1例急性肺栓塞并消化道出血药学监护  

Pharmaceutical Care for One Patient with Acute Pulmonary Embolism Complicated with Gastrointestinal Bleeding

作　　者：翟巧利 朱秋珍 李婷[1] 侯晓丽[1] 辛蓓玮 刘娟[1] 时扣荣[1] ZHAI Qiaoli;ZHU Qiuzhen;LI Ting;HOU Xiaoli;XIN Beiwei;LIU Juan;SHI Kourong(The Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine,Shanghai,China 200137)

机构地区：[1]上海中医药大学附属第七人民医院,上海200137

出　　处：《中国药业》2023年第15期117-119,共3页China Pharmaceuticals

基　　金：上海市浦东新区卫生健康委员会学科建设计划项目[PWZxk2022-07];上海中医药大学附属第七人民医院人才培养计划项目[XX2021-19,BDX2022-01]。

摘　　要：目的探讨临床药师在急性肺栓塞患者药物治疗中的作用。方法临床药师对1例急性肺栓塞并消化道出血患者实施个体化药学监护,协助医师调整药物治疗方案。患者凝血功能异常,临床药师建议停用低分子肝素钙,加用质子泵抑制剂抑酸护胃;考虑2种止血药联用会增加血栓风险,建议停用氨甲环酸;患者无黑便、粪隐血阴性,临床药师建议恢复低分子肝素钙;后继续调整艾司奥美拉唑(40 mg、静脉滴注、每天2次)抑酸护胃,换用利伐沙班(15 mg、口服、每天1次)抗凝治疗。结果医师采纳临床药师建议。患者病情稳定,下肢静脉血流通畅,电子计算机断层扫描肺动脉造影(CTPA)提示肺栓塞治疗后较前明显好转,予以出院。结论临床药师对抗凝治疗的停用、重启及药物选择提出合理建议,并开展个体化药学监护和用药宣教,有利于保障患者的用药安全。Objective To investigate the role of clinical pharmacists in the drug treatment of patients with acute pulmonary embolism.Methods A clinical pharmacist conducted individualized pharmaceutical care on a patient with acute pulmonary embolism complicated with gastrointestinal bleeding,and assisted the physician to adjust the medication treatment plan.Due to the patient's abnormal coagulation function,the clinical pharmacist suggested discontinuing low molecular weight heparin calcium and adding proton pump inhibitors to inhibit acid and protect the stomach.The clinical pharmacist considered that the combination of two hemostatic drugs could increase the risk of thrombosis,and suggested discontinuing tranexamic acid.The patient had no black stools and negative fecal occult blood,so the clinical pharmacist recommended using low molecular weight heparin calcium,adjusting esperazole omeprazole(40 mg,intravenous drip,twice a day)to inhibit acid and protect the stomach,and use rivaroxaban(15 mg,oral,once a day)for anticoagulation treatment.Results The physician adopted the clinical pharmacist's suggestion.The patient's condition was stable,with unobstructed venous blood flow in the lower limbs.Electronic computed tomography pulmonary angiography(CTPA)showed a significant improvement after pulmonary embolism treatment,and the patient discharged.Conclusion Clinical pharmacists provide reasonable suggestions for the discontinuation,reuse,and selection of drugs for anticoagulant therapy,and carry out individualized pharmaceutical care and medication education,which is beneficial for ensuring medication safety of patients.

关 键 词：临床药师 药学监护 急性肺栓塞 消化道出血 抗凝 合理用药 

分 类 号：R95[医药卫生—药学] R969.3