CAJ | 학술논문

目的：探讨临床药师参与急性肺血栓栓塞症伴肝、肾功能不全患者的治疗、提供药学监护的切入点。方法：临床药师深入临床，针对1例急性肺血栓栓塞症伴肝、肾功能不全患者，应用药学知识对该患者肝、肾功能与国际化标准比值（ INR）及药物相互作用等方面进行药学监护。结果：临床药师根据患者的肌酐清除率确定磺达肝癸钠使用初始剂量即可不需调整剂量；患者用药过程中，因抗感冒药与华法林的相互作用而引起INR值发生波动，临床药师及时发现并与医师商讨拟定治疗方案，使患者INR值波动在2左右。结论：临床药师对该患者进行了全程药学监护，在药物治疗过程中发挥了一定的作用。
목적：탐토림상약사삼여급성폐혈전전새증반간、신공능불전환자적치료、제공약학감호적절입점。방법：림상약사심입림상，침대1례급성폐혈전전새증반간、신공능불전환자，응용약학지식대해환자간、신공능여국제화표준비치（ INR）급약물상호작용등방면진행약학감호。결과：림상약사근거환자적기항청제솔학정광체간계납사용초시제량즉가불수조정제량；환자용약과정중，인항감모약여화법림적상호작용이인기INR치발생파동，림상약사급시발현병여의사상토의정치료방안，사환자INR치파동재2좌우。결론：림상약사대해환자진행료전정약학감호，재약물치료과정중발휘료일정적작용。
OBJECTIVE:To probe into the treatment of patient with acute pulmonary thromboembolism ( PTE) and hepatic renal insufficiency and the entry point of provision of pharmaceutical care by clinical pharmacists .METHODS:The clinical pharmacists did deeply research in clinic , aimed at a patient with acute PTE and hepatic renal insufficiency , pharmaceutical knowledge was applied into the pharmaceutical care in respect of the patients'liver and kidney function , INR values and drug interactions etc .RESULTS:According to the patient's creatinine clearance rate ( CCR) , the clinical pharmacists can determine the initial dose of fondaparinux sodium , by which the dose didn't need to be adjusted .During the process , INR values changed since the interactions between anti-cold medicine and warfarin; the clinical pharmacists found this situation timely and formulated treatment regimen with the physician , which made the INR value fluctuated at about 2. CONCLUSIONS: The clinical pharmacists provide entire pharmaceutical care for the patient , which play an important role in the process of medication .