对1例肝硬化并肝性脑病患者的药学监护

Pharmaceutical care on a patient with hepatic cirrhosis complicated with hepatic encephalopathy

1例54a男性患者,因肝硬化并肝性脑病、2型糖尿病入院,给予降血氨、保肝、抑酸、抗感染等综合治疗。入院后4d患者出现肝昏迷现象,为及时降低血氨浓度、改善患者临床症状,临床药师建议增加门冬氨酸鸟氨酸给药剂量,并联合使用精氨酸,之后患者症状好转;考虑到患者对青霉素过敏,对硫普罗宁致过敏反应进行判断和评估,并建议将硫普罗宁换为多烯磷脂酰胆碱;并对双歧三联活菌与双八面体蒙脱石的相互作用给予监测,建议将两药间隔1h服用;结合患者肝硬化病情建议对奥美拉唑的给药剂量进行调整,以减少对肝功能损害。

A 54-year-old male patient with hepatic cirrhosis accompanied with hepatic encephalopathy and type 2 diabetes mellitus was hospitalized. The patient was treated with lowering ammonia, protective liver, inhibiting acid secretion, anti-infection. Four days after the patient＇ s hospitalization, he developed coma hepaticum. To timely reduce the plasma concentration of ammonia and improve the patient＇ s clinical symptom, clinical pharmacist suggested increasing the dose of L-ornithine-L-aspartate and combination treatment with arginine. The symptoms of the patient improved. Considering the patient＇ s allergic history of penicillin, clinical pharmacist recommended tiopronin should be replaced with polyene phosphatidylcholine for avoiding adverse reactions. The potential interaction between live combined bifidobacterium, lactobacillus and streptococcus thermophilus table and dioctahedral smectite was monitored, and clinical pharmacist suggested the interval time of the two drugs taken should be at least 1 hour. To lighten the burden of patient＇ s liver, the clinical pharmacist suggested adjusting the dosage of omeprazole.