Nkhani

Funso: Norepinephrine ndi mankhwala omwe amapezeka kwambiri omwe amaperekedwa kudzera m'mitsempha (IV) ngati kulowetsedwa kosalekeza. Ndi vasopressor yomwe nthawi zambiri imatchulidwa kuti isunge kuthamanga kwa magazi kokwanira ndikuwongolera kutulutsa kwa chiwalo kwa akulu omwe akudwala kwambiri komanso ana omwe ali ndi hypotension kwambiri kapena kugwedezeka komwe kumapitilirabe ngakhale kuti madzi okwanira am'madzi. Ngakhale zolakwika zazing'ono mu titration kapena mlingo, komanso kuchedwa kwa chithandizo, kungayambitse zotsatira zoopsa. Multicenter Health System posachedwapa inatumiza ISMP zotsatira za kafukufuku wamba (CCA) wa zolakwika za 106 za norepinephrine zomwe zinachitika mu 2020 ndi 2021. Kufufuza zochitika zambiri ndi CCA zimalola mabungwe kuti asonkhanitse zomwe zimayambitsa mizu ndi zovuta za dongosolo. Deta yochokera mu pulogalamu yochitira malipoti ya bungwe ndi mapampu anzeru olowetsera zidagwiritsidwa 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 amenewa anali okhudza zoopsa zomwe zimagwirizanitsidwa ndi mayina ofanana, zilembo, kapena zoikamo, koma palibe zolakwika zomwe zinanenedwa. Tasindikiza malipoti a zolakwa zisanu ndi ziwiri za odwala a norepinephrine: zolakwika zinayi za dosing (April 16, 2020; August 26, 2021; February 24, 2022); cholakwika chimodzi cha ndende yolakwika; cholakwika chimodzi cha titration olakwika a mankhwala; kusokoneza mwangozi kulowetsedwa kwa norepinephrine. Malipoti onse 16 a ISMP adawonjezedwa ku CCA multicenter health system (n=106) ndipo zotsatira zophatikizidwa (N=122) pa sitepe iliyonse yakugwiritsa ntchito mankhwala zikuwonetsedwa pansipa. Cholakwika chomwe chanenedwacho chikuphatikizidwa kuti chipereke chitsanzo cha zomwe zimayambitsa.
Lemberani. Tazindikira zifukwa zingapo zomwe zimagwirizanitsidwa ndi zolakwika zolembera, kuphatikizapo kugwiritsa ntchito mosayenera malamulo a pakamwa, kulembera norepinephrine popanda kugwiritsa ntchito malamulo, ndi zolinga zosadziwika bwino kapena zosadziwika bwino ndi / kapena magawo a titration (makamaka ngati malamulo sagwiritsidwa ntchito). Nthawi zina zolembedwa za titration zimakhala zokhwimitsa kwambiri kapena zosatheka (mwachitsanzo, kuchuluka komwe kwaperekedwa kumakhala kokulirapo), zomwe zimapangitsa kuti zikhale zovuta kwa anamwino kutsatira poyang'anira kuthamanga kwa magazi kwa wodwala. Nthawi zina, madokotala angapereke mlingo wotengera kulemera kapena wosalemera, koma nthawi zina zimasokonezeka. Kufotokozera kwa kunja kwa bokosi kumawonjezera mwayi wa madokotala akumunsi kulakwitsa, kuphatikizapo zolakwika za pulogalamu ya pampu, popeza njira ziwiri za dosing zilipo mu laibulale ya mpope. Kuonjezera apo, kuchedwa kunanenedwa kuti kumafuna kufotokozedwa kwa dongosolo pamene malamulo amaphatikizapo malangizo a dosing okhudzana ndi kulemera komanso osalemera.
Dokotala akufunsa namwino kuti alembe mankhwala a norepinephrine kwa wodwala yemwe ali ndi kuthamanga kwa magazi kosakhazikika. Namwino adalowa mu dongosolo ndendende momwe adotolo adalamulira pakamwa: 0.05 mcg / kg / min IV yojambulidwa ku chandamale cha kupanikizika kwapakati (MAP) pamwamba pa 65 mmHg. Koma malangizo a dokotala kusakaniza sanali kulemera ofotokoza mlingo escalation ndi kulemera zochokera pazipita mlingo: titrate pa mlingo wa 5 mcg/mphindi mphindi 5 aliyense pazipita mlingo wa 1.5 mcg/kg/min. Pampu yolowetsera yanzeru ya bungwe sinathe kutsitsa mlingo wa mcg/min kufika pa mlingo waukulu wotengera kulemera kwake, mcg/kg/min. Madokotala adayenera kuyang'ana malangizo ndi madotolo, zomwe zidapangitsa kuti achedwe kupereka chithandizo.
Konzekerani ndi kugawa. Zolakwa zambiri zokonzekera ndi kuwerengera zimachitika chifukwa cha kuchuluka kwa ntchito zachipatala, zomwe zimachulukitsidwa ndi ogwira ntchito m'mafakitale omwe amafunikira kulowetsedwa kwa norepinephrine (32 mg / 250 ml) (omwe akupezeka ku 503B kupanga pharmacies koma osapezeka m'malo onse). kumabweretsa ntchito zambiri komanso kutopa. Zina zomwe zimayambitsa zolakwika zogawa ndi monga zolemba za noradrenaline zobisika m'matumba opepuka komanso kusamvetsetsa kwa ogwira ntchito ku pharmacy kuti apereke mwachangu.
Kulowetsedwa kwa norepinephrine ndi nicardipine mu thumba lakuda la amber kunalakwika. Kwa kulowetsedwa kwamdima, dongosolo la dosing linasindikiza malemba awiri, wina pa thumba lolowetsedwa lokha ndi lina kunja kwa thumba la amber. Kulowetsedwa kwa norepinephrine kunayikidwa mosadziwa m'mapaketi amber otchedwa "nicardipine" asanagawidwe mankhwala kuti agwiritsidwe ntchito ndi odwala osiyanasiyana komanso mosiyana. Zolakwika sizinawonekere asanaperekedwe kapena kuperekedwa. Wodwala yemwe amathandizidwa ndi nicardipine adapatsidwa norepinephrine koma sanawononge nthawi yayitali.
utsogoleri. Zolakwa zambiri zimaphatikizapo kulakwitsa kwa mlingo kapena kusokoneza, kulakwitsa kwa mlingo wolakwika, ndi zolakwika zolakwika za mankhwala. Zambiri mwa zolakwika izi zimachitika chifukwa cha kulakwitsa kolakwika kwa mpope wanzeru kulowetsedwa, mwa zina chifukwa cha kupezeka kwa kusankha kwa mlingo mu laibulale yamankhwala, ponse pawiri komanso popanda; zolakwika zosungirako; kugwirizana ndi kulumikizanso kwa kusokonezedwa kapena kuyimitsidwa kulowetsedwa kwa wodwalayo kunayambitsa kulowetsedwa kolakwika kapena kulibe chizindikiro mizere ndipo sanawatsatire poyambitsa kapena kuyambiranso kulowetsedwa. Chinachake chinalakwika m'zipinda zangozi ndi zipinda zogwirira ntchito, ndipo kugwirizanitsa kwapope kwanzeru ndi zolemba zaumoyo zamagetsi (EHR) kunalibe. Kuchulukitsa komwe kumayambitsa kuwonongeka kwa minofu kwanenedwanso.
Namwino kutumikiridwa norepinephrine monga ananenera pa mlingo wa 0.1 µg/kg/mphindi. M'malo mopanga mpope kuti apereke 0.1 mcg / kg / min, namwino adakonza mpope kuti apereke 0.1 mcg / min. Chifukwa, wodwalayo analandira 80 zina zochepa norepinephrine kuposa analamula. Pamene kulowetsedwa kunali pang'onopang'ono titrated ndi kufika pa mlingo wa 1.5 µg/mphindi, namwino anaweruza kuti anafika zoikidwiratu pazipita malire 1.5 µg/kg/mphindi. Chifukwa chakuti kupanikizika kwapang'onopang'ono kwa wodwalayo kunali kosazolowereka, vasopressor yachiwiri inawonjezeredwa.
Inventory ndi yosungirako. Zolakwika zambiri zimachitika mukadzaza makabati odziyimira pawokha (ADCs) kapena kusintha Mbale za norepinephrine m'ngolo zojambulidwa. Chifukwa chachikulu cha zolakwika zowerengera izi ndikulemba zilembo ndi kuyika komweko. Komabe, zifukwa zina zodziwika bwino zadziwikanso, monga kuchepa kwa mlingo wa norepinephrine infusions ku ADC zomwe sizinali zokwanira kukwaniritsa zosowa za gulu losamalira odwala, zomwe zimayambitsa kuchedwa kwa mankhwala ngati ma pharmacies amayenera kupanga infusions chifukwa cha kusowa. Kulephera kuyang'ana barcode ya chinthu chilichonse cha norepinephrine ndikusunga ADC ndi gwero lina lolakwika.
Katswiri wa zamankhwala anadzazanso ADC molakwika ndi mankhwala okonzekera 32 mg/250 ml ya norepinephrine mu drawer ya 4 mg/250 ml ya premix ya wopanga. Namwinoyo anakumana ndi vuto pamene akuyesera kulandira 4 mg / 250 ml kulowetsedwa kwa norepinephrine kuchokera ku ADC. Barcode pa kulowetsedwa kwa munthu aliyense sanayesedwe asanaikidwe mu ADC. Namwinoyo atazindikira kuti panali thumba la 32 mg / 250 ml mu ADC (liyenera kukhala mufiriji gawo la ADC), adapempha kuti athetse vutoli. Norepinephrine 4mg/250mL infusion solutions sapezeka m'ma pharmacies chifukwa cha kusowa kwa premixed 4mg/250mL kwa wopanga, zomwe zimapangitsa kuchedwa kusakaniza thandizo la kulowetsedwa.
kuyang'anira. Kuwunika molakwika kwa odwala, kuchuluka kwa kulowetsedwa kwa norepinephrine kunja kwa dongosolo, komanso kusayembekezera nthawi yomwe thumba lotsatira la kulowetsedwa likufunika ndizomwe zimayambitsa zolakwika zowunika.
Wodwala wakufa ndi malamulo oti "musatsitsimutse" amabayidwa ndi norepinephrine kuti akhale nthawi yayitali kuti banja lake litsanzike. Kulowetsedwa kwa norepinephrine kunatha, ndipo panalibe thumba lopuma mu ADC. Namwinoyo nthawi yomweyo anaitana pharmacy ndikupempha chikwama chatsopano. Pharmacy analibe nthawi yokonzekera mankhwalawo asanamwalire ndipo anatsanzikana ndi banja lake.
Ngozi. Zowopsa zonse zomwe sizinapangitse cholakwika zimanenedwa ku ISMP ndipo zimaphatikizapo zilembo zofananira kapena mayina amankhwala. Malipoti ambiri akuwonetsa kuti kuyika ndi kulemba zolemba zosiyanasiyana za kulowetsedwa kwa norepinephrine zoperekedwa ndi 503B kunja kwa 503B kumawoneka ngati kofanana.
Malangizo achitetezo. Ganizirani zotsatirazi mukamakonza kapena kukonzanso njira ya malo anu kuti muchepetse zolakwika pakugwiritsa ntchito bwino kwa norepinephrine (ndi vasopressor) infusions:
kuchepetsa ndende. Okhazikika kwa chiwerengero chochepa cha ndende zochizira ana ndi/kapena akuluakulu odwala. Tchulani malire a kulemera kwa kulowetsedwa kokhazikika komwe kumayenera kusungidwa kwa odwala omwe ali ndi malire amadzimadzi kapena omwe amafunikira mlingo waukulu wa norepinephrine (kuchepetsa kusintha kwa thumba).
Sankhani njira imodzi yokhayokha. Sinthani kulowetsedwa kwa norepinephrine malinga ndi kulemera kwa thupi (mcg/kg/min) kapena popanda (mcg/min) kuti muchepetse ngozi yolakwika. Bungwe la American Society of Health System Pharmacists (ASHP) Safety Standards Initiative4 limalimbikitsa kugwiritsa ntchito mayunitsi a mlingo wa norepinephrine mu micrograms/kg/minute. Zipatala zina zimatha kuyimitsa mlingo kukhala ma micrograms pamphindi kutengera zomwe adokotala amakonda - zonse ndizovomerezeka, koma njira ziwiri za dosing ndizosaloledwa.
Imafunika kuperekedwa molingana ndi template yokhazikika. Pamafunika kulowetsedwa kwa norepinephrine pogwiritsa ntchito template yokhazikika yokhala ndi magawo ofunikira kuti mukhazikike, chandamale yoyezeka (mwachitsanzo, SBP, systolic blood pressure), magawo a titration (mwachitsanzo, mlingo woyambira, kuchuluka kwa mlingo, kuchuluka kwa kuchuluka, ndi kuchuluka kwa mlingo) kapena pansi ), njira yoyendetsera ndi mlingo waukulu womwe suyenera kupitirira ndi / kapena dokotala wopezekapo ayenera kuyitanidwa. Nthawi yosinthira iyenera kukhala "chiwerengero" kuti maodawa akhale patsogolo pamzere wapamankhwala.
Chepetsani malamulo apakamwa. Chepetsani kulamula kwapakamwa pazochitika zenizeni kapena pamene dokotala sangathe kulowa kapena kulemba oda pakompyuta. Madokotala ayenera kupanga makonzedwe awoawo pokhapokha ngati pali mikhalidwe yowonjezereka.
Gulani mayankho okonzeka akapezeka. Gwiritsani ntchito zosakaniza za premixed norepinephrine solutions kuchokera kwa opanga ndi / kapena zothetsera zokonzedwa ndi ogulitsa ena (monga 503B) kuchepetsa nthawi yokonzekera mankhwala, kuchepetsa kuchedwa kwa mankhwala, ndi kupewa zolakwika za kupanga mankhwala.
kusiyana maganizo. Kusiyanitsa madera osiyanasiyana powapanga kukhala osiyana pamaso pa dosing.
Perekani milingo yokwanira ya ADC. Sungani pa ADC ndikupereka ma infusions okwanira a norepinephrine kuti mukwaniritse zosowa za odwala. Yang'anirani kagwiritsidwe ntchito ndikusintha milingo yomwe ikufunika.
Pangani njira zopangira ma batch ndi / kapena kuphatikiza pakufunika. Chifukwa zingatenge nthawi kusakaniza ndende yosawomboledwa, ma pharmacies angagwiritse ntchito njira zosiyanasiyana kuti ayambe kukonzekera ndi kubereka panthawi yake, kuphatikizapo dosing ndi / kapena compressing pamene zotengera zilibe kanthu mkati mwa maola, chifukwa cha chisamaliro kapena zidziwitso za imelo ziyenera kukhala. kukonzekera.
Phukusi lililonse / vial ndi scanned. Kuti mupewe zolakwika panthawi yokonzekera, kugawa, kapena kusungirako, jambulani barcode pa thumba lililonse la kulowetsedwa kwa norepinephrine kapena vial kuti mutsimikizire musanakonzekere, kugawa, kapena kusungidwa mu ADC. Ma barcode atha kugwiritsidwa ntchito pamalebulo omwe amalumikizidwa mwachindunji ndi phukusi.
Yang'anani chizindikiro pachikwama. Ngati thumba lokhala ndi kuwala likugwiritsidwa ntchito poyang'ana mlingo wa chizolowezi, kulowetsedwa kwa norepinephrine kuyenera kuchotsedwa kwa kanthawi m'thumba kuti ayezedwe. Kapenanso, ikani chikwama chodzitetezera chopepuka pamwamba pa kulowetsedwa musanayese ndikuchiyika m'thumba mukangoyesa.
Pangani malangizo. Khazikitsani zitsogozo (kapena protocol) za kulowetsedwa kwa norepinephrine (kapena mankhwala ena omwe ali ndi titrated), kuphatikiza kuchuluka kwanthawi zonse, milingo yotetezeka ya mlingo, kuchuluka kwa mlingo wa titration, ma frequency a titration (mphindi), kuchuluka kwa mlingo/mlingo, zoyambira, ndi kuwunika kofunikira. Ngati n'kotheka, gwirizanitsani malingaliro ku dongosolo la kalembedwe mu Medicines Regulatory Record (MAR).
Gwiritsani ntchito pampu yanzeru. Ma infusions onse a norepinephrine amalowetsedwa ndi kusinthidwa pogwiritsa ntchito mpope wanzeru wokhala ndi Dose Error Reduction System (DERS) yothandizidwa kuti DERS athe kuchenjeza akatswiri azaumoyo za zolakwika zomwe zingachitike, kuwerengera, kapena kukonza mapulogalamu.
Yambitsani Kugwirizana. Ngati kuli kotheka, yambitsani pampu yanzeru yolumikizira ya bi-directional yomwe imagwirizana ndi mbiri yaumoyo yamagetsi. Kusagwirizana kumapangitsa kuti mapampu ayambe kudzazidwa ndi zovomerezeka zovomerezeka zovomerezeka ndi dokotala (osachepera kumayambiriro kwa titration) komanso kumawonjezera kuzindikira kwa pharmacy za kuchuluka komwe kwatsala mu infusions ya titrated.
Lembani mizere ndikutsata mapaipi. Lembani mzere uliwonse wothira pamwamba pa mpope komanso pafupi ndi malo olowera odwala. Kuonjezera apo, musanayambe kapena kusintha thumba la norepinephrine kapena mlingo wa kulowetsedwa, perekani pamanja chubu kuchokera ku chidebe cha yankho kupita ku mpope ndi wodwala kuti atsimikizire kuti mpope / njira ndi njira yoyendetsera ntchito ndizolondola.
Landirani kuyendera. Kulowetsedwa kwatsopano kutayimitsidwa, kuyang'ana mwaukadaulo (mwachitsanzo, barcode) kumafunika kutsimikizira mankhwala / njira, kuchuluka kwa mankhwala ndi wodwala.
Imitsani kulowetsedwa. Ngati wodwalayo ali wokhazikika mkati mwa maola 2 atasiya kulowetsedwa kwa norepinephrine, ganizirani kupeza chilolezo chosiya kwa dokotala. Pamene kulowetsedwa kuyimitsidwa, nthawi yomweyo kusagwirizana kulowetsedwa kwa wodwalayo, kuchotsa pa mpope, ndi kutaya kupewa kupewa mwangozi makonzedwe. Kulowetsedwa kuyeneranso kuchotsedwa kwa wodwalayo ngati kulowetsedwa kumasokonekera kwa maola opitilira 2.
Kupanga ndondomeko ya extravasation. Khazikitsani ndondomeko yowonjezera ya frothing norepinephrine. Anamwino ayenera kudziwitsidwa za regimen, kuphatikizapo mankhwala ndi phentolamine mesylate ndi kupewa compresses ozizira pa zinkakhala m`dera, amene akhoza kukulitsa kuwonongeka minofu.
Unikani kachitidwe ka titration. Yang'anirani kutsata kwa ogwira ntchito ndi malingaliro a kulowetsedwa kwa norepinephrine, ma protocol ndi madotolo apadera, komanso zotsatira za odwala. Zitsanzo za njira zikuphatikizapo kutsata magawo a titration ofunikira pa dongosolo; kuchedwa kwa chithandizo; kugwiritsa ntchito mapampu anzeru okhala ndi DERS (ndi kugwirizana); yambani kulowetsedwa pamlingo wokonzedweratu; titration molingana ndi pafupipafupi komanso magawo a dosing; mpope wanzeru umakudziwitsani za kuchuluka ndi mtundu wa mlingo, zolembedwa za magawo a titration (ayenera kufanana ndi kusintha kwa mlingo) ndi kuvulaza odwala panthawi ya chithandizo.