Labarai

Tambaya: Norepinephrine magani ne mai yawan samuwa wanda ake gudanarwa ta hanyar jini (IV) azaman jiko mai ci gaba.Yana da wani vasopressor wanda aka fi dacewa don kula da isasshen karfin jini da kuma zubar da gabobin gabobin jiki a cikin manya marasa lafiya da yara masu fama da hauhawar jini ko girgiza wanda ke ci gaba duk da isasshen ruwa.Ko da ƙananan kurakurai a cikin titration ko kashi, da kuma jinkirin jiyya, na iya haifar da illa mai haɗari.Tsarin Kiwon Lafiya na Multicenter kwanan nan ya aika da ISMP sakamakon bincike na gama gari (CCA) don kurakuran norepinephrine 106 da suka faru a cikin 2020 da 2021. Binciken abubuwan da yawa tare da CCA yana ba ƙungiyoyi damar tattara tushen tushen gama gari da raunin tsarin.An yi amfani da bayanai daga shirin bayar da rahoto na ƙungiyar da kuma famfunan jiko mai wayo don gano kurakurai masu yuwuwa.
ISMP ta sami rahotannin noradrenaline guda 16 a cikin 2020 da 2021 ta hanyar ISMP Kuskuren Bayar da Rahoton Kuskuren Magunguna na Ƙasa (ISMP MERP).Kusan kashi ɗaya bisa uku na waɗannan rahotannin sun yi maganin hatsarori da ke da alaƙa da sunaye iri ɗaya, alamomi, ko marufi, amma ba a sami rahoton kurakurai a zahiri ba.Mun buga rahotannin kurakurai bakwai na norepinephrine: kurakuran allurai guda huɗu (16 ga Afrilu, 2020; Agusta 26, 2021; Fabrairu 24, 2022);kuskure ɗaya na maida hankali ba daidai ba;kuskure ɗaya na titration na miyagun ƙwayoyi ba daidai ba;katsewar jiko na norepinephrine na bazata.Dukkan rahotannin ISMP na 16 an ƙara su zuwa tsarin kiwon lafiya na CCA multicenter (n=106) da kuma sakamakon da aka tattara (N=122) don kowane mataki a cikin tsarin amfani da miyagun ƙwayoyi an nuna a ƙasa.An haɗa kuskuren da aka ruwaito don samar da misalin wasu dalilai na gama gari.
Rubuta.Mun gano abubuwan da ke haifar da dalilai da yawa waɗanda ke da alaƙa da rubutawa kurakurai, gami da yin amfani da umarnin baka da ba dole ba, rubuta norepinephrine ba tare da amfani da saitin umarni ba, da maƙasudai ko rashin tabbas da/ko sigogin titration (musamman idan ba a yi amfani da saitin umarni ba).Wani lokaci sigogin titration da aka tsara suna da tsauri ko rashin aiki (misali, ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙa'idodi sun yi yawa), yana sa ma'aikatan jinya wahala su bi yayin lura da hawan jini na majiyyaci.A wasu lokuta, likitoci na iya ba da izini na tushen nauyi ko marasa nauyi, amma wannan yana rikicewa wani lokaci.Wannan bayanan bayan-da-akwatin yana ƙara yuwuwar likitocin da ke ƙasa su yi kurakurai, gami da kurakuran shirye-shiryen famfo, tunda ana samun zaɓin allurai biyu a ɗakin karatu na famfo.Bugu da kari, an bayar da rahoton jinkiri na buƙatar bayanin oda lokacin da aka tsara umarni ya haɗa da tushen nauyi da umarnin allurai marasa nauyi.
Likita ya tambayi ma'aikaciyar jinya ta rubuta takardar sayan magani na norepinephrine ga majiyyaci da hawan jini mara karko.Ma'aikaciyar jinya ta shigar da tsari daidai kamar yadda likita ya umarta: 0.05 mcg/kg/min IV wanda aka ƙaddara zuwa maƙasudin ma'anar bugun jini (MAP) sama da 65 mmHg.Amma umarnin sashi na likita ya haɗu da haɓakar kashi mara nauyi tare da matsakaicin matsakaicin matsakaicin nauyi: titrate a ƙimar 5 mcg / min kowane minti 5 zuwa matsakaicin adadin 1.5 mcg/kg/min.Fim ɗin jiko mai wayo na ƙungiyar ya kasa ƙaddamar da kashi na mcg/min zuwa iyakar tushen nauyi, mcg/kg/min.Masu harhada magunguna sun duba umarnin tare da likitoci, wanda ya haifar da jinkirin ba da kulawa.
Shirya kuma rarraba.Yawancin shirye-shirye da kurakurai na allurai sun kasance saboda yawan aikin kantin magani, wanda ma'aikatan kantin magani suka tsananta da ke buƙatar infusions na norepinephrine mafi girma (32 mg / 250 ml) (ana samun su a cikin kantin magani na 503B amma ba'a samuwa a duk wurare).kai ga multitasking da gajiya.Sauran abubuwan gama gari na rarraba kurakurai sun haɗa da alamun noradrenaline da ke ɓoye a cikin jakunkuna masu haske da kuma rashin fahimtar ma'aikatan kantin magani na gaggawar rarrabawa.
Haɗin haɗin norepinephrine da nicardipine a cikin jakar amber mai duhu ya yi kuskure.Don infusions masu duhu, tsarin dosing ɗin ya buga alamomi guda biyu, ɗaya akan jakar jiko kanta kuma wani a waje na jakar amber.An sanya jiko na Norepinephrine ba da gangan ba a cikin fakitin amber masu lakabin "nicardipine" kafin rarraba samfurin don amfani da marasa lafiya daban-daban kuma akasin haka.Ba a lura da kurakurai ba kafin rabawa ko allurai.An ba majinyacin da aka yi da nicardipine norepinephrine amma bai haifar da lahani na dogon lokaci ba.
gudanarwa.Kurakurai na gama gari sun haɗa da kuskuren kashi ko kuskuren taro, kuskuren ƙimar kuɗi mara daidai, da kuskuren magani.Yawancin waɗannan kurakuran sun kasance saboda shirye-shiryen da ba daidai ba na famfo jiko mai kaifin baki, a wani ɓangare saboda kasancewar zaɓin kashi a cikin ɗakin karatu na miyagun ƙwayoyi, duka ta nauyi kuma ba tare da shi ba;kurakurai na ajiya;haɗi da sake haɗawa da katsewa ko dakatarwar infusions ga mai haƙuri ya fara jiko mara kyau ko ba su yi alama ba kuma ba su bi su ba lokacin farawa ko ci gaba da jiko.Wani abu ya faru ba daidai ba a cikin dakunan gaggawa da dakunan aiki, kuma ba a samu daidaiton famfo mai wayo tare da bayanan lafiyar lantarki (EHR) ba.An kuma bayar da rahoton ɓarna da ke haifar da lalacewar nama.
Ma'aikaciyar jinya ta gudanar da norepinephrine kamar yadda aka umarce ta akan adadin 0.1 μg/kg/min.Maimakon shirya famfo don isar da 0.1 mcg/kg/min, ma’aikaciyar jinya ta tsara famfo don isar da 0.1 mcg/min.A sakamakon haka, mai haƙuri ya sami sau 80 ƙasa da norepinephrine fiye da yadda aka tsara.Lokacin da jiko ya kasance a hankali titrated kuma ya kai adadin 1.5 µg/min, ma'aikaciyar jinya ta yanke hukuncin cewa ta kai iyakar da aka tsara na 1.5 µg/kg/min.Saboda ma'anar ma'anar bugun jini na majiyyaci har yanzu ba shi da kyau, an ƙara vasopressor na biyu.
Kayayyaki da ajiya.Yawancin kurakurai suna faruwa lokacin da ake cika akwatunan rarrabawa ta atomatik (ADCs) ko canza vials na norepinephrine a cikin kuloli masu lamba.Babban dalilin waɗannan kurakuran ƙira shine lakabi iri ɗaya da marufi.Duk da haka, an gano wasu dalilai na yau da kullum, irin su ƙananan matakan norepinephrine infusions a ADC wanda bai isa ba don biyan bukatun sashin kula da marasa lafiya, wanda ke haifar da jinkirin jiyya idan har kantin magani ya gyara infusions saboda ƙarancin.Rashin bincika lambar barcode na kowane samfurin norepinephrine yayin adana ADC shine wani tushen kuskure na kowa.
Likitan harhada magunguna yayi kuskure ya sake cika ADC tare da maganin norepinephrine wanda aka shirya 32 mg/250 ml a cikin 4 mg/250 ml premix drawer na masana'anta.Ma'aikaciyar jinya ta ci karo da kuskure yayin ƙoƙarin karɓar jiko na norepinephrine na 4 mg/250 ml daga ADC.Ba a bincika lambar lamba akan kowane jiko ba kafin a sanya shi a cikin ADC.Lokacin da ma'aikaciyar jinya ta gane cewa akwai jakar 32 mg/250 ml kawai a cikin ADC (ya kamata a kasance a cikin firiji na ADC), ta nemi daidaitaccen taro.Maganin jiko na Norepinephrine 4mg/250mL ba a samun su a cikin kantin magani saboda ƙarancin fakitin ƙera na 4mg/250mL, wanda ke haifar da jinkiri a haɗar taimakon jiko.
saka idanu.Kulawa mara kyau na marasa lafiya, titration na norepinephrine infusions a waje da sigogi na tsari, da rashin tsammanin lokacin da ake buƙatar jakar jiko na gaba shine mafi yawan abubuwan da ke haifar da kurakuran sa ido.
Majinyacin da ke mutuwa tare da umarni don "kada ku farfado" ana allurar norepinephrine don ya daɗe don danginta su yi ban kwana.Jiko na norepinephrine ya ƙare, kuma babu jakar ajiyar ajiya a cikin ADC.Nan take ma’aikaciyar jinya ta kira pharmacy ta bukaci sabuwar jaka.Pharmacy din bai samu lokacin shirya maganin ba kafin majinyacin ya rasu ya yi bankwana da danginta.
Hadari.Dukkan haɗarin da bai haifar da kuskure ba ana ba da rahoto ga ISMP kuma sun haɗa da lakabi iri ɗaya ko sunayen ƙwayoyi.Yawancin rahotanni sun nuna cewa marufi da lakafta nau'ikan nau'ikan jiko na norepinephrine da masu fitar da kayayyaki na 503B ke bayarwa sun yi kama da juna.
Shawarwari don aiki mai aminci.Yi la'akari da shawarwari masu zuwa lokacin haɓakawa ko sake duba dabarun kayan aikin ku don rage kurakurai a cikin amintaccen amfani da norepinephrine (da sauran vasopressor) infusions:
iyaka maida hankali.Daidaitacce don ƙayyadaddun adadin ƙididdiga don kula da lafiyar yara da / ko manya marasa lafiya.Ƙayyade iyakar nauyi don jiko mai mahimmanci da za a tanada don marasa lafiya tare da ƙuntatawa na ruwa ko buƙatar mafi girma na norepinephrine (don rage yawan canjin jaka).
Zaɓi hanyar allurai guda ɗaya.Daidaita takaddun jiko na norepinephrine kamar yadda ya dogara da nauyin jiki (mcg/kg/min) ko kuma ba tare da shi ba (mcg/min) don rage haɗarin kuskure.Societyungiyar American Tsarin Jakadan Kiwon Jaladama na Jakadan Kasuwanci (AshP) OF-ORINGUWAR CIGABA (AURP) Rarraba raka'a norepinephrine a cikin rubutun cuta / kg / minti / minti.Wasu asibitoci na iya daidaita ma'auni zuwa micrograms a cikin minti ɗaya dangane da zaɓin likita - duka biyun abin karɓa ne, amma ba a yarda da zaɓin allurai biyu ba.
Yana buƙatar rubutawa bisa ga daidaitaccen samfurin tsari.Yana buƙatar takardar sayan jiko na norepinephrine ta amfani da daidaitaccen samfurin tsari tare da filayen da ake buƙata don maida hankali da ake so, maƙasudin titration (misali, SBP, hawan jini na systolic), sigogi na titration (misali, farkon kashi, kewayon kashi, naúrar karuwa, da mitar dosing) sama ko ƙasa ), hanyar gudanarwa da matsakaicin adadin da ba dole ba ne a wuce shi da / ko likitan halartar ya kamata a kira shi.Tsohuwar lokacin juyawa yakamata ya zama “stat” don waɗannan umarni su zama fifiko a layin kantin magani.
Iyakance umarni na baki.Iyakance umarni na baki zuwa ga gaggawa na gaske ko lokacin da likita ya kasa shiga ko rubuta oda ta hanyar lantarki.Likitoci dole ne su yi nasu shirye-shiryen sai dai idan akwai wasu yanayi masu tsauri.
Sayi hanyoyin da aka yi shirye-shiryen lokacin da suke samuwa.Yi amfani da ƙididdiga na maganin norepinephrine da aka riga aka haɗa daga masana'anta da/ko mafita waɗanda masu siye na ɓangare na uku suka shirya (kamar 503B) don rage lokacin shirye-shiryen kantin magani, rage jinkirin jiyya, da guje wa kurakuran ƙirar kantin magani.
bambancin maida hankali.Bambance nau'o'i daban-daban ta hanyar sanya su bambanta da gani kafin a sha.
Samar da isassun matakan ƙimar ADC.Ajiye akan ADC kuma samar da isassun jiko na norepinephrine don saduwa da bukatun haƙuri.Saka idanu amfani da daidaita daidaitattun matakan kamar yadda ake buƙata.
Ƙirƙiri matakai don sarrafa tsari da/ko haɗawa akan buƙata.Saboda yana iya ɗaukar lokaci don haɗa matsakaicin matsakaicin matsakaicin da ba a fanshi ba, kantin magani na iya amfani da dabaru iri-iri don ba da fifikon shirye-shirye da bayarwa akan lokaci, gami da dosing da/ko matsawa lokacin da kwantena ba su da komai a cikin sa'o'i, wanda ya haifar da ma'anar kulawa ko sanarwar imel da ake buƙatar zama. shirya.
Ana duba kowane fakiti/kwali.Don guje wa kurakurai yayin shirye-shiryen, rarrabawa, ko ajiya, bincika lambar lamba akan kowace jakar jiko na norepinephrine ko vial don tabbatarwa kafin shiri, rarrabawa, ko ajiya a cikin ADC.Za'a iya amfani da lambobin barke kawai akan tambarin da aka liƙa kai tsaye a cikin kunshin.
Duba lakabin akan jakar.Idan an yi amfani da jakar da ke da haske yayin duban allurai na yau da kullun, ya kamata a cire jiko na norepinephrine na ɗan lokaci daga cikin jakar don gwaji.A madadin, sanya jakar kariya ta haske akan jiko kafin gwaji kuma sanya shi cikin jakar nan da nan bayan gwaji.
Ƙirƙiri jagorori.Ƙaddamar da jagororin (ko yarjejeniya) don jiko titration na norepinephrine (ko wasu titrated magani), gami da daidaitattun ƙididdiga, jeri mai aminci, ƙayyadaddun adadin titration na yau da kullun, mitar titration (minti), matsakaicin adadin / ƙimar, tushe, da sa ido da ake buƙata.Idan zai yiwu, haɗa shawarwarin zuwa odar titration a cikin Rikodin Ka'idojin Magunguna (MAR).
Yi amfani da famfo mai wayo.Ana shigar da duk infusions na norepinephrine da titrated ta amfani da famfon jiko mai kaifin baki tare da kunna Tsarin Rage Kuskuren Kashi (DERS) don DERS na iya faɗakar da ƙwararrun kiwon lafiya ga yuwuwar rubutawa, lissafi, ko kurakuran shirye-shirye.
Kunna Daidaituwa.Inda zai yiwu, ba da damar famfo jiko mai kaifin baki guda biyu wanda ya dace da bayanan lafiyar lantarki.Haɗin kai yana ba da damar cika famfo tare da ingantattun saitunan jiko wanda likita ya tsara (aƙalla a farkon titration) kuma yana ƙara wayar da kan kantin magani na nawa aka bari a cikin titrated infusions.
Alama layin kuma gano bututu.Sanya kowane layin jiko sama da famfo kuma kusa da wurin samun majiyyaci.Bugu da ƙari, kafin farawa ko canza jakar norepinephrine ko adadin jiko, da hannu ta hanyar tubing daga kwandon bayani zuwa famfo da haƙuri don tabbatar da cewa famfo / tashar da hanyar gudanarwa daidai ne.
Karɓi dubawa.Lokacin da aka dakatar da sabon jiko, ana buƙatar binciken fasaha (misali lambar lamba) don tabbatar da magani/maganin, maida hankali na miyagun ƙwayoyi da haƙuri.
Dakatar da jiko.Idan mai haƙuri ya tsaya a cikin sa'o'i 2 na dakatar da jiko na norepinephrine, yi la'akari da samun odar dakatarwa daga likitan kulawa.Da zarar an dakatar da jiko, nan da nan cire haɗin jiko daga majiyyaci, cire shi daga famfo, kuma jefar don guje wa gudanar da haɗari.Hakanan dole ne a cire haɗin jiko daga majiyyaci idan an katse jiko fiye da sa'o'i 2.
Ƙirƙiri ƙa'idar ƙaura.Ƙirƙiri ƙa'idar ƙaƙƙarfan ƙa'idar don fitar da norepinephrine.Ya kamata a sanar da ma'aikatan jinya game da wannan tsarin, ciki har da jiyya tare da phentolamine mesylate da kuma guje wa matsalolin sanyi a yankin da abin ya shafa, wanda zai iya tsananta lalacewar nama.
Yi kimanta aikin titration.Kula da bin ka'idodin ma'aikata tare da shawarwarin jiko na norepinephrine, ka'idoji da takamaiman takaddun likita, da kuma sakamakon haƙuri.Misalan matakan sun haɗa da bin ka'idodin titration da ake buƙata don oda;jinkiri a magani;amfani da famfo mai kaifin baki tare da kunna DERS (da aiki tare);fara jiko a ƙimar da aka ƙaddara;titration bisa ga ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun ƙayyadaddun abubuwa;famfon mai wayo yana faɗakar da ku akan mita da nau'in kashi, takaddun sigogi na titration (ya dace da canjin kashi) da cutar da haƙuri yayin jiyya.