血液透析伴亚急性感染性心内膜炎患者的药学监护  

Pharmaceutical Care for A Patient with Hemodialysis Complicated with Subacute Infective Endocarditis

作　　者：刘震[1] 侯幸赟[1] 恽芸蕾[1] 陈万生[1] 

机构地区：[1]上海长征医院药材科,上海200003

出　　处：《中国药房》2016年第29期4150-4152,共3页China Pharmacy

基　　金：上海医院药学科研项目(No.2014-YY-01-12)

摘　　要：目的:探讨临床药师在血液透析伴亚急性感染性心内膜炎(IE)患者抗感染药物治疗中的作用。方法:临床药师参与1例血液透析伴亚急性IE患者的抗感染药物治疗过程,根据药物抗菌谱、实验室和影像学检查结果和患者的病情变化,协助医师优化用药方案,先后建议亚胺培南西司他丁钠应在血液透析后给药,调整替考拉宁的首剂量,首次给予万古霉素负荷剂量1 g,于每次透析结束后给予维持剂量0.5 g,并根据血药浓度监测结果调整其使用剂量;在治疗过程中,临床药师密切观察抗感染药物治疗效果及药品不良反应,并进行血药浓度监测、用药提醒和用药教育等药学监护。结果:医师部分采纳临床药师建议,患者未再出现发热症状,血象恢复正常,心脏彩超未见异常,准予出院。结论:临床药师通过调整血液透析伴亚急性IE患者抗感染药物的剂量、评价药物疗效、监测药品不良反应,并定期监测万古霉素血药浓度,协助医师优化治疗方案,确保了患者用药的安全、有效。OBJECTIVE： To explore the role of clinical pharmacists providing pharmaceutical care for hemodialysis patients complicated with subacute infective endocarditis（IE）. METHODS： Clinical pharmacists participated in the anti-infection treatment for a hemodialysis patients complicated with subacute IE, according to the antimicrobial spectrum, laboratory and imaging findings, and patient＇ s condition changes, assisted physician to optimize the regimen, clinical pharmacists suggested to give imipenem cilastatin sodium after hemodialysis, adjust the initial dose of teicoplanin and give 1 g vancomycin firstly, and maintained 0.5 g after hemodialysis, then adjust its dose based on blood plasma concentration; during treatment, clinical pharmacists closely observed the treatment effect and adverse reactions, providing blood plasma concentration monitoring, medication reminding and medication education. RESULTS ： Physicians adopted parts of suggestions of clinical pharmacists, no fever was found, hemogram returned to normal, no abnormal echocardiography, and patient discharged. CONCLUSIONS： Clinical pharmacists guarantee the safety and efficacy of drug use by adopting dose of anti-infection drugs, evaluating efficacy, monitoring adverse reactions and vancomycin plasma concentration, and assisting physicians to optimize treatment regimen.

关 键 词：亚急性感染性心内膜炎 血液透析 临床药师 药学监护 

分 类 号：R542.42[医药卫生—心血管疾病] R939.6[医药卫生—内科学]