临床药师参与肾衰竭患者连续静脉-静脉血液滤过治疗下抗感染药个体化给药的药学监护

Pharmaceutical Practice of Clinical Pharmacists in Individual Anti-infection Treatment for Renal Failure Patient with Continuous Veno-venous Hemofiltration

目的：探讨临床药师参与肾衰竭患者连续静脉-静脉血液滤过（continuous veno-venous hemofiltration,CVVH）期间抗感染治疗的药学实践。方法：介绍临床药师参与会诊的1例肾衰竭合并肺部感染患者行CVVH治疗,临床药师建议万古霉素首剂给予1 g,维持剂量0.5 g/次、每12 h给药1次,达到稳态后监测血药谷浓度,根据监测结果调整万古霉素给药方案,使其谷浓度控制在15~20μg/ml内;CVVH治疗期间增大美罗培南的用量为1 g、每8 h给药1次,延长每次滴注时间至3 h。结果：万古霉素首次血药浓度监测结果为22.14μg/ml,根据Ritschel一点法调整万古霉素给药方案为0.4 g、每12 h给药1次,再次监测谷浓度为18.05μg/ml。临床药师通过治疗药物监测和个体化剂量调整保证了抗感染药治疗的有效性与安全性,促使患者的病情好转。结论：临床药师参与临床药物治疗,可对此类特殊患者开展药学服务,制订个体化抗感染给药方案,发挥在药物治疗中的作用。

OBJECTIVE： To investigate the pharmaceutical practice of clinical pharmacists in formulating the individualized dosage regimen of anti-infective drugs for a renal failure patient with continuous veno-venous hemofiltration（ CVVH）. METHODS： A case of lung infection combined with renal failure undergoing CVVH therapy was reported.Clinical pharmacists recommended a loading dose of 1 g of vancomycin,followed by a maintenance dose of 0. 5 g q 12 h.Therapeutic drug monitoring was taken after plasma concentration reached steady value,the administration scheme of vancomycin was adjusted according to the monitoring results,and the trough concentration was controlled within 15-20 μg / ml. During the treatment of CVVH,the dosage of meropenem had been increased to 1 g q 8h,and the infusion time had been prolonged to 3 h. RESULTS： The first monitoring result of plasma concentration of vancomycin was 22. 14 μg / ml;according to the Ritschel one-point method,clinical pharmacists decreased vancomycin dose to 0. 4 g q12 h,and then the steady state plasma concentration of vancomycin reached 18. 05 μg / ml. Individualized dosage adjustment by clinical pharmacists ensured the efficacy and safety of anti-infective drugs and made the patients get better.CONCLUSIONS： In order to play a role in drug treatment,clinical pharmacists could carry out pharmaceutical services for patients with such special treatment as CVVH and formulate individualized dosage regimen.