临床药师参与肝移植术后伴急性免疫排异反应患者的药学监护

Pharmaceutical Care for Liver Transplantation Patient with Acute Rejection

目的:探讨临床药师在肝移植术后伴急性免疫排异反应患者药物治疗中的作用。方法:临床药师参与1例肝移植术后出现急性免疫排异反应患者的治疗,通过分析患者病情,查阅临床指南和文献,协助医师优化抗排异、抗感染的药物治疗方案。为及时控制急性免疫排异反应,临床药师建议在大剂量糖皮质激素冲击治疗的基础上,迅速增加他克莫司胶囊的剂量。患者多次痰培养出鲍曼不动杆菌,药师综合分析患者病情后,建议将抗感染方案调整为注射用替加环素首剂100 mg,维持剂量50 mg,静脉滴注,每12 h给药1次;注射用头孢哌酮舒巴坦2 g,静脉滴注,每12 h给药1次;注射用舒巴坦1 g,静脉滴注,每12 h给药1次。为减轻患者经济负担,临床药师建议降阶梯使用抗真菌药,将注射用伏立康唑调整为氟康唑片。药师对患者所用药物的不良反应保持全程监护。结果:临床药师的建议被采纳,患者急性免疫排异反应得到有效控制,未出现感染,治疗15 d后由肝移植监护室转入普通病房。结论:临床药师参与肝移植术后伴急性免疫排异反应患者的治疗,可协助医师完善用药方案,促进临床合理用药。

OBJECTIVE：To investigate the role of clinical pharmacists in the treatment of one liver transplantation patient with acute rejection. METHODS： The clinical pharmacists participated into the treatment of one liver trarrsplantation patient with acute rejection. Through analyzing patients＇ disease conditions and researching the clinical guide and literature, the clinical pharmacists assisted the clinicians to optimize the treatment regimen of anti-rejection and anti-infection drugs. In order to control the acute rejection, a higher dose of tacrolimus was suggested as a complement to the high-dose corticosteroid by clinical pharmacists. For the culture of sputum showed growth of Acinetobacter baumanii with several times, the adjustment of the anti-infection drugs was advised after analyzing the infections risks by clinical pharmacists： tigecycline with loading dose of 100 mg, maintenance dose of 50 mg, ivgtt, q12 h; cefperazone-sulbactam 2 g, ivgtt, q12 h; sulbactam 1 g, ivgtt, q12 h. The substitution of voriconazole by fluconazole was also advised to decrease the financial burden of the patient. The pharmacy guardianship was kept for the whole treatment process. RESULTS： The suggestions from the clinical pharmacists were adopted. After treatment for 15 days, the acute refection was effectively controlled and the patient was transferred from the liver transplant care unit to the ordinary department without infection symptoms. CONCLUSIONS ： The participation of clinical pharmacists in the treatment of liver transplantation patient with acute rejection can optimize the drug therapy, and promote the rational drug use in clinic.