临床药师参与肾功能不全患者万古霉素持续静脉给药对连续性肾脏替代治疗的药学监护与用药分析

Analysis of Pharmaceutical Care and Medication of Continuous Intravenous Administration of Vancomycin in Patients with Renal Insufficiency Treated by CRRT

目的:分析临床药师参与2例肾功能不全患者万古霉素持续静脉给药对连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)的药学监护与用药。方法:选取CRRT期间发生革兰阳性菌血流感染的患者,病例1采用指南推荐的万古霉素间断给药方案即负荷剂量1.0 g后“0.5g,q24h”,给药后谷浓度6.2 mg/L,予万古霉素加量至“1.0 g,q24h”;病例2根据连续性静脉-静脉血液滤过(continuous veno venous hemofiltration,CVVH)治疗剂量38 mL/(kg·h)采用万古霉素个体化日剂量持续静脉给药,即负荷剂量1.0 g后以1.0 g日剂量持续静脉给药治疗,患者用药后24h、48h和72h测定血药浓度分别为17.97 mg/L、18.69 mg/L和22.50 mg/L。结果:病例1抗感染疗效不佳,预后不良;病例2经抗感染治疗后血培养结果转阴,抗感染疗效较好且未发生相关不良反应。结论:临床药师根据CVVH治疗剂量采用万古霉素个体化的日剂量持续静脉给药方式可使万古霉素浓度快速达标,使其充分发挥抗感染作用。

Objective:To analyze the pharmaceutical care and medication of continuous intravenous administration of vancomycin in patients with renal insufficiency treated by continuous renal replacement therapy(CRRT). Methods:Patients with Gram-positive bacteria bloodstream infection during CRRT were selected. Case 1 was given vancomycin for "0.5 g, q24 h" after loading dose of 1.0 g, with trough concentration of 6.2 mg/L after administration, and intermittent administration of vancomycin for "1.0 g, q24 h". Case 2 was administered vancomycin intravenously at an individualized daily dose, i.e. 1.0 g of loading dose followed by 1.0 g of continuous intravenous administration. Blood concentrations of 17.97 mg/L, 18.69 mg/L and 22.50 mg/L were determined at 24 h, 48 h and 72 h, respectively. Results: Case 1 had poor curative effect and poor prognosis. The blood culture result of case 2 turned negative after anti-infection treatment, and the anti-infection effect was good without related adverse reactions. Conclusion: Based on CVVH treatment dose, clinical pharmacists could quickly reach the standard of vancomycin concentration and give full play to its anti-infection effect by individualized daily and continuous intravenous administration of vancomycin.