一例心脏瓣膜置换术后华法林抗凝治疗INR异常波动案例原因分析及药学监护

Causative Analysis and Pharmaceutical Care of a Case of Excessive Warfarin Anticoagulation after Valve Replacement

关键词:  心脏瓣膜置换术  抗凝治疗  药学监护  药物相互作用

Key words:  valve replacement  anticoagulation therapy  pharmaceutical care  drug interaction

摘要:

摘要：目的 探讨临床药师对心脏瓣膜置换术后华法林抗凝治疗患者的药学监护要点，为抗凝药师在心脏外科开展药学服务提供参考。方法 以一例心脏瓣膜置换术后，因使用华法林抗凝治疗出现INR异常波动的患者为例，临床药师从华法林治疗的基因多态性、围手术期患者疾病状况、合并用药等方面进行分析，提出术后药物治疗方案、用药依从性教育及出院后电话随访的建议，并实施药学监护。结果 临床药师为医生提供了关于患者药物治疗方案调整的合理建议，并进行药学监护。术后一个月的电话回访显示，患者未发生心血管不良事件和药物不良反应，抗凝治疗安全有效，用药依从性较高。结论 针对心脏围手术期抗凝治疗中INR异常波动的患者，临床药师应结合患者临床状况，梳理用药清单，分析原因，并提供准确的药学监护。

Abstract:

ABSTRACT: OBJECTIVE To explore the key points of pharmaceutical care of clinical pharmacists for patients with warfarin anticoagulant therapy after heart valve replacement, and to provide reference for pharmaceutical care of anticoagulant pharmacists in cardiac surgery. METHODS A case of abnormal INR fluctuation during warfarin anticoagulation therapy in a patient after heart valve replacement was analyzed by clinical pharmacists from the aspects of gene polymorphism of warfarin therapy, disease status of perioperative patients, and perioperative concomitant medication, and suggestions and pharmaceutical care were put forward for postoperative drug treatment options, medication compliance education, and telephone follow-up after discharge. RESULTS Clinical pharmacists provided reasonable suggestions for clinicians to adjust the drug treatment regimen of the patients, and pharmaceutical care was implemented for them. One month after operation, no cardiovascular adverse events and adverse drug reactions occurred in the patients by telephone follow-up. Anticoagulation therapy was safe and effective, and the medication compliance of the patients was high. CONCLUSION For patients with abnormal INR fluctuation treated with anticoagulant therapy in cardiac perioperative period, clinical pharmacists should sort out the medication list in combination with the clinical status of patients, analyze the causes, and provide accurate pharmaceutical care.