Page 112 - 2020年2月第31卷第3期

·药师与药学服务·

临床药师通过不同切入点参与会诊的4个典型案例分析 Δ

＊
李 纳 ，张爱玲，刘 楠，汤 姝，时程程（郑州大学第一附属医院药学部，郑州 450052）
#
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2020）03-0358-07
DOI 10.6039/j.issn.1001-0408.2020.03.21
摘 要 目的：积累临床药师会诊工作经验，促进临床安全、合理用药。方法：通过不同切入点，临床药师分别对1例肝移植术后
肺部感染患者使用伏立康唑抗真菌治疗后，出现伏立康唑血药浓度过高；1例咯血伴发肺部感染患者使用抗感染和止血药物治疗
后，出现纤维蛋白原下降；1例肺移植术后伴发肺部感染患者使用抗感染治疗后，出现尿素和肌酐升高；1例肾移植术后突发癫痫
患者给予苯巴比妥、地西泮抗癫痫治疗后，他克莫司血药浓度出现明显下降等4个会诊案例的用药进行分析和评价，提出药学会
诊意见，优化治疗方案。结果：临床药师对4个会诊案例分别提出的建议均被医师采纳。病例1停用伏立康唑、奥美拉唑，换用泮
托拉唑后，患者伏立康唑稳态谷浓度由12.38 μg/mL降至6.86 μg/mL，转氨酶、总胆红素等肝功能指标均好转。病例2停用头孢哌
酮舒巴坦、白眉蛇毒血凝酶，给予维生素K1、纤维蛋白原并输注冷沉淀和血浆进行对症治疗后，患者纤维蛋白原由0.74 g/L逐步升
至2.88 g/L，并维持在正常范围内。病例3调整肾毒性相关药物（美罗培南调整为1 g，q12 h；左氧氟沙星调整为250 mg，qd；更昔洛
韦调整为94 mg，qd；复方磺胺甲噁唑调整为2片，qd）的给药剂量后，患者肾功能指标尿素由37.6 mmol/L降至7.8 mmol/L，肌酐由
173 μmol/L降至68 μmol/L，肾功能恢复正常，同时感染性指标也得到改善。病例4调整他克莫司口服剂量为2 mg，q12 h+五酯软
胶囊口服剂量为1 g，bid后，患者他克莫司血药浓度由0.8 ng/mL升至5.9 ng/mL，达到预期值，住院期间未再出现波动。结论：临床
药师会诊可在个体化治疗方案调整、药品不良反应的识别与救治、特殊人群用药方案调整、药物相互作用的治疗方案优化等方面
起到关键作用，可为患者临床用药安全提供保障。
关键词 临床药师；会诊；案例分析；肺部感染；癫痫；药品不良反应；药物相互作用

Analysis of 4 Typical Cases of Clinical Pharmacists Participating in Consultation from Different Approaches
LI Na，ZHANG Ailing，LIU Nan，TANG Shu，SHI Chengcheng（Dept. of Pharmacy，the First Affiliated Hospital
of Zhengzhou University，Zhengzhou 450052，China）
ABSTRACT OBJECTIVE：To accumulate relevant experience of clinical pharmacists consultation，and to promote clinical safe
and rational drug use. METHODS：From different approaches，the clinical pharmacists analyzed and evaluated of drug use in 4
consultation cases， i.e. a patient of pulmonary infection after liver transplantation was treated with antifungal therapy by
voriconazole，which resulted in excessive blood concentration of voriconazole；a hemoptysis patient with pulmonary infection was
found fibrinogen decreased，after treatmented with anti-infective and hemostatic drugs；a patient with pulmonary infection after
lung transplantation，followed by the increase of urea and creatinine after anti-infective therapy；a patient with grand mal epilepsy
after kidney transplantation was treated with phenobarbital and diazepam， the blood concentration of tacrolimus decreased
significantly. The pharmaceutical consultation opinion was put forward and the treatment plan was optimized by clinical
pharmacists. RESULTS：Clinical pharmacists put forward pharmaceutical consultation suggestions for four consultation cases，
which were adopted by doctors. Case 1 was stopped voriconazole and omeprazole，and changed to pantoprazole for gastric
protection. The steady-state valley concentration of voriconazole decreased from 12.38 μg/mL to 6.86 μg/mL，and the liver function
of transaminase and total bilirubin were improved. Case 2 was stopped cefoperazone-sulbactam and hemocoagulase，given vitamin
K1，fibrinogen，cryoprecipitation，plasma for symptomatic treatment. The fibrinogen was gradually increased from 0.74 g/L to 2.88
g/L，and then remained within the normal range. Case 3 was adjusted the dosages of nephrotoxicity-related drugs（meropenem，
levofloxacin，ganciclovir and Compound sulfamethoxazole were adjusted to 1 g q12 h，250 mg qd，94 mg qd and 2 tablets qd
respectively）. The renal function indicators of urea decreased from 37.6 mmol/L to 7.8 mmol/L；creatinine decreased from 173
μmol/L to 68 μmol/L；the renal function returned to normal，and the infectious indicators also improved. Case 4 adjusted the oral
dose of tacrolimus increasing to 2 mg q12 h，and oral dose of Pentaester soft capsule was increasing to 1 g bid. The blood
concentration of tacrolimus increased from 0.8 ng/mL to 5.9 ng/mL，which reached the expected value，and there was no further
fluctuation during hospitalization. CONCLUSIONS： Clinical
Δ 基金项目：国家自然科学基金资助项目（No.81703759）
pharmacists consultation mainly focuses on the following
＊主管药师，硕士。研究方向：临床药学与药动学。电话：0371-
66295644。E-mail：lina03154312@126.com aspects， such as individual treatment plan adjustment，
# 通信作者：主管药师，博士。研究方向：临床药学与药动学。电 judgment and treatment of ADR，adjustment of medication
话：0371-66295644。E-mail：scc086@126.com plan for special population，optimization of treatment plan for

·358 · China Pharmacy 2020 Vol. 31 No. 3 中国药房 2020年第31卷第3期