1例多囊肝多囊肾合并脑出血患者的药学监护

1例76岁男性患者,因多囊肝多囊肾合并脑出血、肺部感染及高血压入院。针对患者肺部感染,医生经验性给予头孢吡肟,结合患者肾功能不全及药敏培养结果,临床药师建议采用夫西地酸钠、万古霉素及头孢哌酮钠/舒巴坦钠联合抗感染;同时,对脂肪乳引起的脂肪超载综合征进行分析,建议停用脂肪乳静脉滴注,改用葡萄糖注射液供给能量;并对患者降压药物的选择进行讨论,建议将卡托普利、替米沙坦、硝普钠改为福辛普利钠、苯磺酸氨氯地平、呋塞米。经合理优化治疗方案后,患者感染得到及时、有效的治疗,血压控制较平稳,病情明显好转。

Pharmaceutical care on a patient with cerebral hemorrhage with polycystic liver and polycystic kidney disease

One 76-year-old male patient with cerebral hemorrhage, polycystic liver and polycystic kidney, pulmonary infection and hypertension was hospitalized. The patient was given empirical anti-infection treatment with cefepime for pulmonary infection. Considering the renal insufficiency and susceptibility culture results of the patient, clinical pharmacists proposed to treat with fusidic sodium, vancomycin and cefoperazone/sulbactam. Fat overload syndrome induced by intralipid was analyzed, and clinical pharmacist recommended to withdraw the intralipid intravenous infusion and switch to glucose injection to supply of energy. In addition, the elderly patient with renal hypertension, the selection of antihypertensive drugs was discussed, and captopril, telmisartan and sodium nitroprusside should be changed to fosinopril sodium, amlodipine besylate and furosemide. After the rational optimization of the treatment, the pulmonary infection was controlled timely and effectively and the blood pressure was controlled stably. The symptoms of this patient improved markedly.