243临床药师参与双瓣置换术后血小板减少患者华法林抗凝治疗的分析.docxVIP

临床药师参与双瓣置换术后血小板减少患者华法林抗凝治疗的分析王芳芳*，陈秋红，费燕#（解放军第175医院/厦门大学附属东南医院药学科，福建漳州 363000）中图分类号 R973.2；R969 文献标识码 A摘要目的探讨双瓣置换术后并发血小板减少的患者的抗凝治疗策略，为临床药师参与抗凝治疗提供参考。方法临床药师回顾性分析1例双瓣置换术后患者血小板减少的原因，结合药代动力学知识和相关文献资料，确定华法林初始剂量和目标国际标准化比值（INR），优化抗凝方案。结果患者血小板计数逐渐恢复正常；华法林抗凝治疗以5mg为初始剂量，目标INR为1.8-2.5。经过五次剂量调整后以3.125mg的维持剂量带药出院，出院时INR为1.5。结论临床药师参与可为患者提供更加安全、有效的治疗方案。关键词瓣膜置换；血小板减少；华法林；国际标准化比值Analysis of Clinical Pharmacists Participating in the Warfarin Anticoagulation Treatment for a Double Valve Replacement Patient with ThrombocytopeniaWANG Fang-fang, CHEN Qiu-hong, FEI Yan (Department of Pharmacy, 175 Hospital of PLA/Affiliated Southeast Hospital of Xiamen University, Fujian Zhangzhou 363000, China)ABSTRACTObjective To explore the anticoagulation strategies for a double value replacement patient with thrombocytopenia, and summarize the experience of clinical pharmacists participating in the anticoagulant therapy. Methods Clinical pharmacist retrospectively analyzed a patient with thrombocytopenia after double valve replacement. According to pharmacokinetic knowledge and related literatures, the initial dose of warfarin and the target international normalize (INR) were determined and the anticoagulation regimen was optimized. ResultsThe platelet counts gradually returned to normal; the warfarin anticoagulation was started with an initial dose of 5mg, the target INR was 1.8-2.5. After adjusting the dosage five times, the patient discharged with a maintenance dose of 3.125mg and an INR of 1.5. Conclusion The participation of clinical pharmacists can provide more safe and effective treatment regimen for patients.KEYWORDS Valve replacement；Thrombocytopenia；Warfarin；International standardization ratio（INR）心脏瓣膜置换术已成为治疗各种瓣膜性心脏病的主要方法。心脏瓣膜以机械瓣置换，术后需终生抗凝治疗。华法林是目前临床最常用的口服抗凝药，其治疗窗较窄，个体差异大[1]，所以，在治疗过程中应严密监护患者的凝血功能和药物不良反应，根据国际标准化比值（INR）调整华法林剂量，执行个体化给药方案。笔者作为临床药师参与了一例双瓣置换术后血小板减少患者的抗凝治疗过程，现对该病例作如下分析：1 病例介绍患者，男性，45岁，因“活动后胸闷气急10余年，加重1年”于2014年10月13日入院。入院诊断为：（1）风湿性心脏瓣膜病：二尖瓣中度狭窄、主动脉瓣重度关闭不全、三尖瓣中度关闭不全、心功能Ⅱ级；（2）心房纤