1例超高龄大面积脑梗死合并慢性肾脏病Ⅴ期继发深静脉血栓抗凝药物治疗分析  

Analysis of anticoagulant therapy for secondary deep vein thrombosis in a case of massive cerebral infarction complicated with stage V chronic kidney disease in an extremely elderly patient

作　　者：李芳 钟晓闵[2] 胡曦 王建霖 任常谕 LI Fang;ZHONG Xiaomin;HU Xi;WANG Jianlin;REN Changyu(Department of Pharmacy,Chengdu Sixth People's Hospital,Chengdu 610051,China;Department of Neurology,Chengdu Sixth People's Hospital,Chengdu 610051,China;Department of Pharmacy,Chengdu Fifth People's Hospital,Chengdu 611130,China)

机构地区：[1]成都市第六人民医院药剂科,成都610051 [2]成都市第六人民医院神经内科,成都610051 [3]成都市第五人民医院药剂科,成都611130

出　　处：《药物流行病学杂志》2024年第11期1307-1313,共7页Chinese Journal of Pharmacoepidemiology

摘　　要：临床药师全程参与1例104岁超高龄患者大面积脑梗死合并慢性肾脏病Ⅴ期继发深静脉血栓的抗凝药物治疗管理过程。患者明确诊断为深静脉血栓后,临床药师综合分析患者存在的超高龄、既往房颤病史、大面积脑梗死、肾功能极差、深静脉血栓、高出血风险等因素,协助临床医师制定个体化抗凝药物治疗策略,起始给予华法林1.25mg,qd,并监测患者凝血指标,动态复查肾功能。治疗期间患者血肌酐水平未见明显变化,用药第8天后患者国际标准化比值(INR)为2.47,临床药师建议将华法林调整为1.25 mg与0.625 mg隔日交替服药,此后患者INR维持在2.41,病情好转出院。在抗凝药物治疗管理过程中,临床药师参与用药临床决策,给予患者专业的用药指导以及药学监护,保障特殊人群临床用药安全。A Clinical pharmacist was fully involved in the anticoagulation drug treatment management process of a 104-year-old patient with a large area of cerebral infarction combined with chronic kidney disease stage V and secondary deep vein thrombosis.After the patient was diagnosed with deep vein thrombosis,the clinical pharmacist comprehensively analyzed the patient's super-advanced age,history of atrial fibrillation,large area of cerebral infarction,extremely poor kidney function,deep vein thrombosis,and high bleeding risk indicated by the HAS-BLED score.They worked with the clinical doctor to develop an individualized anticoagulation treatment strategy for the patient.At the beginning of the treatment,warfarin was given to the patient at a daily dose of 1.25 mg,and the patient's coagulation indicators and kidney function were dynamically rechecked.The patient's blood creatinine level did not show significant changes throughout the anticoagulation treatment process.On the 8th day of medication,the patient's INR was 2.47,and the clinical pharmacist suggested adjusting the Warfarin to an alternate-day dose of 1.25 mg and 0.625 mg.Subsequently,the patient's INR was 2.41,and the condition improved,leading to discharge.Throughout the anticoagulation drug management process,the clinical pharmacist participated in the clinical decision-making for anticoagulant drug selection,provided professional medication guidance,and pharmacological monitoring to ensure the safe clinical use of drugs for special populations.

关 键 词：超高龄患者 大面积脑梗死 慢性肾脏病Ⅴ期 深静脉血栓 房颤 抗凝治疗 

分 类 号：R969.3[医药卫生—药理学]