临床药师参与1例严重急性肾功能不全合并MRSA感染的药学实践

目的:探讨临床药师在严重急性肾功能不全合并耐甲氧西林金黄色葡萄球菌(MRSA)感染患者救治中的作用。方法:临床药师参与1例严重急性肾功能不全合并MRSA感染会诊病例的治疗方案讨论,建议将初始抗感染方案中头孢唑肟剂量减半为2.0 g,ivgtt,2次/日;1周后患者病情未见好转,建议停用头孢唑肟,换用亚胺培南/西司他丁钠0.5 g,q8 h;确认患者感染MRSA后,建议按说明书剂量给予利奈唑胺。结果:医师采纳药师建议,治疗过程中无明显不良反应发生,患者病情得到了有效控制,治愈后出院。结论:临床药师参与药学监护有助于临床合理用药,确保用药安全。     

1例脓毒症休克合并急性肾功能不全患者使用美罗培南的药学实践

临床药师协助医师对1例脓毒症休克合并急性肾功能不全患者的美罗培南给药方案进行调整，建议采用缩短给药间隔以及采用两步滴定法给药。医师采纳临床药师建议，治疗取得良好效果，患者病情明显好转出院。     

临床药师利用TDM参与1例万古霉素致急性肾损伤病例的药学实践

临床药师参与1例老年心内膜炎患者药物治疗过程,发现患者入院时肌酐升高并在入院后3 d持续上升。通过询问病史、重整入院前医嘱后,推测患者肌酐持续升高可能与万古霉素有关,建议监测万古霉素即时血药浓度并对症治疗。临床药师的临床思维对不良反应发现及保障临床用药安全具有重要意义。     

临床药师参与慢性阻塞性肺疾病急性加重期伴肾功能不全患者抗感染治疗的药学监护实践

目的:探讨临床药师参与慢性阻塞性肺疾病急性加重期(AECOPD)伴肾功能不全老年患者的药学监护过程。方法:临床药师参与1例AECOPD伴肾功能不全患者的会诊,发挥自身药学特长,为医生提供个体化用药信息,对药物选择、用法用量、不良反应的评价提出建议。结果:临床药师参与AECOPD伴肾功能不全患者抗感染治疗,疗效较为显著。结论:临床药师利用药学专业知识,在治疗团队中对提高疗效、保障患者安全用药发挥着积极的作用。     

对1例敌敌畏中毒患者的用药分析及药学监护

患者44岁,因口服"敌敌畏"中毒后神志不清1d入院。入院后临床药师参与解毒、营养神经、保肝等系列治疗,血胆碱酯酶恢复至正常水平80%出院。提示临床药师在实践工作中需加强与临床医师的沟通,注意细节的观察。     

1例急性心功能不全缓解患者的药学监护

1例老年女性患者,因慢性心力衰竭急性发作入院,入院诊断为慢性心功能不全急性发作、肺部感染、慢性阻塞性肺疾病急性发作、高血压Ⅲ级、2型糖尿病。因患者出现下肢静脉血栓及肺栓塞,先后使用低分子肝素和华法林治疗,临床药师评估了低分子肝素和华法林的重叠使用时间,并通过测量INR值调整华法林的用量;因地尔硫卓可能升高华法林的血药浓度,建议停用地尔硫卓;考虑到心衰患者首选ACEI或ARB类降压药,建议停用非洛地平改用氯沙坦,血压控制良好。同时,临床药师分析了影响地高辛血药浓度的因素,提示患者关注可能的中毒症状,并就可能影响华法林血药浓度的药物和食物以及监测血压、血糖、INR值等对患者进行出院教育。     

肾功能不全患者不合理用药医嘱分析

目的：通过对本院肾功能不全患者不合理用药医嘱情况进行分析,为该类患者合理用药提供参考。方法：筛取2019年1~12月前置审方因肾功能不全不合理用药问题被药师打回的医嘱,对不合理医嘱的科室分布、药物种类及药师建议的接受率进行统计分析。结果：在药师打回医嘱496条中,老年科不合理用药问题最多,占医嘱30.04%;在不合理用药种类中,抗感染药物比例最大,占46.77%;在药师建议接受率中,由63.64%上升至88.89%,且外科比内科高,有禁忌症使用较用法用量不合理高。结论：肾功能不全患者用药存在一定问题,建议加强事前审方干预、医师培训以及药学服务等多项措施共同干预,促进肾功能不全患者合理用药。     

1例疑似中药致CKD 5期患者急性高钾血症的药学监护

本文通过中药临床药师参与1例疑似中药致慢性肾脏病（CKD）5期患者急性高钾血症的药学监护,探索中药临床药师参与临床查房的思维模式和工作方式。本病例为CKD 5期患者,因发现蛋白尿8年,间断双下肢水肿4年,复发加重1周入院。在中医科经规范、合理的抗血小板、调脂、护肾、改善贫血、降压、减轻心脏负荷、中药汤剂、中成药等药物对症支持治疗,病情好转,但住院期间血钾偏高,给予西医方法降血钾药物治疗后,血钾仍反复升高。为此,中药临床药师结合现有国内外文献协助临床医师查找引起血钾反复升高的因素,最终考虑中药引起的可能性较高,建议停用中药汤剂和中药注射剂,最终血钾恢复正常。中药引起的高钾血症在临床并不常见而往往被忽视,中药临床药师参与药学监护,结合其用药史及药物作用特点,协助医师查找和判断导致血钾升高的药物因素,并协助其制订和调整用药方案,保障患者用药安全。     

1例PCI术后支架内血栓形成患者的药学监护

1例40岁男性患者,因发作性胸痛3年,加重6h入院。入院诊断为：冠心病,急性前壁心肌梗死,陈旧性下壁心肌梗死,PCI＋支架置入术后。入院后急行冠状动脉造影＋PCI术,并给予抗血小板、抗凝、调脂、稳定斑块、改善心肌缺血等治疗。考虑到辛伐他汀可能与氯吡格雷存在代谢酶竞争,从而导致氯吡格雷抗栓效果不充分,临床药师建议将辛伐他汀调整为经CYP2C9代谢的氟伐他汀,或极少经CYP2C19代谢的瑞舒伐他汀;同时,对患者服用的双联抗血小板药物可能引起的胃肠道不适或出血症状,以及他汀类药物相关不良反应进行监测。并分析患者PCI术后支架内血栓形成的原因是抗血小板药物治疗不充分及不健康的生活方式,并据此对患者进行用药教育,督促患者遵循健康的生活方式,保障患者用药安全、有效。     

对1例腹膜透析患者的药学监护

1例67岁男性患者,因冠心病、急性冠脉综合征入院治疗,入院时合并有风湿性心脏病、慢性肾功能不全尿毒症期（双侧肾脏萎缩）等多种疾病,给予扩冠、降脂、抗血小板、抗凝等治疗,并于入院后第2天行经皮冠状动脉介入治疗,术后患者出现急性左心衰合并肺部感染,给予利尿、强心、化痰、平喘、抗感染等药物治疗。针对患者需要腹膜透析的情况临床药师建议进行强心药物地高辛的血药浓度监测,规避地高辛蓄积中毒的风险。在抗感染治疗中,根据痰培养结果,结合腹膜透析可部分清除氟康唑的特点,建议在透析后给予氟康唑,并给予不受腹膜透析影响的左氧氟沙星进行抗感染治疗,同时对抗感染治疗过程中使用的亚胺培南西司他丁以及左氧氟沙星引起的震颤、失眠等不良反应进行监测。     

新型袢利尿剂托拉塞米治疗心衰进展

组织水肿是心衰发生、发展过程中的重要环节,袢利尿剂的应用是心衰治疗的重要组成部分.托拉塞米是一种新型的吡啶磺酰脲类袢利尿剂.近十余年的研究证实,托拉塞米在心衰的治疗方面有良好的作用:利尿作用更强、生物利用度更高、半衰期更长、作用更持久;对电解质、血糖、血脂代谢均无影响;主要在肝脏代谢.因此,对肾脏功能不全者不会产生蓄积,可以长期使用.本文就新型袢利尿剂托拉塞米治疗心衰的研究作一综述.     

Dose-independent pharmacokinetics of torasemide after intravenous and oral administration to rats

After intravenous (at doses of 1, 2, 5, and 10 mg/kg) and oral (at doses of 1, 5, and 10 mg/kg) administration of torasemide, the pharmacokinetic parameters were dose-independent. Hence, the extent of absolute oral bioavailability (F) was also independent of oral doses; the values were 95.6, 98.8, and 97.3% for oral doses of 1, 5, and 10 mg/kg, respectively. The high F values indicated that the first-pass (gastric, intestinal, and hepatic) effects of torasemide in rats could be almost negligible. After intravenous administration, the total body clearances of torasemide were extensively slower than the reported cardiac output in rats and hepatic extraction ratio was only 3-4% suggesting almost negligible first-pass effects of torasemide in the heart, lung, and liver in rats. Based on in vitro rat tissue homogenate studies, the tissues studied also showed negligible metabolic activities for torasemide. Equilibrium of torasemide between plasma and blood cells of rat blood reached fast and plasma-to-blood cells concentration ratio was independent of initial blood concentrations of torasemide, 1, 5, and 10 microg/ml; the mean value was 0.279. Protein binding of torasemide to fresh rat plasma was 93.9 +/- 1.53% using an equilibrium dialysis technique.     

托拉塞米联合呼吸机对急性左心衰竭患者血气指标及心功能的影响

目的:探讨托拉塞米联合呼吸机对急性左心衰竭患者血气指标及心功能的影响。方法:选取的研究样本均为某院2019年5月~2020年7月收治,共纳入50例患者,对照组接受托拉塞米治疗,研究组接受托拉塞米联合呼吸机治疗,对比两组患者的血气分析指标以及心功能。结果:研究组PaCO_2低于对照组,PaO_2、SaO_2高于对照组(P<0.05);研究组的心功能改善效果以及治疗效果优于对照组(P<0.05)。结论:急性左心衰竭患者接受托拉塞米联合呼吸机治疗,能够有效的改善患者的心功能,改善血气分析指标。     

托拉塞米和呋塞米治疗心肾综合征疗效对比观察

目的 比较托拉塞米和呋塞米治疗心肾综合征的疗效及安全性.方法 60例合并肾功能不全的心力衰竭患者入院肌酐水平Ⅰ级40例、Ⅱ级20例,均完全随机平均分成托拉塞米组和呋塞米组.在常规治疗基础上,托拉塞米组加用托拉塞米20 mg/d静脉注射,呋塞米组加用呋塞米40 mg/d静脉注射.给药前后测定患者血钾、血钠、血钙、肌酐水平,记录24h尿量,同时观察患者的症状、心功能变化及不良反应发生率.结果 不同入院肌酐水平(Ⅰ级和Ⅱ级)患者托拉塞米组日平均尿量均明显高于呋塞米组[( 1685±49)rnl比(1442±38) ml,( 1042±32) ml比(968±38)ml,P＜0.05].肌酐水平Ⅰ级患者托拉塞米组心功能好转率高于呋塞米组[75％ (15/20)比65％ (13/20)],且血钾较呋塞米组明显升高[(+0.03±0.01) mmol/L比(-0.01 ±0.01)mmol/L,P＜0.05],托拉塞米组血肌酐波动范围明显较小(P＜0.05).不同肌酐水平(Ⅰ级和Ⅱ级)2组水肿消退率比较差异无统计学意义(P＞0.05),肌酐水平Ⅱ级患者心功能好转率及血钾变化2组比较差异无统计学意义(P＞0.05).托拉塞米组不良反应发生率为6.7％ (2/30),呋塞米组不良反应发生率为30.0％(9/30),2组比较差异有统计学意义(P＜0.01).结论 对心肾综合征患者,托拉塞米利尿作用及对机体内环境的稳定性明显优于呋塞米.     

托拉塞米治疗充血性心力衰竭的疗效及安全性的临床观察

目的：观察托拉塞米治疗充血性心力衰竭的临床疗效及安全性。方法：选取30例充血性心力衰竭患者,将其随机分为托拉塞米组与呋塞米组,在心力衰竭常规治疗方法一致的情况下,分别予托拉塞米与呋塞米20mg静推,治疗7d,记录两组患者治疗前后血压、血钾浓度、BNP值及EF值。结果：两组患者血压均有下降,但组间差异无统计学意义;托拉塞米组低血钾发生率更低,BNP下降且心功能改善更明显。结论：托拉塞米可一定程度改善心功能,低血钾及血压变化等不良反应较轻。     

Pharmacokinetics of torasemide and its metabolites in end-stage renal disease

The pharmacokinetics of torasemide, a new loop diuretic, as well as its active metabolites M1 and M3, and its inactive main metabolite, M5, were studied in 12 patients with end-stage renal failure during single i.v. (n=6) or single oral (n=6) dosing of 200 mg torasemide, and during chronic oral treatment for 9 days (n=12).The elimination half-life (t_1/2) of torasemide was unchanged in renal failure, whereas t_1/2 of the torasemide metabolites M1, M3, and M5 were markedly prolonged. However t_1/2 as well as the area under the plasma level time curve of torasemide and its metabolites were unchanged during chronic compared to acute administration.The results of this study suggest that despite the increased half-life of torasemide metabolites M1, M3 and M5 in end-stage renal failure patients, no accumulation of the parent drug torasemide and its metabolites during chronic dosing is demonstrable.     

Acute Renal Failure After Administration of Intravenous Immunoglobulin: Review of the Literature and Case Report

Within in last 7 years the literature has published several reports of acute renal failure after the administration of intravenous immunoglobulin. Review of these cases finds that all occurrences in the United States except one involved a sucrose-containing immunoglobulin preparation, leading to the suspicion that sucrose may be the cause of the renal failure. Further investigation found that approximately 50 years ago, when sucrose was used as an osmotic diuretic, investigators reported acute renal failure in humans after intravenous infusions of 50 g or more. A patient at our institution developed acute renal failure similar to that described in published case reports after being administered a sucrose-containing immunoglobulin.     

Pharmacokinetics and pharmacodynamics of bisoprolol in rats with bilateral ureter ligation-induced renal failure

The effect of renal failure on the pharmacokinetics and pharmacodynamics of bisoprolol was investigated in bilateral ureter-ligated (BUL) rats. The blood bisoprolol concentrations following 30-min intravenous infusion at a rate of 60 microg/kg/min were higher in renal artery-occluded (RAO) rats than in control rats, and were higher in BUL rats than in RAO rats. Increased blood bisoprolol concentrations accompanied decreased mean systemic clearances: 50.7, 36.4, and 26.2 mL/min/kg in control, RAO, and BUL rats, respectively. The finding indicated that approximately 30% of administered bisoprolol was excreted via the kidney, and that not only the renal clearance but also non-renal clearance of bisoprolol was decreased in BUL rats. The beta-blocking action of bisoprolol was assessed by the reduction in isoproterenol-induced increases in the heart rate. The relationship between blood concentration and the beta-blocking action of bisoprolol in BUL rats was similar to that in control rats. These results suggested that renal excretion and hepatic metabolism of bisoprolol were significantly reduced in BUL rats, but that pharmacodynamics of bisoprolol was not altered by acute renal failure.     

托拉塞米注射液治疗急性左心衰竭的临床分析

目的：观察分析托拉塞米注射液对急性左心衰竭的疗效及安全性。方法：将102例急性左心衰竭患者随机分为治疗组（51例）和对照组（51例）,治疗组应用托拉塞米注射液20～80mg,对照组应用呋塞米注射液20—100mg,其余治疗相同,观察两组疗效、血气分析及电解质等的变化,并记录不良反应。结果：治疗组有效率90．2％,对照组有效率86-3％,组间差异无统计学意义;治疗组和对照组治疗后氧分压提高显著,P〈0．05;治疗组较对照组钾离子变化较小,两组比较P〈0．05。结论：应用托拉塞米注射液治疗急性左心衰竭疗效显著,安全性好。     

Torasemide (LUPRAC): a review of its pharmacological and clinical profile

Loop diuretics potently excrete water and electrolytes and therefore have been widely prescribed for the treatment of various kinds of edema for a long time. The potent diuretic action of loop diuretics, however, often causes hypokalemia, and therefore potassium sparing diuretics have also been supplied as a concomitant drug. Torasemide (LUPRAC), a novel diuretics, shows not only an effective loop diuretic action but also a potassium sparing action due to its anti-aldosteronergic effect. Torasemide also has a high bioavailability and is only slightly influenced by meals in humans. In addition, its pharmacodynamic features contribute to its stable diuretic action without any individual differences. In animal experiments, torasemide showed about a tenfold more potent diuretic action in comparison with furosemide, an authentic loop diuretic. On the one hand, the increase in the urinary potassium excretion by torasemide was relatively slight compared to the increase in urinary sodium excretion and, as a result, the urinary sodium to potassium (Na+/K+) ratio increased. The diuretic profile of torasemide was equal to that of the concomitant use of furosemide and an anti-aldosteronergic drug, spironolactone. Torasemide showed a significant efficacy and safety in comparison with furosemide in the patients with edema in both domestic and foreign clinical studies. Moreover, torasemide also showed a decreased rate of cardiac death in comparison to furosemide in patients with chronic heart failure in a large-scale clinical study (TORIC Study). The difference in cardiac death between these two diuretics has been suggested to depend on the anti-aldosteronergic effect of torasemide. In Japan, no new loop diuretics have been developed in over 10 years. Torasemide is therefore expected to be useful as an effective diuretic for diseases with edema.