. Chepetsani malamulo olankhulidwa pakamwa ngati pachitika ngozi zenizeni kapena ngati dokotala sangathe kulowa kapena kulemba oda pakompyuta. Madokotala ayenera kupanga mapulani awoawo pokhapokha ngati pali zifukwa zomveka.
Gulani mankhwala opangidwa kale akapezeka. Gwiritsani ntchito kuchuluka kwa mankhwala osakaniza a norepinephrine ochokera kwa opanga ndi/kapena mankhwala okonzedwa ndi ogulitsa ena (monga 503B) kuti muchepetse nthawi yokonzekera mankhwala, kuchepetsa kuchedwa kwa chithandizo, komanso kupewa zolakwika pakupanga mankhwala.
Kusiyanitsa kuchuluka kwa mankhwala. Kusiyanitsa kuchuluka kwa mankhwala osiyanasiyana mwa kuwasiyanitsa ndi ena musanapereke mankhwala.
Perekani mlingo wokwanira wa ADC. Sungani ADC ndipo perekani mankhwala okwanira a norepinephrine kuti akwaniritse zosowa za wodwala. Yang'anirani momwe amagwiritsidwira ntchito ndikusintha milingo yokhazikika ngati pakufunika.
Pangani njira zokonzera zinthu ndi/kapena kuwonjezera zinthu ngati pakufunika. Popeza zingatenge nthawi kuti zisakanize kuchuluka kwa zinthu zomwe sizinagwiritsidwe ntchito, ma pharmacies angagwiritse ntchito njira zosiyanasiyana kuti akonzekere bwino ndi kutumiza zinthu panthawi yake, kuphatikizapo kupereka mankhwala ndi/kapena kukanikiza pamene zinthuzo zilibe kanthu mkati mwa maola angapo, chifukwa cha malo osamalira kapena zidziwitso za imelo ziyenera kukonzedwa.
Phukusi/chidebe chilichonse chimasanthulidwa. Kuti mupewe zolakwika pokonzekera, kugawa, kapena kusungira, sankhani barcode pa thumba lililonse la norepinephrine infusion kapena vial kuti mutsimikizire musanakonze, kugawa, kapena kusungira mu ADC. Ma barcode angagwiritsidwe ntchito kokha pa zilembo zomwe zimamatiridwa mwachindunji pa phukusi.
Chongani chizindikiro chomwe chili pa thumba. Ngati thumba lolimba pang'ono likugwiritsidwa ntchito poyesa mlingo wa mankhwala, kulowetsedwa kwa norepinephrine kuyenera kuchotsedwa kwakanthawi m'thumba kuti mukayesedwe. Kapena, ikani thumba loteteza pang'ono pamwamba pa kulowetsedwa musanayesedwe ndikuyika m'thumba nthawi yomweyo mutayesa.
Pangani malangizo. Khazikitsani malangizo (kapena njira) yoperekera norepinephrine (kapena mankhwala ena owonjezera mphamvu), kuphatikizapo kuchuluka kwa mankhwala, kuchuluka kwa mankhwala otetezeka, kuchuluka kwa mankhwala owonjezera mphamvu, kuchuluka kwa mankhwala owonjezera mphamvu (mphindi), mlingo/chiwerengero chachikulu, chiyambi, ndi kuyang'anira kofunikira. Ngati n'kotheka, gwirizanitsani malangizo ndi dongosolo la mankhwala owonjezera mphamvu mu Zolemba Zoyang'anira Mankhwala (MAR).
Gwiritsani ntchito pampu yanzeru. Ma infusion onse a norepinephrine amathiridwa ndi kusinthidwa pogwiritsa ntchito pampu yanzeru yokhala ndi Dose Error Reduction System (DERS) yoyatsidwa kuti DERS idziwitse akatswiri azaumoyo za zolakwika zomwe zingachitike polemba mankhwala, kuwerengera, kapena pulogalamu.
Yambitsani Kugwirizana. Ngati n'kotheka, yambitsani pampu yanzeru yothira madzi yomwe imagwirizana ndi zolemba zamagetsi zaumoyo. Kugwirizana kumalola mapampu kuti adzazidwe kale ndi makonda ovomerezeka a kuthira madzi omwe adaperekedwa ndi dokotala (osachepera kumayambiriro kwa titration) komanso kumawonjezera chidziwitso cha mankhwala pa kuchuluka kwa mankhwala omwe atsala mu titrated infusions.
Lembani mizere ndi kutsata mapaipi. Lembani mzere uliwonse wa kulowetsedwa pamwamba pa pampu ndi pafupi ndi malo olowera odwala. Kuphatikiza apo, musanayambe kapena kusintha thumba la norepinephrine kapena kuchuluka kwa kulowetsedwa, yendetsani chubucho pamanja kuchokera ku chidebe cha yankho kupita ku pampu ndi wodwalayo kuti muwonetsetse kuti pampu/njira ndi njira yoperekera ndi zolondola.
Landirani kuyesedwa. Pamene kulowetsedwa kwatsopano kwayimitsidwa, kuwunika kwaukadaulo (monga barcode) kumafunika kuti kutsimikizire mankhwala/mankhwala, kuchuluka kwa mankhwala ndi wodwala.
Siyani kumwa mankhwala. Ngati wodwalayo ali bwino mkati mwa maola awiri kuchokera pamene anasiya kumwa mankhwala a norepinephrine, ganizirani zopeza chilolezo chosiya kumwa mankhwala kuchokera kwa dokotala. Mukasiya kumwa mankhwalawo, nthawi yomweyo muchotse mankhwalawa kwa wodwalayo, muchotseni pa pompo, ndipo mutaya kuti mupewe kumwa mankhwalawo mwangozi. Kumwa mankhwalawo kuyeneranso kuchotsedwa kwa wodwalayo ngati kumwa mankhwalawo kwatha kwa maola opitilira awiri.
Konzani njira yogwiritsira ntchito mankhwala ochotsera ululu m'thupi. Konzani njira yogwiritsira ntchito mankhwala ochotsera ululu m'thupi kuti muchotse ululu wa norepinephrine. Anamwino ayenera kudziwitsidwa za njira imeneyi, kuphatikizapo mankhwala a phentolamine mesylate komanso kupewa mankhwala ozizira omwe amakhudza dera lomwe lakhudzidwa, zomwe zingapangitse kuti minofu iwonongeke kwambiri.
Yesani njira yogwiritsira ntchito titration. Yang'anirani momwe ogwira ntchito amatsatira malangizo a norepinephrine infusion, njira zina ndi malangizo a dokotala, komanso zotsatira za odwala. Zitsanzo za njirazi zikuphatikizapo kutsatira magawo a titration ofunikira pa dongosolo; kuchedwa kwa chithandizo; kugwiritsa ntchito mapampu anzeru omwe DERS yalola (ndi kuyanjana); yambani kulowetsa pamlingo wokonzedweratu; titration malinga ndi kuchuluka kwa mankhwala ndi magawo a mlingo; pampu yanzeru imakudziwitsani za kuchuluka ndi mtundu wa mlingo, zolemba za magawo a titration (ayenera kugwirizana ndi kusintha kwa mlingo) ndi kuwonongeka kwa wodwalayo panthawi ya chithandizo.