临床药师对1例乙肝后肝硬化腹水合并食管胃静脉曲张破裂出血患者的药学监护

Pharmaceutical Care for a Patient with Hepatitis B and Liver Cirrhosis Ascites Complicating with Gastroesophageal Varices Bleeding by Clinical Pharmacists

目的:了解肝硬化失代偿期的药物治疗经过,探讨对该类患者的药学监护要点。方法:对1例乙肝后肝硬化腹水合并食管胃静脉曲张破裂出血患者治疗过程所用药物进行分析,发现存在多种治疗矛盾。药师以此为切入点,协助医师共同制订个体化用药方案:调整螺内酯、呋塞米剂量,应用特利加压素减少腹水;选用普萘洛尔降低门脉压;使用恩替卡韦保肝及抗乙肝病毒;合理使用凝血酶、抑酸剂、生长抑素等处理急性上消化道出血,监护患者用药全过程,并对患者开展用药教育。结果:在临床药师和临床医师共同参与下,患者肝硬化腹水明显减少,上消化道出血完全控制后出院。结论:当临床合并多种疾病或出现治疗矛盾时是临床药师工作的切入点。药师可协同临床医师优化治疗方案,实施药学监护,以促进临床合理用药。

OBJECTIVE： To investigate the drug treatment process, and to discuss the pharmaceutical care for the patients with decompensated cirrhosis. METHODS： The drugs used in a patient with hepatitis B and liver cirrhosis ascites complicating with gastroesophageal varices bleeding were analyzed to find various contradictions in therapeutic process. Therefore, pharmacists took it as point of penetration, and formulated individual therapy plan together with doctors： adjusting the dose of spirolactone and furosemide, using terlipressin to decrease ascites; reducing portal vein pressure by using propranolol; using entecavir for liver-protection therapy and anti-hepatitis B virus therapy; using thrombin, acid inhibitor, somatostatin, and other drugs for acute upper gastrointestinal hemorrhage; monitoring medication duration and providing medication education. RESULTS： With the cooperation of pharmacists and doctors, ascites due to cirrhosis decreased significantly, and upper gastrointestinal bleeding could be controlled completely; then the patient discharge from hospital. CONCLUSIONS： The situation is point of penetration for pharmacists that patient suffers from various diseases or therapy contradictions. Clinical pharmacists can optimize treatment plan with doctors and implement pharmaceutical care for patients to promote rational use of drug.