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·药学服务·
心脏生物瓣膜置换术后并发血小板减少症的药学监护实践
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殷欢莉 1， 2＊ ，黄跃洲 ，罗 敏 （1.四川大学华西医院临床药学部，成都 610041；2.四川大学华西天府医院药
剂科，成都 610213）
中图分类号 R969.3 文献标志码 A 文章编号 1001-0408（2026）01-0077-06
DOI 10.6039/j.issn.1001-0408.2026.01.14
摘 要 目的 为心脏生物瓣膜置换术后并发血小板减少症等复杂病例的抗凝治疗、药物不良反应监测及个体化用药调整提供参
考。方法 临床药师参与1例心脏生物瓣膜置换术后并发血小板减少症的药学监护。针对心功能不全，临床药师建议维持口服富
马酸比索洛尔、沙库巴曲缬沙坦钠、螺内酯、呋塞米和氯化钾，加用左西孟旦增强心肌收缩力，监测血压、心率及血钾浓度；针对血
小板减少症，基于文献评估风险，建议应用重组人白细胞介素11（rhIL-11）、输注血小板，并采用那曲肝素钙桥接华法林进行抗凝
治疗，根据国际标准化比值（INR）调整华法林剂量；针对快室率心房颤动，建议予胺碘酮及地高辛治疗；针对急性肝损伤，临床药
师怀疑为胺碘酮及rhIL-11所致，建议停用相关药物，予丁二磺酸腺苷蛋氨酸联合多烯磷脂酰胆碱行保肝治疗；对患者进行抗凝用
药教育，强调需严密监测INR，密切观察出血及血栓事件。结果 临床医师采纳上述建议。经干预后，患者肝功能显著改善，丙氨
酸氨基转移酶降至70 U/L，天冬氨酸氨基转移酶降至42 U/L，心率稳定为70～100次/min，心功能平稳，INR控制在1.80～2.50，病
情好转出院。结论 临床药师通过权衡抗凝与出血风险，协助临床制定个体化抗凝方案，开展药物不良反应监测与评估，优化用药
策略，有效保障了患者的用药安全与疗效。
关键词 心脏生物瓣膜置换术；血小板减少症；抗凝治疗；药物性肝损伤；药学监护
Pharmaceutical care in thrombocytopenia after bioprosthetic heart valve replacement
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YIN Huanli ，HUANG Yuezhou ，LUO Min（1. Dept. of Clinical Pharmacy， West China Hospital， Sichuan
University， Chengdu 610041， China；2. Dept. of Pharmacy， West China Tianfu Hospital， Sichuan University，
Chengdu 610213， China）
ABSTRACT OBJECTIVE To provide a reference for anticoagulation therapy， adverse drug reaction monitoring， and
individualized medication adjustment in complex cases， such as those with thrombocytopenia following bioprosthetic heart valve
replacement. METHODS Clinical pharmacists participated in the pharmaceutical care of a patient with thrombocytopenia following
bioprosthetic heart valve replacement. For cardiac insufficiency， the pharmacists recommended maintaining oral bisoprolol，
sacubitril/valsartan， spironolactone， furosemide， and potassium chloride， with levosimendan added to enhance myocardial
contractility， while monitoring blood pressure， heart rate and serum potassium levels. For thrombocytopenia， based on literature-
based risk assessment， the pharmacists advised administering recombinant human interleukin-11 （rhIL-11）， platelet transfusion，
and employing anticoagulation therapy with nadroparin calcium bridging to warfarin， with warfarin dosage adjusted according to the
international normalized ratio （INR）. For rapid ventricular rate atrial fibrillation， amiodarone and digoxin were recommended. For
acute liver injury， suspected to be induced by amiodarone and rhIL-11， the pharmacists suggested discontinuing the relevant drugs
and treating with ademetionine 1，4-butanedisulfonate combined with polyene phosphatidylcholine for liver protection treatment. The
patient received anticoagulation medication education emphasizing strict INR monitoring and close observation for bleeding or
thrombotic events. RESULTS The clinicians adopted these recommendations. Following the intervention， the patient’s liver
function showed significant improvement， with alanine aminotransferase decreasing to 70 U/L and aspartate aminotransferase to 42
U/L. The ventricular rate stabilized at 70-100 beats per minute， cardiac function remained stable， the INR was maintained within
the target range of 1.80-2.50， and the patient was ultimately discharged with improved condition. CONCLUSIONS Through
balancing anticoagulation and bleeding risks， the clinical
Δ 基金项目 四川省干部保健科研课题（No.川干研2021-110） pharmacists applied pharmaceutical expertise to assist in
＊ 第一作者 药 师 ，硕 士 。 研 究 方 向 ：临 床 药 学 。 电 话 ：028-
developing personalized anticoagulation regimens， conducted
85422965。E-mail：yinhuanli@wchscu.cn
# 通信作者 副主任药师，硕士。研究方向：临床药学。电话：028- adverse drug reaction monitoring and evaluation， and
85422965。E-mail：luomin200703@126.com optimized medication strategies， thereby effectively ensuring
中国药房 2026年第37卷第1期 China Pharmacy 2026 Vol. 37 No. 1 · 77 ·
