神经血管支架植入术后肾大出血患者的药学监护

Pharmaceutical Care for Patient with Renal Massive Hemorrhage after Neuroendovascular Stenting

目的:探讨临床药师对神经血管支架植入术后肾大出血患者药学监护的方法和作用。方法:临床药师参与1例神经血管支架植入术后肾大出血患者的初始抗栓方案评估、出血原因分析和抗栓方案制订。临床药师根据患者出血程度判断其为肾大出血,且与强化抗栓治疗有关。2次行左侧肾动脉造影+出血动脉栓塞术+输血后,临床药师建议停用阿司匹林与氯吡格雷,予醋酸奥曲肽注射液0.025 mg/h,ivgtt止血,注射用埃索美拉唑钠20 mg,ivgtt,qd抑酸、预防应激性溃疡,注射用头孢曲松钠2 g,ivgtt,qd抗感染,甲钴胺注射液0.5 mg,ivgtt,tiw营养神经;患者肾出血得到控制后建议重启抗栓治疗,予硫酸氢氯吡格雷片75 mg,po,qd。结果:医师采纳临床药师建议。患者肾出血得到有效控制,未发生栓塞事件。结论:强化抗栓治疗可减少神经血管支架植入术围术期栓塞事件,但会增加出血风险。临床药师需充分权衡患者栓塞与出血风险,协助医师制订合理的抗栓方案。

OBJECTIVE：To explore the method and effect of clinical pharmacists providing pharmaceutical care for renal massive hemorrhage patient after neuroendovascular stenting. METHODS：Clinical pharmacist participated in the primary antithrombotic treatment protocol evaluation,the cause analysis of hemorrhage and the formulation of antithrombotic treatment protocol of orce patient with renal massive hemorrhage after neuroendovascular stenting. According to the hemorrhage degree of patients,clinical pharmacists judged it was renal massive hemorrhage and correlated to intensified antithrombotic treatment;after receiving left renal artery amgiography＋bleeding artery embolization＋blood transfusion for twice suggested to stop taking aspirin and clopidogrel;suggested to take Octreotide acetate injection 0.025 mg/h,ivgtt,for stopping bleeding,Esomeprazole sodium for injection 20 mg,ivgtt,qd,for inhibiting acid and preventing stress ulcer,Ceftriaxone sodium for injection 2 g,ivgtt,qd,for anti-infective treatment and Mecobalamine injection 0.5 mg,ivgtt,tiw,for nourishing nerve;the patient received antithrombotic treatment again after renal hemorrhage had been controlled and took Clopidogrel hydrogen sulfate tablet 75 mg,po,qd. RESULTS：Physicians adopted the suggestions of clinical pharmacists. Bleeding was controlled and no embolic events occurred. CONCLUSIONS：Intensified antithrombotic treatment can reduce embolism events during neuroendovascular stenting but the risk of bleeding is increased. Clinical pharmacists need to assist physicians in formulating rational antithrombotic treatment protocol for patients by balancing the hemorrhage and thrombosis risk.