丙戊酸钠用药差错致肝损伤:病例分析

Liver damage caused by sodium valproate medication error:a case report

目的 从1例脑卒中后继发癫痫患者丙戊酸钠用药错误的处置过程,探讨医疗团队中临床药师在纠正治疗用药错误中的作用。方法 临床药师参与丙戊酸钠用药错误处置的全程治疗,向临床宣教血药浓度监测、丙戊酸钠合理用药(剂量和用法),以及最常见的不良反应和潜在的药物相互作用。结果 患者抽搐症状得以控制,丙戊酸钠引起肝损伤得以恢复。结论 临床药师参与药物治疗,既要关注正常用法、用量下的药物不良反应,也应具有处置用药错误的能力,充分发挥临床药师的专业作用。

Objective To analyze the participation effect of clinical pharmacist during the treatment process of sodium valproate in a patient with secondary epilepsy after stroke. Methods The correct dose and usage of sodium valproate under TDM,the most common ADR and the potential DI were introduced by clinical pharmacists who participated in the whole course treatment of sodium valproate. Results The convulsion was controlled and the liver damage caused by sodium valproate was recovered. Conclusion Clinical pharmacist should not only pay attention to ADRs under normal usage and dosage,but also pay special attention to the ability to deal with drug errors,so as to promote rational and individualized drug use.