体外膜肺氧合患者抗感染治疗的药学监护

目的 分析体外膜肺氧合（ECMO）时抗感染治疗药物监护的重点和难点。方法 回顾性分析28例使用体外膜肺氧合治疗的危重症患者，统计患者的临床基本情况、病原学检出、抗感染药物使用和治疗药物监测情况。结果 28例患者中男性20例，女性8例，平均年龄为44.7岁，平均ECMO持续时间20.3 d，使用ECMO前即有肝功能不全者16例、肾功能不全5例、心衰7例、低蛋白血症18例，12例合并使用持续肾脏替代治疗（CRRT），平均APACHEII评分为19.1分，SOFA评分为7.6分。ECMO撤离后最终治疗成功、存活患者7例，死亡、自动出院或放弃治疗21例。共培养出病原体55例，多数为多重耐药革兰阴性杆菌、碳青霉烯类药物耐药，治疗药物监测为万古霉素19例、碳青霉烯类11例、伏立康唑4例，血药浓度监测各品种均有超过半数未在治疗范围内。结论 ECMO影响危重患者的血药浓度，应加强对该类患者的抗感染治疗药学监护。

Pharmaceutical care of anti-infective therapy in patients with ECMO

Objective The emphases and difficulties of anti-infective drug monitoring in extracorporeal membrane oxygenation (ECMO) were analyzed. Methods A retrospective analysis of 28 critically ill patients treated with ECMO was performed. The clinical characteristics, pathogen detection, anti-infective agent''s application, and therapeutic drug monitoring were statistically analyzed. Results Of the 28 patients, 20 were male and 8 were female, with an average age of 44.7 years. The mean ECMO duration was 20.3 d. There were 16 patients with hepatic insufficiency, 5 patients with renal insufficiency, and 7 patients with heart failure, 18 cases of hypoproteinemia before ECMO. And there were 12 cases combined with CRRT; the average APACHE II score was 19.1 and SOFA score was 7.6. The overall outcomes were 7 patients survived, and 21 patients died or discharged automatically or abandoning therapy. A total of 55 pathogens were collected, most of which were multi-drug resistant Gram-negative bacilli and carbapenem-resistant. The therapeutic drugs application were vancomycin 19, carbapenems 11, voriconazole 4, etc. More than half of the TDM were not in the treatment range. Conclusion ECMO affects the blood concentration of anti-infective agents in critically ill patients and pharmaceutical care need to be strengthened.