Ngā Pūrongo

Pātai: He rongoā wātea nui te Norepinephrine e tukuna ana mā te uaua (IV) hei werohanga tonu. He vasopressor e whakamahia ana hei pupuri i te toto toto me te rere o te toto ki ngā okana e hiahiatia ana i roto i ngā pakeke me ngā tamariki e tino mate ana me te hypotension nui, te ohorere rānei e mau tonu ana ahakoa te nui o te wai e whakahokia ana. Ahakoa ngā hapa iti i roto i te itration, i te horopeta rānei, me te whakaroa i te maimoatanga, ka arahi pea ki ngā pānga taha kino. Nō nā tata nei i tukuna e te Multicenter Health System ki te ISMP ngā hua o te tātari take noa (CCA) mō ngā hapa norepinephrine 106 i puta i te tau 2020 me te 2021. Mā te tūhura i ngā kaupapa maha me te CCA ka taea e ngā whakahaere te kohikohi i ngā take pūtake noa me ngā ngoikoretanga o te pūnaha. I whakamahia ngā raraunga mai i te kaupapa pūrongo a te whakahaere me ngā papu werohanga atamai hei tautuhi i ngā hapa pea.
I whiwhi a ISMP i ngā pūrongo e 16 e pā ana ki te noradrenaline i te tau 2020 me te 2021 mā te ISMP National Medication Error Reporting Program (ISMP MERP). Tata ki te hautoru o ēnei pūrongo i pā ki ngā tūponotanga e pā ana ki ngā ingoa, tapanga, takai rānei rite tonu, engari kāore he hapa i pūrongohia. Kua whakaputaina e mātou he pūrongo mō ngā hapa o te tūroro norepinephrine e whitu: e whā ngā hapa horopeta (16 o Paenga-whāwhā, 2020; 26 o Ākuhata, 2021; 24 o Pēpuere, 2022); kotahi te hapa o te kukū hē; kotahi te hapa o te titration hē o te rongoā; te whakamutua ohorere o te werohanga norepinephrine. I tāpirihia ngā pūrongo ISMP e 16 katoa ki te pūnaha hauora maha-pokapū CCA (n=106) ā, ko ngā hua kua huihuia (N=122) mō ia taahiraa i roto i te tukanga whakamahinga rongoā e whakaaturia ana i raro nei. Kua whakaurua te hapa kua pūrongohia hei whakarato i tētahi tauira o ētahi take noa.
Tohutohu. Kua tautuhia e mātou ētahi take e pā ana ki ngā hapa tohu, tae atu ki te whakamahinga koretake o ngā whakahau ā-waha, te tohu i te norepinephrine me te kore e whakamahi i ngā huinga whakahau, me ngā whāinga me/ranei ngā tawhā ine ine kāore i te mārama, kāore rānei i te tino mārama (ina koa mēnā kāore ngā huinga whakahau e whakamahia). I ētahi wā he tino pakari, he koretake rānei ngā tawhā ine ine kua tohua (hei tauira, he nui rawa ngā pikinga kua tohua), ā, he uaua ki ngā nēhi te whakarongo ki te aroturuki i te toto toto o te tūroro. I ētahi atu wā, ka tohu pea ngā tākuta i ngā horopeta e hangai ana ki te taumaha, ki te kore rānei e hangai ki te taumaha, engari he pōhēhē tēnei i ētahi wā. Mā tēnei tohu ine hou ka nui ake te tūponotanga o ngā tākuta e hē ana, tae atu ki ngā hapa hōtaka papu, nā te mea e rua ngā kōwhiringa ine e wātea ana i roto i te whare pukapuka papu. Hei tāpiri, i pūrongohia ngā whakaroa e hiahia ana kia whakamāramahia te ota i te wā i whakaurua ai e ngā ota tohu ngā tohutohu ine ine e hangai ana ki te taumaha me te kore e hangai ki te taumaha.
Ka tono te tākuta ki tētahi nēhi kia tuhia he rongoā norepinephrine mō tētahi tūroro he toto toto koretake tōna. I whakaurua e te nēhi te ota kia rite tonu ki tā te tākuta i whakahau ai: 0.05 mcg/kg/min IV i titrated ki te taumata pēhanga toto toharite (MAP) neke atu i te 65 mmHg. Engari ko ngā tohutohu inenga a te tākuta e whakakotahi ana i te whakanui i te horopeta kāore i runga i te taumaha me te horopeta mōrahi e runga i te taumaha: titrated i te tere o te 5 mcg/min i ia 5 meneti ki te horopeta mōrahi o te 1.5 mcg/kg/min. Kāore i taea e te papu werohanga atamai o te whakahaere te titrated i te horopeta mcg/min ki te horopeta mōrahi e runga i te taumaha, mcg/kg/min. I tirohia e ngā kaiwhakaora rongoā ngā tohutohu me ngā tākuta, ā, nā tēnei i whakaroa ai te whakarato tiaki.
Te whakarite me te tohatoha. He maha ngā hapa whakarite me te inenga i puta mai i te nui rawa o te mahi a te whare rongoā, ā, ka nui haere te kino o ngā werohanga norepinephrine kukū nui rawa atu (32 mg/250 ml) e hiahiatia ana e ngā kaimahi whare rongoā (e wātea ana i ngā whare rongoā 503B engari kāore e wātea ana i ngā wāhi katoa). Ka hua ake te mahi maha me te ngenge. Ko ētahi atu take noa o ngā hapa tohatoha ko ngā tapanga noradrenaline e huna ana i roto i ngā putea mārama me te kore mārama o ngā kaimahi whare rongoā ki te hiahia nui o te tohatoha.
I hē te whakaurunga ngātahi o te norepinephrine me te nicardipine ki roto i tētahi putea karaka pouri. Mō ngā whakaurunga pouri, e rua ngā tapanga i tāia e te pūnaha inenga, tētahi ki runga i te putea inenga, tētahi ki waho o te putea karaka. I whakanohoia ngā whakaurunga norepinephrine ki roto i ngā putea karaka kua tohua ko "nicardipine" i mua i te tohatoha i te hua hei whakamahi mā ngā tūroro rerekē, me te ritenga kē. Kāore i kitea ngā hapa i mua i te tohatoha, i te inenga rānei. I hoatu te norepinephrine ki te tūroro i rongoatia ki te nicardipine, engari kāore i pā he kino mō te wā roa.
whakahaere. Ko ngā hapa noa ko te hapa horopeta hē, te hapa reiti hē, me te hapa rongoā hē. Ko te nuinga o ēnei hapa nā te hōtaka hē o te papu werohanga atamai, i ētahi wā nā te kōwhiringa horopeta i roto i te whare pukapuka rongoā, mā te taumaha me te kore; ngā hapa rokiroki; te hononga me te hono anō o ngā werohanga kua whakamutua, kua whakatarewahia rānei ki te tūroro i tīmata te werohanga hē, kāore rānei i tohu i ngā rārangi, ā, kāore i whai i aua rārangi i te tīmatanga, i te tīmatanga anō rānei o te werohanga. I puta he hapa i roto i ngā rūma ohorere me ngā rūma pokanga, ā, kāore i te wātea te hototahi o te papu atamai ki ngā pūkete hauora hiko (EHR). Kua pūrongohia hoki te extravasation e arahi ana ki te kino o te kiko.
I hoatu e te nēhi te norepinephrine e ai ki te whakahau i te tere o te 0.1 µg/kg/min. Engari i te whakarite i te papu kia tukuna te 0.1 mcg/kg/min, i whakarite te nēhi kia tukuna te 0.1 mcg/min. Nō reira, i whiwhi te tūroro i te 80 ngā wā iti iho o te norepinephrine i te mea i whakaritea. I te wā i āta tāpirihia ai te werohanga, ā, ka tae ki te tere o te 1.5 µg/min, i whakatau te nēhi kua eke ia ki te rohenga mōrahi kua whakaritea, arā, 1.5 µg/kg/min. Nā te mea he rerekē tonu te pēhanga toto toharite o te tūroro, i tāpirihia he vasopressor tuarua.
Te rarangi taonga me te rokiroki. Ko te nuinga o ngā hapa ka puta i te wā e whakakī ana i ngā kāpata tuku aunoa (ADC) me te whakawhiti rānei i ngā ipu norepinephrine i roto i ngā kaata kua whakakōwaea. Ko te take matua mō ēnei hapa rarangi taonga ko te tapanga me te takai ōrite. Heoi anō, kua tautuhia hoki ētahi atu take noa, pērā i te iti o ngā taumata paerewa o ngā werohanga norepinephrine i te ADC kāore i te rawaka hei whakatutuki i ngā hiahia o te wāhanga tiaki tūroro, ka hua ake he whakaroa maimoatanga mēnā me hanga e ngā whare rongoā ngā werohanga nā te korenga. Ko te korenga e matawai i te waehere pae o ia hua norepinephrine i te wā e penapena ana i te ADC tētahi atu pūtake noa o te hapa.
I hē te kaiwhakaora rongoā ki te whakakī anō i te ADC ki te otinga norepinephrine 32 mg/250 ml i whakaritea e te whare rongoā i roto i te pouaka ranunga 4 mg/250 ml a te kaihanga. I tūtaki te nēhi ki tētahi hapa i a ia e ngana ana ki te whiwhi i tētahi werohanga norepinephrine 4 mg/250 ml mai i te ADC. Kāore i matawaihia te waehere pae i runga i ia werohanga takitahi i mua i te whakatakotoranga ki roto i te ADC. I te kitenga o te nēhi he putea 32 mg/250 ml anake kei roto i te ADC (me noho ki te wāhanga pouaka whakamātao o te ADC), ka pātai ia mō te kukū tika. Kāore e wātea ana ngā otinga werohanga Norepinephrine 4mg/250mL i ngā whare rongoā nā te korenga o ngā kete 4mg/250mL kua whakaranua e te kaihanga, ā, ka roa te wā e uru ai te āwhina werohanga ki te whakaranu.
aroturuki. Ko te aroturuki hē o ngā tūroro, te ine i ngā werohanga norepinephrine i waho o ngā tawhā ota, me te kore e matapae i te wā e hiahiatia ai te pēke werohanga e whai ake nei, koinei ngā tino take o ngā hapa aroturuki.
I werohia he tūroro e tata mate ana, me te whakahau kia "kaua e whakaora" ki te norepinephrine kia roa ai te wā e poroporoaki ai tōna whānau. I mutu te werohanga norepinephrine, ā, kāore he putea tāpiri i roto i te ADC. I waea tonu te nēhi ki te whare rongoā, ā, i tono kia hangaia he putea hou. Kāore i te wā te whare rongoā ki te whakarite i te rongoā i mua i te matenga o te tūroro, ā, i poroporoaki ki tōna whānau.
Mōrearea. Ko ngā mōrearea katoa kāore i puta he hapa ka ripoatatia ki te ISMP, ā, kei roto ko ngā tapanga rite, ngā ingoa rongoā rānei. Ko te nuinga o ngā pūrongo e tohu ana he tata rite te takai me te tapanga o ngā kukū rerekē o ngā werohanga norepinephrine i tukuna e ngā kaihoko o waho o te 503B.
Ngā taunakitanga mō ngā mahi haumaru. Whakaarohia ēnei taunakitanga e whai ake nei i te wā e whakawhanake ana, e whakahou ana rānei i te rautaki a tō whare hauora hei whakaiti i ngā hapa i roto i te whakamahinga haumaru o te norepinephrine (me ētahi atu werohanga vasopressor):
te kukū whakawhāiti. Kua whakaritea mō tētahi maha iti o ngā kukū mō te maimoatanga o ngā tūroro tamariki me/ranei pakeke. Tauwhāitihia te taumaha whakawhāiti mō te werohanga tino kukū hei rāhui mā ngā tūroro he iti te wai, he nui ake rānei ngā horopeta o te norepinephrine e hiahiatia ana (hei whakaiti i ngā whakawhiti putea).
Kōwhiria he tikanga ine kotahi. Whakapūmautia ngā whakahaunga werohanga norepinephrine kia rite ki te taumaha o te tinana (mcg/kg/min) me te kore rānei (mcg/min) hei whakaiti i te tūponotanga o te hapa. E taunaki ana te American Society of Health System Pharmacists (ASHP) Safety Standards Initiative4 kia whakamahia ngā waeine inenga norepinephrine i roto i ngā maikorokaramu/kg/miniti. Tērā pea ka whakapūmautia e ētahi hōhipera te inenga ki ngā maikorokaramu ia meneti i runga i te hiahia o te tākuta – e whakaaetia ana ngā mea e rua, engari kāore e whakaaetia ngā kōwhiringa inenga e rua.
Me whakarite kia rite ki te tauira tono paerewa. Me whakarite he tono werohanga norepinephrine mā te whakamahi i tētahi tauira tono paerewa me ngā āpure e hiahiatia ana mō te kukū e hiahiatia ana, te whāinga ine ine (hei tauira, SBP, toto toto systolic), ngā tawhā ine (hei tauira, te horopeta tīmatanga, te whānuitanga horopeta, te waeine whakanui, me te auau ine) ki runga, ki raro rānei), te huarahi tuku me te horopeta mōrahi kāore e tika kia hipa atu, me/ranei me karanga te tākuta e haere mai ana. Ko te wā hurihanga taunoa me "stat" kia whai mana ai ēnei ota i roto i te rarangi o te whare rongoā.
Whakawhāitihia ngā whakahau ā-waha. Whakawhāitihia ngā whakahau ā-waha ki ngā āhuatanga ohorere tūturu, ki te kore rānei e taea e te tākuta te whakauru, te tuhi rānei i tētahi whakahau mā te hiko. Me whakarite e ngā tākuta ā rātou ake whakaritenga mēnā kāore he āhuatanga motuhake.
Hokona ngā otinga kua oti te hanga ina wātea. Whakamahia ngā kukū o ngā otinga norepinephrine kua whakaranua i mua mai i ngā kaihanga me/ngā otinga rānei i whakaritea e ngā kaihoko tuatoru (pēnei i te 503B) hei whakaiti i te wā whakarite rongoā, hei whakaiti i ngā whakaroa maimoatanga, me te karo i ngā hapa whakatakotoranga rongoā.
te rerekētanga o te kukū. Te wehewehe i ngā kukū rerekē mā te whakarite kia kitea te rerekētanga i mua i te horopeta.
Whakaratohia ngā taumata ADC e tika ana. Whakaratohia he ADC, ā, whakaratohia hoki he werohanga norepinephrine e tika ana hei whakatutuki i ngā hiahia o te tūroro. Aroturukihia te whakamahinga, ā, whakarerekētia ngā taumata paerewa ina hiahiatia.
Waihangahia ngā tukanga mō te tukatuka puranga me/ranei te whakaranu i runga i te tono. Nā te mea ka roa pea te wā ki te whakaranu i te kukū mōrahi kāore anō kia hokona, ka taea e ngā whare rongoā te whakamahi i ngā rautaki maha hei whakarite i te whakarite me te tuku i te wā tika, tae atu ki te ine me/ranei te kōpeke ina takoto kau ngā ipu i roto i ngā hāora, nā te mea me whakarite ngā whakamōhiotanga a te tari tiaki, īmēra rānei.
Ka matawaihia ia kete/pouaka. Hei karo i ngā hapa i te wā whakarite, tohatoha, rokiroki rānei, matawaihia te waehere pae i runga i ia putea werohanga norepinephrine, i ia ipu rānei hei manatoko i mua i te whakarite, tohatoha, rokiroki rānei i roto i te ADC. Ka taea anake te whakamahi i ngā waehere pae i runga i ngā tapanga kua piri tika ki te kete.
Tirohia te tapanga kei runga i te putea. Mena ka whakamahia he putea mārama-ki-te-tinana i te wā e tirohia ana te horopeta o ia rā, me tango te werohanga norepinephrine mai i te putea mō te whakamātautau. Tērā atu rānei, whakatakotoria he putea tiaki mārama ki runga i te werohanga i mua i te whakamātautau, ā, whakanohoia ki roto i te putea i muri tonu i te whakamātautau.
Waihangahia he aratohu. Whakatūria he aratohu (he tikanga rānei) mō te werohanga o te norepinephrine (tētahi atu rongoā rānei kua werohangahia), tae atu ki ngā kukū paerewa, ngā awhe horopeta haumaru, ngā pikinga horopeta werohanga noa, te auau werohanga (meneti), te horopeta/tere mōrahi, te turanga, me te aroturukitanga e hiahiatia ana. Mena ka taea, honoa ngā taunakitanga ki te raupapa werohanga i roto i te Medicines Regulatory Record (MAR).
Whakamahia he papu atamai. Ka werohia ngā werohanga norepinephrine katoa, ā, ka tātarihia mā te whakamahi i tētahi papu werohanga atamai me te Pūnaha Whakaiti Hapa Inenga (DERS) kua whakahohea kia taea ai e te DERS te whakatūpato i ngā tohunga hauora ki ngā hapa pea o te whakahaunga, te tatau, te hōtaka rānei.
Whakahohe i te Hototahi. Ki te taea, whakahohehia he papu werohanga atamai e rua ngā taha e hototahi ana ki ngā pūkete hauora hiko. Mā te mahi tahi ka taea te whakakī i mua i ngā papu ki ngā tautuhinga werohanga kua manatokohia kua whakaritea e te tākuta (i te tīmatanga o te titration) ā, ka whakanui ake hoki i te mōhiotanga o te whare rongoā mō te nui o te toenga i roto i ngā werohanga titrated.
Tohua ngā rārangi, ā, tuhia hoki ngā paipa. Tāpirihia he tapanga ki ia rārangi werohanga i runga ake i te papu, me te taha tata ki te pūwāhi urunga a te tūroro. Hei tāpiri, i mua i te tīmatanga, i te whakarerekētanga rānei i te putea norepinephrine, i te tere werohanga rānei, me arahi ā-ringa te ngongo mai i te ipu otinga ki te papu me te tūroro hei manatoko kei te tika te papu/hongere me te huarahi hoatutanga.
Whakaaetia te tirotiro. Ina whakatarewahia he werohanga hou, me tirotirohia he hangarau (hei tauira, te waehere pae) hei manatoko i te rongoā/wairewa, te kukū o te rongoā me te tūroro.
Kati te werohanga. Mena kei te noho pumau te tūroro i roto i ngā haora e 2 i muri i te whakamutu i te werohanga norepinephrine, whakaarohia te tiki i tētahi ota whakamutu mai i te tākuta e rongoā ana. Kia mutu te werohanga, momotu tonu te werohanga mai i te tūroro, tangohia mai i te papu, ka maka atu kia kore ai e tukuna tūpono. Me momotu hoki te werohanga mai i te tūroro mena ka neke atu i te 2 haora te roa o te whakamutua o te werohanga.
Whakatūria he tikanga extravasation. Whakatūria he tikanga extravasation mō te whakaputa huka o te norepinephrine. Me whakamōhio ngā nēhi mō tēnei tikanga, tae atu ki te maimoatanga ki te phentolamine mesylate me te karo i ngā kōpeke makariri ki te wāhi e pāngia ana, ka taea ai e ēnei te whakararu i te kino o te kiko.
Arotakehia ngā mahi titration. Aroturukihia te tutuki a ngā kaimahi i ngā taunakitanga mō te werohanga norepinephrine, ngā tikanga me ngā whakahaunga motuhake a te tākuta, tae atu ki ngā putanga o te tūroro. Ko ngā tauira o ngā mahi ko te tutuki i ngā tawhā titration e hiahiatia ana mō te whakahau; te whakaroa i te maimoatanga; te whakamahi i ngā papu atamai me te DERS whakahohea (me te mahi tahi); tīmata te werohanga i te tere kua whakaritea; te titration e ai ki te auau kua whakaritea me ngā tawhā inenga; ka whakatūpato te papu atamai i a koe ki te auau me te momo inenga, te tuhi i ngā tawhā titration (me ōrite ki ngā huringa inenga) me te kino o te tūroro i te wā e maimoatanga ana.