1例心脏瓣膜置换术后合并房颤的终末期肾病患者个体化用药监护  

Individualized Pharmaceutical Care for One Patient with End-stage Renal Disease and Atrial Fibrillation after Aortic Valve Replacement

作　　者：浦峤雪 刘震[2] 

机构地区：[1]上海中医药大学附属曙光医院药剂科,上海200021 [2]上海长征医院药材科

出　　处：《中国药师》2017年第4期683-686,共4页China Pharmacist

基　　金：上海医院药学科研基金项目(编号:2014-YY-01-12);上海市临床药学重点专科建设项目(编号:2016-40044-002)

摘　　要：目的:对1例心脏瓣膜置换术后合并房颤的终末期肾脏病患者进行个体化用药监护,探讨特殊药物在肾脏病患者中应用药学监护的重要性及临床药师工作的切入点。方法:临床药师检测地高辛血药浓度、监测华法林用药期间的国际标准化比值(INR),并根据结果提供药学监护及干预。结果:医师采纳药师建议,密切关注患者的地高辛血药浓度及INR值变化,根据患者肾功能调整用药;患者地高辛中毒症状得到缓解,服药依从性提高,并了解了相关指标监测的必要性。结论:临床药师可以从个体化角度出发,以血药浓度、电解质平衡、INR监测、药物相互作用、蛋白结合率、肝肾功能等多方面指标作为切入点开展药学监护工作,协助医师优化治疗方案,保障患者用药安全、有效。Objective： To explore the importance and the breakthrough points of pharmaceutical care for patients with renal disease, especially using drugs with narrow therapeutic window and notable individual difference. Methods： Digoxin concentration and international normalized ratio （INR） were detected by clinical pharmacists, and then individualized pharmaceutical care was given to the patient according to the monitoring results. Results： Physician increased the monitoring frequency and adjusted the drug usage according to the patient＇ s renal function. The patient＇ s condition was improved and understood the necessity of related index monitoring. Conclusion： Clinical pharmacists can assist physicians in optimizing the treatment, and ensure safe, reasonable and effective medication by providing pharmaceutical care in various aspects.

关 键 词：药学监护 慢性肾脏病 地高辛 血药浓度 华法林 国际标准化比值 

分 类 号：R97[医药卫生—药品]